The work-up
| Question | Test |
|---|---|
| Is she ovulating? | Cycle history; mid-luteal progesterone; TSH, prolactin; AMH and antral follicle count for ovarian reserve (a predictor of response to stimulation, not of natural fertility) |
| Is the sperm normal? | Semen analysis (WHO reference limits); repeat if abnormal; refer for azoospermia |
| Are the tubes open and the cavity normal? | Hysterosalpingogram (or hysterosalpingo-contrast sonography); saline sonography or hysteroscopy for the cavity; laparoscopy when endometriosis or adhesions are suspected |
| Anything else? | Rubella immunity, cervical screening, folic acid, weight, smoking, alcohol, medications, genetic carrier screening where offered |
Treatment by cause
- Anovulation (PCOS): letrozole first line, clomiphene, gonadotrophins, laparoscopic ovarian drilling; weight management where relevant.
- Hypothalamic amenorrhoea: address energy balance and stress; pulsatile GnRH or gonadotrophins.
- Tubal factor: IVF; surgery for selected proximal or mild distal disease; salpingectomy for hydrosalpinx before IVF.
- Male factor: lifestyle, treat varicocele in selected cases, intrauterine insemination, IVF with intracytoplasmic sperm injection, donor sperm.
- Unexplained: expectant management in the young, then ovarian stimulation with intrauterine insemination, then IVF.
- Fertility preservation before gonadotoxic treatment: oocyte or embryo cryopreservation; sperm banking.
Left hydrosalpinx
Transvaginal, left adnexa. An elongated, tubular, fluid-filled structure with incomplete septa (the folded tube).
Open in the Ultrasound LabOn the modelFallopian tubesOvariesEndometrium