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Diagnostic Evaluation of the Infertile Female: a Committee Opinion

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Diagnostic Evaluation of the Infertile Female: a Committee Opinion Diagnostic evaluation of the infertile female: a committee opinion Practice Committee of the American Society for Reproductive Medicine American Society for Reproductive Medicine, Birmingham, Alabama Diagnostic evaluation for infertility in women should be conducted in a systematic, expeditious, and cost-effective manner to identify all relevant factors with initial emphasis on the least invasive methods for detection of the most common causes of infertility. The purpose of this committee opinion is to provide a critical review of the current methods and procedures for the evaluation of the infertile female, and it replaces the document of the same name, last published in 2012 (Fertil Steril 2012;98:302–7). (Fertil SterilÒ 2015;103:e44–50. Ó2015 by American Society for Reproductive Medicine.) Key Words: Infertility, oocyte, ovarian reserve, unexplained, conception Use your smartphone to scan this QR code Earn online CME credit related to this document at www.asrm.org/elearn and connect to the discussion forum for Discuss: You can discuss this article with its authors and with other ASRM members at http:// this article now.* fertstertforum.com/asrmpraccom-diagnostic-evaluation-infertile-female/ * Download a free QR code scanner by searching for “QR scanner” in your smartphone’s app store or app marketplace. diagnostic evaluation for infer- of the male partner are described in a Pregnancy history (gravidity, parity, tility is indicated for women separate document (5). Women who pregnancy outcome, and associated A who fail to achieve a successful are planning to attempt pregnancy via complications) pregnancy after 12 months or more of insemination with sperm from a known Previous methods of contraception regular unprotected intercourse (1). or anonymous donor may also merit Coital frequency and sexual dys- Since approximately 85% of couples evaluation before such treatment function may be expected to achieve pregnancy begins. Past surgery (procedures, indica- within that time interval without med- tions, and outcomes), previous ical assistance, evaluation may be indi- hospitalizations, serious illnesses or cated for as many as 15% of couples. HISTORY AND PHYSICAL injuries, pelvic inflammatory dis- Earlier evaluation is warranted after 6 EXAMINATION ease, or exposure to sexually trans- months of unsuccessful efforts to Ideally, the initial consultation should mitted infections conceive in women over age 35 years be scheduled to allow sufficient time Thyroid disease, galactorrhea, hir- due to the observed age related decline to obtain a comprehensive medical, sutism, pelvic or abdominal pain, in fertility as a woman approaches age reproductive, and family history and and dyspareunia 40, and also may be justified based on to perform a thorough physical exami- Previous abnormal pap smears and medical history and physical findings, nation. This is also an opportune time any subsequent treatment including, but not limited to, the to counsel patients regarding precon- Current medications and allergies following (2–5): ception care and screening for relevant Family history of birth defects, genetic conditions. developmental delay, early meno- History of oligomenorrhea or Relevant history should include the pause, or reproductive problems amenorrhea following: Occupation and exposure to known Known or suspected uterine/tubal/ environmental hazards – peritoneal disease or stage III IV Duration of infertility and results of Use of tobacco, alcohol, and recrea- endometriosis any previous evaluation and treatment tional or illicit drugs Known or suspected male subfertility Menstrual history (age at menarche, Where applicable, evaluation of cycle length and characteristics, Physical examination should docu- both partners should begin at the presence of molimina, and onset/ ment the following: same time. Methods for the evaluation severity of dysmenorrhea) Weight, body mass index (BMI), Received March 13, 2015; accepted March 16, 2015; published online April 30, 2015. blood pressure, and pulse Reprint requests: Practice Committee of the American Society for Reproductive Medicine, 1209 Mont- gomery Hwy, Birmingham, Alabama 35216 (E-mail: [email protected]). Thyroid enlargement and presence of any nodules or tenderness Fertility and Sterility® Vol. 103, No. 6, June 2015 0015-0282/$36.00 Breast characteristics and evaluation Copyright ©2015 American Society for Reproductive Medicine, Published by Elsevier Inc. http://dx.doi.org/10.1016/j.fertnstert.2015.03.019 for secretions e44 VOL. 103 NO. 6 / JUNE 2015 Fertility and Sterility® Signs of androgen excess ovulation and can become tedious. Consequently, this assess- Vaginal or cervical abnormality, secretions, or discharge ment is no longer considered the best or preferred method for Pelvic or abdominal tenderness, organ enlargement, or evaluating ovulatory function for most infertile women. masses Serum progesterone determinations provide a reliable Uterine size, shape, position, and mobility and objective measure of ovulatory function as long as they Adnexal masses or tenderness are obtained at the appropriate time in the cycle. Given the Cul-de-sac masses, tenderness, or nodularity range of normal variation in ovulatory cycles, a serum pro- gesterone measurement generally should be obtained approx- imately 1 week before the expected onset of the next menses, DIAGNOSTIC EVALUATION rather than on any one specific cycle day (e.g., cycle-day 21). Subsequent evaluation should be conducted in a systematic, A progesterone concentration greater than 3 ng/mL provides expeditious, and cost-effective manner so as to identify all presumptive but reliable evidence of recent ovulation (11). relevant factors, with initial emphasis on the least invasive Although higher threshold values at the mid-luteal phase methods for detection of the most common causes of infer- have been used commonly as a measure of the quality of tility. The pace and extent of evaluation should take into ac- luteal function (e.g., greater than 10 ng/mL) (12), the criterion count the couple's preferences, patient age, the duration of is not reliable because corpus luteum progesterone secretion is infertility, and unique features of the medical history and pulsatile and serum concentrations may vary up to 7-fold physical examination. within an interval of a few hours (13). Urinary luteinizing hormone (LH) determinations using various commercial ‘‘ovulation predictor kits’’ can identify OVULATORY FUNCTION the mid-cycle LH surge that precedes ovulation by 1 to 2 Ovulatory dysfunction will be identified in approximately days. Urinary LH detection provides indirect evidence of 15% of all infertile couples and accounts for up to 40% of ovulation and helps to define the interval of greatest fertility: infertility in women (6). It commonly results in obvious men- the day of the LH surge and the following day (14). Results strual disturbances (oligomenorrhea/amenorrhea), but can be generally correlate well with the peak in serum LH, particu- more subtle. The underlying cause should be sought because larly when the test is performed on midday or evening urine specific treatment may be indicated, and some conditions specimens (8). However, accuracy, ease of use, and reliability may have other health implications and consequences. The vary among products, and testing may yield false-positive most common causes of ovulatory dysfunction include poly- and false-negative results (15). cystic ovary syndrome (PCOS), obesity, weight gain or loss, Endometrial biopsy (EBM) and histology can demonstrate strenuous exercise, thyroid dysfunction, and hyperprolacti- secretory endometrial development, which results from the nemia. However, the specific cause of ovulatory dysfunction action of progesterone and thus implies ovulation. ‘‘Dating’’ often remains obscure. Methods for evaluating ovulatory the endometrium using traditional histologic criteria (16) function may include any of the following: was long considered the ‘‘gold standard’’ among methods Menstrual history may be all that is required. In most for evaluating the quality of luteal function and for diagnosis ovulatory women, menstrual cycles are regular and predict- of luteal phase deficiency (LPD). However, careful studies able, generally occurring at intervals of 21–35 days, exhibit- have since demonstrated clearly that histologic endometrial ing consistent flow characteristics, and accompanied by a dating is not a valid diagnostic method because it lacks consistent pattern of moliminal symptoms (7). Some degree both accuracy and precision (17) and because the test cannot of variation is entirely normal; in a study of more than distinguish fertile from infertile women (18). Therefore, endo- 1,000 cycles, variations in inter-menstrual interval exceeding metrial biopsy is no longer recommended for the evaluation 5 days were observed in 56% of patients within 6 months and of ovulatory or luteal function in infertile women and should in 75% of those followed for 1 year (8). The expected range of be limited to those in whom specific endometrial pathology menstrual cycle length also varies according to age with the (e.g., neoplasia, chronic endometritis) is strongly suspected. minimum degree of individual variation occurring at age 36 Transvaginal ultrasonography can reveal the size and years (9). Patients with abnormal uterine bleeding, oligome- number of developing follicles and also provide presumptive norrhea, or amenorrhea generally do not require specific evidence of ovulation and
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