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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 Aroutine 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. As will be discussed later, 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.

Ovulation
There are many ways to evaluate ovulation. The simplest of these is the basal body temperature (BBT) chart. This is an inexpensive, noninvasive, and relatively easy test. Using a specialized thermometer, the woman takes her temperature every morning before getting out of bed or doing anything, and then records it on a special chart.

If BBTs are recorded for a couple of months, they will provide the physician with important information about the cycles. BBTs will demonstrate clearly not only the length of the cycles, and their regularity, but also the approximate time of ovulation and the length of the second half of the cycle.

There are several aspects of BBTs that are important to remember:
1. Don't try to interpret them yourself, especially day to day. It will drive you crazy trying to make sense of the changes. Temperature charts really only make sense when looked at in terms of the entire cycle.

2. Don't use temperatures to predict ovulation. The temperature goes up after you ovulateConce the temperature goes up it is too late to have intercourse in hopes of getting pregnant. You may hear that there is a drop in the temperature at the time of ovulation and that this can be used to time intercourse. Well, sometimes there is and sometimes there isn't, but it certainly isn't reliable enough to use to time intercourse. (Ovulation predictors work much better.)

3. Don't record BBTs for too long. A couple of cycles is usually enough unless the physician wants to evaluate the response to a change in medications. Infertility is difficult enoughCthe last thing you need is a daily reminder in the form of a thermometer in your mouth the first thing when you wake up every morning.

4. If you forget a couple of days, don't worry. Just record as many days as you can.

5. Record any information on the chart you think may be worthwhile.

6. After a couple of months, sit down with your physician and review the charts.

There are also many brands of ovulation predictors sold over the counter. Most of these are very simple to perform, one-step tests that you do at home. All of these tests function by identifying large amounts of the hormone LH in the urine. (LH is the trigger of ovulation and rises significantly twenty-four to thirty-six hours before ovulation.) These are reliable tests and are good predictors of ovulation. They can be helpful not only for timing intercourse, but also for providing additional information when coupled with a BBT chart.

The Postcoital Test
The cervical mucus thins out just prior to ovulation and actually facilitates the transfer of the sperm to the uterus. The postcoital test (PCT ) is a good way to evaluate not only the cervical mucus, but also the interaction of the sperm and the mucus. This test must be performed right around the time of ovulation. It cannot be performed more than a couple of days before ovulation, nor after ovulation, as the cervical mucus will be too thick for this test to be meaningful.
Following intercourse, a sample of cervical mucus is gently removed from the cervix at the time of a normal pelvic exam and evaluated microscopically. The quality of the cervical mucus as well as the number of sperm present and their motility can all be checked. While it is often stated that this test must be performed within two hours of intercourse, it can actually be checked as many as twelve to fourteen hours after intercourse (do not douche or take a bath, but showers are okay) as long as the physician is informed of the time. If properly timed, this test reveals a great deal about the adequacy of the cervical mucus production, the survivability of the sperm in the cervical mucus, and the interaction of the sperm and the cervical mucus.

Evaluating The Fallopian Tubes
There are basically two techniques available for evaluating the fallopian tubes: a hysterosalpingogram and a laparoscopy.

Hysterosalpingogram (HSG)
A hysterosalpingogram (HSG) is an X?ray procedure that does not require any anesthesia and can be performed in just a few minutes. It is performed at the time in the cycle after the period stops but before ovulation occurs. A regular speculum exam is performed in the X?ray department, and a small instrument is attached to the cervix. A special X?ray dye is then injected through the cervix, up into the uterus, and out into the fallopian tubes. This procedure allows visualization of the uterine cavity and of the fallopian tubes. If the tubes are open, the dye can be seen spilling into the abdominal cavity.
The advantages of the HSG include the fact that it is a nonsurgical procedure, does not require anesthesia, and is relatively inexpensive. A further advantage is the fact that if oil-soluble dye is used, pregnancy rates after a HSG are actually increased, thus rendering it therapeutic as well as diagnostic. (HSG can be performed using water-soluble contrast material or oil-soluble contrast material; postprocedure enhancement of conception rates has been demonstrated only following the use of oil-soluble contrast material.) The biggest disadvantage of the HSG is the inability to visualize other pelvic structures. Only the interior of the tubes and uterus can be seen, and thus adhesions, endometriosis, or other problems lying outside the tubes and uterine cavity may go undetected.

Laparoscopy
Laparoscopy is an outpatient surgical procedure performed under general anesthesia, although microinstruments are now available that allow this procedure to also be performed in the office under local anesthesia. A small telescopelike instrument is inserted into the abdominal cavity just beneath the umbilicus (navel). This allows visualization of the abdominal contents in their entirety, including the ovaries, tubes, uterus and the surrounding structures. Additional small incisions may be placed in the abdominal wall to allow insertion of specially designed instruments, including lasers.

Laparoscopy does not need to be a purely diagnostic procedure. Many physicians performing laparoscopic surgery have the ability to correct virtually any abnormality that they may encounter. Laparoscopy should probably be done each and every time as a potentially operative and therapeutic procedure. Find out if your physician has the ability to treat endometriosis, remove adhesions, correct tubal blockage and remove ovarian cysts through the laparoscope. Some surgeons prefer to do laparoscopy as a purely diagnostic procedure and then do major surgery to correct abnormalities they may encounter. While both approaches are equally effective, the latter has the disadvantage of requiring two surgeries and being significantly more expensive.
The biggest advantage of laparoscopy over the HSG is its potential for surgical correction of abnormalities. It does also allow direct visualization of the abdominal contents. The disadvantages of laparoscopy include the fact that it is invasive, requires general anesthesia, and is vastly more expensive than an HSG.

The decision as to which of these procedures should be used to evaluate the tubes must again be based on the individual circumstances. The findings on a pelvic exam must be considered. If there is significant, palpable endometriosis, or especially if ovarian endometriosis is noted on ultrasound, then laparoscopy may be indicated. Similarly, if the chlamydia titer is high suggesting prior infection, if there is a history of prior infection, or if there has been previous pelvic surgery, then laparoscopy must be considered. Note that these are all specific indications for proceeding with a laparoscopy. There should be a very specific reason for choosing laparoscopy over HSG. If there is not some specific indication for doing a laparoscopy, then the HSG is the procedure of choice for tubal evaluation. In the following sections, we will look at each step in the evaluation process in more detail and begin to see how these steps suggest which interventions may be worthwhile. The evaluation process must always be dynamic and ongoing. In up to forty percent of couples, more than one factor contributes to their difficulty conceiving. It should not be presumed that because one factor has been discovered there may not be another factor that may be equally or more important.