Assessment & Workup
Female Factor Evaluation
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:
- Day 3 FSH elevated may indicate ovarian failure
- TSH test for thyroid dysfunction and treat accordingly
- Prolactin - assess medication list and rule out hyperprolactinemia
- 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
- Add 17 alpha-hydroxyprogesterone if suspect congenital adrenal hyperplasia
- Add free and total testosterone, dehydroepiandrosterone sulfate, and androstenedione for androgen-secreting tumours (if suspect hyperandrogenism)
Assessment of Ovarian Reserve
- Day 3 FSH: if higher than 20 can indicate ovarian failure
- Day 3 estradiol: if high, can indicate poor ovarian reserve
- Transvaginal ultrasound for antral follicle count (not commonly done in primary care)
- Anti-müllerian hormone (not commonly done in primary care, costly)
Imaging (If Indicated)
- Transvaginal ultrasound to assess for polycystic ovaries, structural abnormalities, antral follicle count
- 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