Almost 90% of couples conceive after a year of unprotected intercourse. Evaluation of infertility is indicated if the female partner is under 35 years of age and the couple has been trying to conceive for one year. Immediate evaluation and treatment of infertility are appropriate in cases of known problems that impact fertility such as irregular menstrual cycles, pelvic endometriosis, past history of pelvic infection or sexually transmitted disease, previous abdominal or pelvic surgery, or severe male factor infertility. Because fertility declines with advancing age of the female, evaluation of infertility are warranted for a couple when the female partner is older than 35 and has been trying to conceive for 6 months without success. In the subgroup of women older than 40 years of age, a more aggressive approach in evaluating and treating infertility is generally recommended because of the high likelihood for significant and rapid loss of ovarian reserve in this age group.


After a thorough history and physical examination, additional infertility diagnostic testing is undertaken to refine the diagnosis. These initial tests are:

  • Ovarian reserve testing (one or more of the following tests may be taken)
    • Day 3 blood test for FSH (follicle stimulating hormone) and estradiol (estrogen)
    • Day 3 antral follicle count: an ultrasound examination to measure the number of follicles between 4-8 mm on both ovaries.
    • Blood test for anti-mullerian hormone
    • Clomiphene citrate challenge test
  • Testing for tubal and/or uterine anatomy
    • Hysterosalpingogram (tubal dye test) and/or
    • Sonohysterogram (an ultrasound examination)
  • Testing to determine ovulation
    • Ultrasound to document the time of ovulation
    • Blood test to check progesterone level in the mid-luteal phase
  • Testing to assess mucus and sperm interaction
    • Postcoital test: to see if cervical mucus is optimal and sperm survival is sufficient
  • Semen testing
    • Semen analysis
    • Anti-sperm antibodies

In the majority of cases, this list of information is enough to indicate the appropriate initial treatment plan. Laparoscopy is not routinely indicated because it has the risks of surgery and does not usually change the initial treatment plan. However, laparoscopy may be indicated if there is suspected endometriosis or tubal disease based on the history, physical findings or ultrasounds examinations; or if there are other specific gynecologic reasons to perform this procedure.

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