Female Infertility Investigations

Clinical History

• Number and outcome of previous pregnancies
• Number of living children
• Any complication or miscarriage in the last pregnancy
• Family planning methods used previously
• First day of her last menstrual period
• Pain during sexual intercourse and where it is
• Abnormal vaginal discharge
• Length of the menstrual discharge
• Previous treatment for infertility
• Previous investigations for infertility
• Medical history
• Pelvic infections in the past
• Excessive alcohol consumption or drug abuse
• Frequency of sexual intercourse
• Previous surgeries
• Exposure to toxins
• Post-coital bleeding.

Physical Examination

• General physical examination
• Body mass index (BMI): kg/m2
• Weight change >10% within past year
• Blood pressure
• Body shape and stature
• Abdominal scars
• Abnormalities in body systems
• Assessment of hirsutism
• Assessment of body hair distribution to check for adequate growth of hair in the pubic region and axilla
• Breast development
• Abdominal examination
• Vaginal and pelvic examination

Routine Investigations
The function of the reproductive organs and their associated organs can be assessed using a number of tests.

• Tests for ovulation
• Basal body temperature monitoring:

  — Indirect measure of ovulation based on biphasic pattern     of progesterone secretion
  

Basal body temperature chart

—  Measure of woman's temperature upon awakening      before any activity
—  BBT charts cannot predict fertile days

• Cervical mucus
• Endometrial biopsy:

  —  Assess whether uterus can sustain a pregnancy Usually      performed close to menstruation
  —  Small plastic catheter inserted through cervical canal,      piece of endometrial lining removed
  —  Biopsy should be examined microscopically and reveal a      postovulatory histological pattern
  —  Should be performed to R/o endometritis (TB)

• Ultrasonography
• Sonohysterogram:

  —  Evaluate uterine cavity
  —  Saline   injected   through   cervix   during transvaginal      ultrasound
  —  Fibroids, polyps, or adhesions may be seen

1. Day 21 progesterone assay
2. Luteinizing hormone surge assay:

—  LH Urine Test

Predict ovulation by detecting LH levels
above a certain threshold
Home test available (OTC)
Most test kits can detect urinary LH levels
as low as 20-40 IU/L

• Prolactin estimation
• Thyroid function tests
• Serum or plasma estrogen estimation

  - Plasma FSH: FSH determined early in menstrual cycle can be significant indicator of "ovarian age"
  Serum FSH
  Serum Estradiol

Inhibin B: Low day 3 values reflect increased ovarian ageing (Poor ovarian reserve).

Progesterone Test

• Serum progesterone
• Assess whether ovulation is occurring
• Blood test between days 20-24 of menstrual cycle for 28 day cycle

Spinnbarkeit

• Assess quality of cervical mucus
• Can be used for charting
• Schedule test near expected day of ovulation
• pH paper is put in contact with cervical mucus and lifted vertically
• Mucus should thread >6 cm
• pH should be > 6.5

Ferning

• Assess when ovulation is occurring
• Dried cervical mucus examined microscopically
• Pattern resembling fern leaves should be apparent near ovulation.

Tubal Patency Tests

1. Rubin's tests (obsolete).
2. Hysterosalpingogram (HSG)
3. Sonosalpingography (Color Doppler and 3D ultrasound)
4. Laparoscopy and dye test
5. Hysteroscopy
6. Cervical mucus test
7. HyCoSy (Hysterosalpingo contrast sonography)