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Evaluating the Female
Female evaluation should also begin with a history and physical. Important aspects of the history include: 1) a complete gynecologic history, concentrating on the regularity and nature of the menstrual cycles, 2) a history of prior surgical procedures or pelvic infections, 3) prior pregnancies and the outcomes and complications thereof, 4) any dysmenorrhea, or pain with the periods, and the nature and history of that pain, and 5) the frequency of sexual intercourse, and any pain or problems associated therewith. A thorough history will also include a general medical history, including other illnesses or problems, smoking or drug use, and medications.
The physical exam should include an evaluation of the breasts, checking both for abnormalities and for discharge. A careful pelvic exam should also be performed. The ovaries and uterus can be carefully checked, with special attention to any findings that may suggest the presence of endometriosis. A pelvic ultrasound is also worthwhile in that it allows the physician to see the ovaries and uterus and further ensures that no abnormalities are present.
Prolactin Level, Chlamydia Titer, and TSH
There should be no such thing as a "routine infertility panel" when it comes to blood tests. All testing should be individualized to the couple and dictated by the findings at the time of the history and physical. There are, however, a couple of tests that are almost always worthwhile: a prolactin level and a chlamydia titer. Prolactin is a pituitary hormone that controls breast milk production. It can be slightly to moderately elevated without causing any symptoms such as breast discharge. However, even slight elevations of prolactin can have significant effects on the menstrual cycles and thereby make it much harder if not impossible to conceive. If cycles are anything but perfectly normal, prolactin should be checked.
Chlamydia is an infectious organism that is sexually transmitted. Chlamydia can cause severe damage to the fallopian tubes without causing pain, fever, or any other symptoms. The Centers for Disease Control considers chlamydia an epidemic. Therefore, since it is so widespread and since a woman may never know she has had it, this needs to be checked. A chlamydia culture can be performed which will detect an ongoing infection, but a better test is a chlamydia titer. A chlamydia titer is a blood test that will detect any prior exposure to chlamydia. If prior exposure is detected, and either partner is symptomatic or has a positive culture, both partners should be treated with a course of an appropriate antibiotic. This eliminates concerns about ongoing infection. The results of the chlamydia titer will dictate the procedure chosen for evaluation of the fallopian tubes.
Thyroid disturbances can also result in alterations of the menstrual cycles. TSH (thyroid-stimulating hormone) is the pituitary hormone that regulates the functioning of the thyroid gland. If the cycles are anything but perfectly normal, TSH should also be checked. If there is any abnormality of thyroid function, it will be reflected by this single test. An entire thyroid panel is necessary only if an abnormality of TSH is detected.