Diagnosis of Female Infertility

Where to Begin

Any evaluation for infertility should be done in a focused and cost-effective way to find all relevant factors. The least invasive methods that can detect the most common causes of infertility should be done first.

The speed and extent of evaluation should take into account the couple’s preferences, the woman’s age, the duration of infertility, and unique features of the medical history and physical examination.

Fertility Testing for Females

Ovarian Reserve Testing: The most common test to evaluate ovarian reserve is a blood test for:

Follicle stimulating hormone (FSH) drawn on cycle day 3.
Anti-Mullerian hormone (AMH) is another test of ovarian reserve. It is made in the follicle and is related to the number of eggs produced. AMH levels can be drawn at any time during the menstrual cycle.
Antral follicle: A transvaginal ultrasound may be done in the early part of the menstrual cycle to count the number of small (2mm-9mm) follicles in the ovary. These are called antral follicles and are where eggs develop. The number of antral follicles can tell us about the quantity of eggs available and the response to gonadotropin medicines.

Ovarian reserve testing is more important for women who have a higher risk of reduced ovarian reserve such as women who:

are over age 35 years
have a family history of early menopause
have a single ovary
have a history of previous ovarian surgery, chemotherapy, or pelvic radiation therapy
have unexplained infertility
have shown poor response to gonadotropin ovarian stimulation

Sonohysterogram (SHG) or Saline Infusion Sonohysterography (SIS) is a procedure to evaluate the uterus and the shape of the uterine cavity.

SHG uses ultrasound and sterile fluid to show the uterus and endometrial (uterine lining) cavity.

The ovaries are also seen at the time of SHG. The purpose is to detect any abnormalities and for tubal patency evaluation.

Laparoscopy: This is a surgical procedure in which a lighted telescope-like instrument (laparoscope) is inserted through the wall of the abdomen into the pelvic cavity.

It is useful in assessing the pelvic cavity for endometriosis, pelvic adhesions, and other abnormalities. This procedure may be recommended depending on the results of other testing and a woman’s history such as pelvic pain and previous surgeries.

Hysteroscopy: This is a surgical procedure in which a lighted telescope-like instrument (hysteroscope) is passed through the cervix to view the inside of the uterus.

This procedure can help diagnose and treat abnormalities inside the uterine cavity such as polyps, fibroids, and adhesions (scar tissue).

Other Blood Tests:

Luteinizing Hormone (LH): Urinary LH testing helps define the times of greatest fertility – the day of the LH surge and the following two days. Over the counter “ovulation predictor kits” detect the presence of LH in urine and can detect a rise in this hormone that occurs 1-2 days before ovulation.

In contrast to blood progesterone levels, urinary LH tests can predict ovulation before it occurs. These tests can be expensive and should only be used by women with menstrual cycles that are consistently 25-35 days in length.

Thyroid-stimulating Hormone (TSH) and Prolactin (PRL) levels are useful to identify thyroid disorders and hyperprolactinemia, which may cause problems with fertility, menstrual irregularities, and repeated miscarriages.

Dehydroepiandrosterone Sulfate (DHEAS), 17-α Hydroxyprogesterone (17-OHP), and Total Testosterone (TTST) should be considered in women who show symptoms of hirsutism (excess hair on the face, chest, and/or abdomen).