Assessment & Workup

Female Factor Evaluation

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Initial History

Female Partner

  • • Menstrual history (cycle length, regularity)
  • • Previous pregnancies and outcomes
  • • Contraceptive history
  • • Medical conditions (PCOS, thyroid, etc.)
  • • Surgical history (especially pelvic)
  • • STI history
  • • Current medications
  • • Family history of infertility

Male Partner

  • • Previous paternity
  • • Erectile/ejaculatory function
  • • Testicular trauma/surgery
  • • Undescended testes history
  • • STI history
  • • Current medications
  • • Heat exposure (hot tubs, saunas)
  • • Substance use

Physical Examination

Female Examination

  • • BMI calculation
  • • Signs of hyperandrogenism (hirsutism, acne)
  • • Thyroid examination
  • • Breast examination (galactorrhea)
  • • Pelvic examination (masses, tenderness, cervical abnormalities)

Male Examination

  • • BMI calculation
  • • Absence of secondary sexual characteristics
  • • Testicular volume (normal >15mL)
  • • Varicocele assessment

Initial Laboratory Tests

⚠️ Timing is crucial for many tests

Female Partner Tests

General Investigations

  • • Infectious work-up: Rubella titer, Varicella titer, Anti-HbS, HbSAg, STI screening
  • • HPV testing up-to-date
  • • A1C, fasting blood glucose

Assessment of Ovulatory Function

If cycles are regular:

  • • Luteal phase progesterone (7 days prior to expected menses) if >10nmol/L - reassuring of ovulation
  • • Home ovulation detection kits - mostly useful for proper intercourse timing

Assessment of Ovulatory Dysfunction

If cycles are irregular:

  1. Day 3 FSH elevated may indicate ovarian failure
  2. TSH test for thyroid dysfunction and treat accordingly
  3. Prolactin - assess medication list and rule out hyperprolactinemia
  4. PCOS suspect: Rotterdam Criteria (2/3 of the criteria)
    • Oligo or anovulation/irregular periods
    • Clinical or biochemical evidence of hyperandrogenism
    • Polycystic ovaries on transvaginal ultrasound
  5. Add 17 alpha-hydroxyprogesterone if suspect congenital adrenal hyperplasia
  6. Add free and total testosterone, dehydroepiandrosterone sulfate, and androstenedione for androgen-secreting tumours (if suspect hyperandrogenism)

Assessment of Ovarian Reserve

  1. Day 3 FSH: if higher than 20 can indicate ovarian failure
  2. Day 3 estradiol: if high, can indicate poor ovarian reserve
  3. Transvaginal ultrasound for antral follicle count (not commonly done in primary care)
  4. Anti-müllerian hormone (not commonly done in primary care, costly)

Imaging (If Indicated)

  1. Transvaginal ultrasound to assess for polycystic ovaries, structural abnormalities, antral follicle count
  2. Hysterosalpingogram (diagnostic or therapeutic) for tubal occlusion

Male Partner Tests

Semen Analysis (Primary Test)

  • • Abstinence: 2-7 days before collection
  • • Analyze within 1 hour of collection
  • • If abnormal, repeat in ≥1 month

Normal Parameters (WHO 2010):

  • • Volume: ≥1.5 mL
  • • Concentration: ≥15 million/mL
  • • Total motility: ≥40%
  • • Progressive motility: ≥32%
  • • Morphology: ≥4% normal forms

Hormonal Tests:

Collected before 10AM

  • • FSH
  • • LH
  • • Estradiol
  • • Prolactin
  • • Total testosterone

Male Factor Evaluation

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