History and Physical Exam- A careful history can often suggest the cause of infertility:

1. Irregular periods can indicate problem with ovulation. Short cycles (<25 days) are especially worrisome since they can be early sign of diminished ovarian reserve (aging ovaries). Long cycles (>35 days) are usually caused by emotional or physical stress and are easier to treat with medications.

2. Excessive facial or body hair, weight gain, or milky breast discharge can indicate hormonal imbalances that can impair ovulation. These symptoms are often found in polycystic ovary syndrome and thyroid conditions.

3. Prior STD treatment for chlamydia, condyloma (HPV), herpes, or syphilis can suggest tubal damage and pelvic adhesions.

4. Prior abnormal Pap smear with treatment to the cervix such as conization, cryosurgery, or LEEP can result in cervical stenosis or constriction of the cervix that can impede the movement of sperm into the uterus, where they can survive for several days.

5. Pain during menstruation or intercourse can indicate endometriosis, a condition in which menstrual implants colonize the pelvis outside of the uterus. These implants can lead to scarring of the pelvic structures thus impairing the ability of the tubes to pick up the egg.

6. Heavy menstrual flow (with clots) can indicate abnormalities within the uterine cavity such as fibroid tumors or polyps. These lesions can prevent embryo implantation through their destabilizing effect on the endometrium.

7. Recurrent miscarriages can indicate multiple problems and will require extensive testing.

8. Prior abdominal operations such as appendectomy, myomectomy, tubal surgery can suggest pelvic adhesions and tubal problems.

Hormonal Evaluation- is conducted to assess ovarian function:

1. Day 3 FSH- can provide information on the ovarian egg reserve. The pituitary constantly secretes FSH to recruit eggs. When the egg supply is exhausted, the pituitary will compensate by overproducing FSH in an attempt to provide eggs for the cycle. A baseline FSH level of 10 mIU/ml or higher is abnormal, suggesting low egg reserve. A FSH level of ≥15 is rarely associated with pregnancy even with IVF treatment. Donor egg IVF may be required.

2. Day 10 FSH- is measured after a 5 days course of clomiphene to allow detection of patients with borderline egg reserve who may have normal baseline FSH level.  The clomiphene challenge test can give a better assessment of the ovarian reserve than a single baseline FSH. Passing the test requires that both FSH levels on day 3 and 10 be less than 10 mIU/ml.

3. Estradiol- is produced by a growing follicle to promote egg development, increase production of cervical mucus, and thicken the endometrial lining.

4. Progesterone- is produced by the same dominant follicle after ovulation. Progesterone transform the endometrium to prepare it for embryo implantation. Progesterone level is usually measured a week after ovulation (i.e.. day 20-22), and a level of  ≥12 ng/ml is desirable.

5. Thyroid Stimulating Hormone (TSH)- reflects the function of the thyroid gland. Abnormal thyroid activity can interfere with egg development.

6. Prolactin- Overproduction of this hormone can lead to undesired milk production and impairment of egg recruitment and development.

7. Androgens- are male hormones that are normally produced by women in small amount. Excess production of these hormones can impair egg development.

Hysterosalpingogram- The HSG is performed to assess the internal anatomy of the tubes and the uterus.  A special dye that glows under X-Ray is injected into the cervix while the pelvis is being X-rayed. The dye outlines the contour of the uterine cavity and will show abnormalities within the uterus. The dye then follows the tubes and spills into the pelvic cavity if the tubes are open. The test can sometime cause cramping that can close the tubes at their insertion into the uterus, leading to a false impression of tubal occlusion. Because it outlines only the internal surfaces of the uterus and tubes, the HSG cannot diagnose external pelvic abnormalities such as endometriosis and adhesions. The test is usually performed after the cessation of menses ( on day 7-10). An antibiotic (Doxycycline) is taken 1-2 days prior the HSG to prevent infection.

Sonograms- A lot of information on egg development can be obtained by performing vaginal ultrasound at different parts of the cycle. A sonogram done at the beginning of the cycle (day 2-3) can give an indication of the egg reserve. A normal ovary should have at least 5 immature (antral) follicles at baseline. Finding of small ovaries with few antral follicles indicates low egg reserve. In addition, exhausted ovaries also tend to have cysts, probably due to the stimulatory effect of high baseline FSH level. A sonogram performed at midcyle (day 13-14) can assess the growth of the follicle and the endometrium. The average diameter of the follicle should be at least 18 mm, and the uterine lining should be at least 7 mm at this time. Smaller follicle means suboptimal egg development and indicates a need for medications.

Hysteroscopy- In this procedure a small camera attached to a thin scope is introduced into the cervix to inspect the uterine cavity. The examination can be performed easily in the office taking only 10 minutes. It is performed to confirm suspicious findings by the HSG.

Laparoscopy- is usually deferred as the last step in the infertility investigation due to the risks associated with surgery and anesthesia. Under general anesthesia a fiberoptic scope is inserted into the abdominal cavity via small incisions to allow examination of the pelvic and abdominal organs. Laparoscopy is used to diagnose endometriosis and pelvic adhesions, findings not detectable by the HSG. Often abnormalities found can be corrected in the same setting.