Women who are unable to achieve a successful pregnancy after 12 months or more of regular unprotected intercourse require infertility evaluation.

Nearly 85% of couples are expected to achieve pregnancy without medical help within one year. Assessment is indicated for 15% of couples.

Earlier evaluation is warranted after six months if efforts to conceive in women over 35 years are unsuccessful. Earlier tests are also warranted in women missing periods, have uterine or Fallopian tube disease or have adhesions or endometriosis. Male subfertility warrants investigation.

It is best if assessment of the couple is done at the same time.

Methods for the evaluation of the male partner are described in a separate document.

Women who are planning to attempt pregnancy via insemination with sperm from a known or anonymous donor may also merit evaluation before such treatment begins.

At Initial Consultation your fertility specialist would obtain comprehensive history, a thorough physical examination, preconception care counseling and relevant genetic screening.

• How long have you been trying for a baby?, previous evaluation and treatment
• Your menstrual cycle details (menarche, cycle characteristics, molimina, and painful periods ‘dysmenorrhea’, severity)
• Pregnancy history (number of pregnancy, number of births, pregnancy outcome i.e. miscarriage, ectopic, preterm birth, and complications
• Contraception methods used and how long?
• Sexual intercourse frequency and dysfunction
• Pelvic inflammatory disease or exposure to sexually transmitted infections
• Pelvic pain
• Abdominal pain
• Pain with deep intercourse (deep dyspareunia)
• Past surgery or injuries (procedures, indications, outcomes complications) in particular pelvic surgery
• Previous illnesses and hospitalizations
• Thyroid gland disease
•  Milk secretion (galactorrhea)
•  Hirsutism (excess facial and body hair ‘male distribution’),
•  Previous abnormal pap smears and treatment
•  Current medications
•  Allergies
• Family history of birth defects / abnormality and mental retardation
• Family history of early menopause or reproductive failure or compromise
• History of exposure to Chemotherapy and or Radiation.
• Occupational exposure to known agents i.e. chemicals
• Environmental hazards
• Use of tobacco, alcohol
• Use of recreational or illicit drugs

• Weight, body mass index (BMI)
• Blood pressure and pulse
• Thyroid enlargement and nodules or tenderness
• Breast secretions and their character
• Signs of androgen excess, facial or body hair, acne
•  Vulval, Vaginal or cervical abnormality, secretions, or discharge
• Pelvic or abdominal tenderness, organ enlargement, or masses
• Uterine size, shape, position, and mobility
•  Adnexal masses or tenderness
• Cul-de-sac (the area between uterus and rectum) masses, tenderness, or nodularity

• Systematic
• Expeditious
• Cost-effective
• Initially least invasive
• Detect the most common causes of infertility.

• Couple's preferences
• Patient age
• Duration of infertility
•  Couple's medical history and physical examination

Obtained at the appropriate time in the cycle provides a reliable and objective measure of ovulatory function. A serum progesterone measurement should be obtained approximately one week before the expected onset of the next menses. A progesterone concentration more than 9.54 nmol/L provides presumptive but reliable evidence of recent ovulation. Higher values have been used commonly as a measure of the quality of luteal function (≥31.8 nmol/L). This criterion is not reliable because corpus luteum progesterone secretion is pulsatile and serum concentrations may vary up to 7-fold within an interval of a few hours.

Using various over the counter ovulation predictor kits can identify the mid-cycle LH surge that precedes ovulation by one to two days. Urinary LH detection provides indirect evidence of ovulation. It helps to define the interval of greatest fertility i.e. the day of the LH surge and the following two days. Midday or Evening Urinary LH particularly correlates well with the peak in serum LH.

Accuracy, ease of use, and reliability vary among ovulation predictor kits, and testing may yield false positive and false negative results.

Can demonstrate secretory change in endometrium due to action of progesterone and thus implies ovulation.

Endometrium Dating using histologic criteria was the gold standard for evaluating the quality of luteal function and for diagnosis of luteal phase deficiency (LPD). Now Endometrium Dating is not a valid diagnostic method because it lacks both accuracy and precision and the test cannot distinguish fertile from infertile women. It is no longer recommended for the evaluation of ovulatory or luteal function in infertile women. It is indicated only in women strongly suspected to have specific endometrial pathology e.g., neoplasia or chronic endometritis.

• Determines the size and number of developing follicles
• Provides presumptive evidence of ovulation and luteinization by demonstrating progressive follicular growth, sudden collapse of the pre-ovulatory follicle, a loss of clearly defined follicular margins, the appearance of internal echoes, and an increase in cul-de-sac fluid volume.

Because of the associated cost and logistical demands, the method generally should be reserved for women in whom simpler methods fail to provide the necessary information and those receiving ovarian stimulation for purposes of ovulation induction.

The concept of ovarian reserve views reproductive potential of a woman as a function of the number and quality of her remaining oocytes.

Decreased or diminished ovarian reserve (DOR) describes women of reproductive age having regular menses whose response to ovarian stimulation or fecundity is reduced compared to those women of comparable age.

• Cycle day 3 FSH and Estradiol measurements
• Clomiphene Citrate Challenge Test CCCT
• Antral Follicle Count in early follicular phase (transvaginal ultrasound)
•  Serum Anti-Mullerian Hormone (AMH) level.

These tests may provide prognostic information in women at increased risk of diminished ovarian reserve,

1)  Women over age 35 years

2)  Women who have a family history of early menopause

3)  Women who have a single ovary or history of previous ovarian surgery, chemotherapy, or pelvic radiation therapy

4)  Women with unexplained infertility

5)  Women who have demonstrated poor response to gonadotropin stimulation

6)  Women who are planning treatment with Assisted Reproductive Technology.

• Do not establish a diagnosis of diminished ovarian reserve.
•  Help to predict response to ovarian stimulation with exogenous gonadotropins.
• Help to a, lesser extent, predict the likelihood for achieving a successful pregnancy with ART.
• Poor results with any of the tests however, do not necessarily imply inability to conceive.

• FSH obtained on cycle day2–5 is commonly used as a measure of ovarian reserve. High values (10–20 IU/L) have been associated with both poor ovarian stimulation (usually defined as < 2–3 follicles or ≤ 4 retrieved oocytes) and the failure to conceive. Basal estradiol has value only as an aid to correct interpretation of a ‘‘normal’’ basal serum FSH value. When the basal FSH concentration is ‘‘normal’’ but the estradiol level is elevated (>220 pmol/L – 294 pmol/L) in the early follicular phase, there is limited evidence for an association with poor response, increased cancellation rates, and lower pregnancy rates.