Diagnosing Infertility: The Female Workup, Step by Step

Clomiphene 50 mg twice daily from day 2 to day 6, plus HMG 150 IU on days 7 and 9. HMG is avoided in PCOS patients because of hyperstimulation risk; PCOS is diagnosed by an antral follicle count above 15 with a necklace pattern on ultrasound and a high AMH, which Dr. Pai called their gold-standard test. He also recommends AMH testing for daughters to check ovarian reserve, with egg freezing considered before age 35 if a woman is not yet married.

Most commonly amenorrhoea or very scanty periods, occasionally heavy bleeding. Diagnosis relies on TB-PCR and D&C with histopathology, but because PCR can be falsely negative, Dr. Pai prefers laparoscopy for direct visual confirmation, alongside a chest X-ray, palpation of cervical and groin lymph nodes, family history, sputum AFB testing on three consecutive days where indicated, interferon-gamma release assays and a Mantoux test. Treatment is AKT-4 for two months followed by AKT-2 continuation therapy, nine months in total, which must be completed fully to avoid multidrug-resistant TB; laparoscopy and hysteroscopy are repeated afterward before trying IUI, and IVF only if that fails.

WHO's pathway is stepwise: rule out anovulation with day-21 progesterone above 10 ng/ml, rule out tubal block with an HSG, rule out uterine factors with 2D or 3D ultrasound, and test semen; if all are normal, try timed intercourse with clomiphene for 3 to 6 months, then 2 to 3 cycles of IUI (up to 6 if needed), which Dr. Pai's practice sees succeed in about 30% of cases, before moving to IVF. He named failure to conceive as IVF's biggest drawback, though across three attempts roughly 80 to 90% of patients achieve pregnancy, and frozen-embryo banking means most repeat cycles no longer require re-stimulation. In his estimate, about 80% of patients never need IVF at all if laparoscopy, hysteroscopy, ultrasound and a competent IUI lab are available; only 20% require it.

Age is the dominant factor. Citing the US SART and UK HFEA registries, Dr. Pai gave approximate success rates by age band: under 35 about 40%, 35 to 37 roughly 35 to 40%, 37 to 39 about 25 to 30%, 39 to 41 about 15%, and over 41 about 5 to 10%, because genetic abnormality rates in eggs rise with age even when embryos form. Low ovarian reserve, with AMH sometimes as low as 0.3 to 0.4 ng/ml, is the other major factor; for patients who decline donor eggs, he tries platelet-rich plasma injected under ultrasound or laparoscopic guidance and, in some cases, stem-cell therapy, using the laparoscopy to also rule out genital tuberculosis, which can itself lower ovarian reserve.

This is usually a fungal infection, and both partners need treatment, along with lactobacillus supplements. Because a wet mount or culture can miss organisms such as Trichomonas, Chlamydia or Mycoplasma, Dr. Pai often gives combination therapy (an antifungal such as fluconazole plus an antibiotic such as azithromycin) with local clotrimazole cream, and screens for diabetes, since fungal infections are common in patients who are obese or diabetic.

Mid-luteal progesterone testing, drawn on day 21 of a 28-day cycle, confirms ovulation when the result is above 10 nanograms per ml.

TSH should be kept below 2.5 mIU per ml in infertility patients, tighter than the general population's normal threshold of 5, with a level above that calling for thyroxine to be added to the protocol. Prolactin above 20 nanograms per ml calls for bromocriptine or cabergoline.

An antral follicle count under 7 signals low ovarian reserve, 7 to 15 is normal, and above 15 combined with a necklace-pattern appearance on ultrasound points to PCOS. AMH follows the same pattern: below 1.5 nanograms per ml is poor reserve, 1.5 to 3.5 is normal, and above 3.5 is suggestive of PCOS.

HyCoSy involves injecting saline and watching it appear in the pouch of Douglas on transvaginal ultrasound, compared with hysterosalpingography, which injects 5 to 8 ml of radiopaque dye and uses X-rays. Saline is favoured over contrast media on cost grounds, since contrast adds expense without adding much diagnostic value.

The preferred option in that setting is saline infusion sonohysterography, using disposable balloon catheters that cost roughly 1,500 rupees, about 15 to 20 US dollars, rather than the older Rubin cannula. Where three-dimensional ultrasound is available, it is still recommended.