Don’t perform routine diagnostic laparoscopy for the evaluation of unexplained infertility.
In patients undergoing evaluation for infertility, routine diagnostic laparoscopy should not be performed unless there is a suspicion of pelvic pathology based on clinical history, an abnormal pelvic exam or abnormalities identified with less invasive testing. In patients with a normal hysterosalpingogram or the presence of a unilaterally patent tube, diagnostic laparoscopy typically will not change the initial recommendation for treatment.
Don’t perform advanced sperm function testing, such as sperm penetration or hemizona assays, in the initial evaluation of the infertile couple.
Studies document that extreme variability exists among these tests, with very little correlation between results and outcomes. They have also been shown not to be cost-effective and often lead to more expensive treatments.
Don’t perform a postcoital test (PCT) for the evaluation of infertility.
The PCT suffers from poor reproducibility and its predictive value for pregnancy is no better than chance. Utilizing the PCT leads to more tests and treatments but yields no improvement in cumulative pregnancy rates.
Don’t routinely order thrombophilia testing on patients undergoing a routine infertility evaluation.
There is no indication to order these tests, and there is no benefit to be derived in obtaining them in someone that does not have any history of bleeding or abnormal clotting and in the absence of any family history. This testing is not a part of the infertility workup. Furthermore, the testing is costly, and there are risks associated with the proposed treatments, which would also not be indicated in this routine population.
Don’t perform immunological testing as part of the routine infertility evaluation.
Diagnostic testing of infertility requires evaluation of factors involving ovulation, fallopian tube patency and spermatogenesis based upon clinical history. Although immunological factors may influence early embryo implantation, routine immunological testing of couples with infertility is expensive and does not predict pregnancy outcome.
Don’t obtain a karyotype as part of the initial evaluation for amenorrhea.
Amenorrhea is the absence of menstruation and can be attributed to many causes. A karyotype (chromosomal analysis) is not indicated as an initial test for amenorrhea as it is not a screening test. However, it is indicated to further evaluate the etiology of an elevated follicle-stimulating hormone (FSH) in a woman under 40 years of age or in the presence of physical findings suggestive of disorders of sexual development.
Don’t prescribe testosterone or testosterone products to men contemplating/attempting to initiate pregnancy.
Testosterone therapy is widely used as treatment for hypoandrogenemia and associated symptoms such as sexual dysfunction. However, it is well established that exogenous testosterone and other androgens can lead to decreased or absent sperm production, low sperm count, and infertility. Furthermore, this is not always reversible, even after removing the exogenous androgens.
Don’t obtain follicle-stimulating hormone (FSH) levels in women in their 40s to identify the menopausal transition as a cause of irregular or abnormal menstrual bleeding.
Menstrual bleeding patterns for women after age 40 are less predictable than in the younger years due to the normal menopausal transition. Menopause is defined as the absence of menstrual periods for one year when no other cause can be identified (it is often accompanied by symptoms such as hot flashes and night sweats). During this time, blood levels of FSH vary both from woman to woman and from day to day in the same woman. An FSH level does not predict when the transition to menopause will occur, diagnose that it has begun or provide reassurance that contraception is no longer necessary. If there are no other causes of irregular or abnormal bleeding, the treatment for these women will not change based on the FSH level.
Don’t perform endometrial biopsy in the routine evaluation of infertility.
Endometrial biopsy performed for histologic dating does not distinguish fertile from infertile women. Chronic endometritis on endometrial biopsy does not predict the likelihood of pregnancy in general nor is it associated with live birth rates in assisted reproductive technology cycles. Endometrial biopsy should not be utilized in the routine evaluation of infertility.
Don’t perform prolactin testing as part of the routine infertility evaluation in women with regular menses.
It has become common practice to obtain prolactin levels in the routine infertility evaluation. However, there is no reason to expect that a woman would exhibit clinically significant, elevated prolactin levels in the presence of normal menstrual cycles and without galactorrhea (milk discharge from breast). Therefore, serum testing of prolactin levels in a normally menstruating woman without galactorrhea provides no benefit and would not impact clinical management.
These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.
The American Society for Reproductive Medicine (ASRM) is a multidisciplinary organization dedicated to the advancement of the art, science and practice of reproductive medicine. The Society accomplishes its mission through the pursuit of excellence in education and research and through advocacy on behalf of patients, physicians and affiliated health care providers. The Society is committed to facilitating and sponsoring educational activities for the lay public and continuing medical education activities for professionals who are engaged in the practice of and research in reproductive medicine.
For more information about ASRM, visit www.asrm.org.
The Practice Committee of the American Society for Reproductive Medicine (ASRM) reviewed evidence from ASRM’s practice documents to identify possible topics along with suggestions for possible topics from the ASRM Board of Directors. By consensus, the Practice Committee narrowed the list to the top five most overused tests within specified parameters. Additional input was sought from the ASRM Board of Directors and incorporated. The final list was reviewed and approved by the ASRM Board of Directors. The ASRM Board of Directors and Practice Committee are comprised of representatives from every aspect of reproductive medicine through our five affiliated societies including the Society for Assisted Reproductive Technology, the Society of Reproductive Surgeons, the Society for Reproductive Endocrinology and Infertility, the Society for Male Reproduction and Urology and the Society of Reproductive Biologists and Technologists.
ASRM’s disclosure and conflict of interest policy can be found at www.asrm.org.
Pavone ME, Hirshfeld-Cytron JE, Kazer RR. The progressive simplification of the infertility evaluation. Obstet Gynecol Surv. 2011 Jan;66(1):31–41.
Lavy Y, Lev-Sagie A, Holtzer H, Revel A, Hurwitz A. Should laparoscopy be a mandatory component of the infertility evaluation in infertile women with normal hysterosalpingogram or suspected unilateral distal tubal pathology? Eur J Obstet Gynecol Reprod Biol. 2004 May 10;114(1):64–8.
Badawy A, Khiary M, Ragab A, Hassan M, Sherif L. Laparoscopy – or not – for management of unexplained infertility. J Obstet Gynaecol. 2010;30(7):712–5.
Bosteels J, Van Herendael B, Weyers S, D’Hooghe T. The position of diagnostic laparoscopy in current fertility practice. Hum Reprod Update. 2007 Sep-Oct;13(5):477–85.
Male Infertility Best Practice Policy Committee of the American Urological Association; Practice Committee of the American Society for Reproductive Medicine. Report on optimal evaluation of the infertile male. Fertil Steril. 2004; 82(suppl 1):S123–S130 (updated 2010).
Oei SG, Helmerhorst FM, Keirse MJ. Routine postcoital testing is unnecessary. Hum Reprod. 2001;16:1051–3.
Leushuis E, van der Steeg JW, Steures P, Koks C, Oosterhuis J, Bourdrez P, Bossuyt PM, van der Veen F, Mol BW, Hompes PG. CECERM study group. Prognostic value of the postcoital test for spontaneous pregnancy. Fertil Steril. 2011;95:2050–5.
Oei SG, Helmerhorst FM, Keirse MJ. Routine postcoital testing is unnecessary. Hum Reprod. 2001;16:1051–3.
Oei SG, Helmerhorst FM, Bloemenkamp KW, Meerpoel DEM, Keirse MJNC. Effectiveness of the postcoital test: randomised controlled trial. BMJ. 1998;317:502–5.
Glatstein IZ, Best CL, Palumbo A, Sleeper LA, Friedman A, Hornstein MD. The reproducibility of the postcoital test: a prospective study. Obstet Gynecol. 1995;85:396–400.
Griffith CS, Grimes DA. The validity of the postcoital test. Am J Obstet Gynecol. 1990;162:615–20.
Collins JA, So Y, Wilson EH, Wrixon W, Casper RF. The postcoital test as a predictor of pregnancy among 355 infertile couples. Fertil Steril. 1984;41:703–8.
Lockwood C, Wendel G; Committee on Practice Bulletins— Obstetrics. Practice bulletin no. 124: inherited thrombophilias in pregnancy. Obstet Gynecol. 2011 Sept;118(3):730–40.
Casadei L, Puca F, Privitera L, Zamaro V, Emidi E. Inherited thrombophilia in infertile women: implication in unexplained infertility. Fertil Steril. 2010 Jul;94(2):755–7.
The Practice Committee of the American Society for Reproductive Medicine. Diagnostic evaluation of the infertile female: a committee opinion. Fertil Steril. 2012 Aug;98:302–7.
Baglin T, Gray E, Greaves M, Hunt B, Keeling D, Machin S, Mackie I, Makris M, Nokes T, Perry D, Talt RC, Walker I, Watson H. Clinical guidelines for testing for heritable thrombophilia. Br J Haematol. 2010;149:209–20.
Cervera R, Balasch J. Bidirectional effects on autoimmunity and reproduction. Hum Reprod. 2008;14:359–66.
Carp HJA, Selmi C, Shoenfel Y. The autoimmune bases of infertility and pregnancy loss. J Autoimmun. 2012;38:J266–74.
Baker VL. Primary ovarian insufficiency in the adolescent. Curr Opin Obstet Gynecol. 2013 Oct;25(5):375-81.
Nelson LM, Covington SN, Rebar RW. An update: spontaneous premature ovarian failure is not an early menopause. Fertil Steril. 2005 May;83(5):1327–32.
Bachmann GA, Kemmann E. Prevalence of oligomenorrhea and amenorrhea in a college population. Am J Obstet Gynecol. 1982 Sep 1;144(1):98–102.
Reindollar RH, Byrd JR, McDonough PG. Delayed sexual development: a study of 252 patients. Am J Obstet Gynecol. 1981 Jun 15;140(4):371–80.
Reindollar RH, Novak M, Tho SP, McDonough PG. Adult-onset amenorrhea: a study of 262 patients. Am J Obstet Gynecol. 1986 Sep;155(3):531–43.
Klein DA, Poth MA. Amenorrhea: an approach to diagnosis and management. Am Fam Physician. 2013 Jun 1;87(11):781–8.
Amory JK. Progress and prospects in male hormonal contraception. Curr Opin Endocrinol Diabetes Obes. 2008 Jun;15(3):255–60.
Gu Y, Liang X, Wu W, Liu M, Song S, Cheng L, Bo L, Xiong C, Wang X, Liu X, Peng L, Yao K. Multicenter contraceptive efficacy trial of injectable testosterone undecanoate in Chinese men. J Clin Endocrinol Metab. 2009;94(6):1910–5.
Moss JL, Crosnoe LE, Kim ED. Effect of rejuvenation hormones on spermatogenesis. Fertil Steril. 2013 jun;99(7):1814–20.
Paramsothy P, Harlow SD, Greendale GA, Gold EB, Crawford SL, Elliott MR, Lisabeth LD, Randolph JF Jr. Bleeding patterns during the menopausal transition in the multi-ethnic Study of Women’s Health Across the Nation (SWAN): a prospective cohort study. BJOG. 2014 Nov;121(12):1564–73.
Harlow SD, Lin X, Ho MJ. Analysis of menstrual diary data across the reproductive life span applicability of the bipartite model approach and the importance of within-woman variance. J Clin Epidemiol. 2000 Jul;53(7):722–33.
Treloar AE, Boynton RE, Behn BG, Brown BW. Variation of the human menstrual cycle through reproductive life. Int J Fertil. 1967 Jan-Mar;12(1 Pt 2):77–126.
Vollman RF. The degree of variability of the length of the menstrual cycle in correlation with age of woman. Gynaecologia. 1956 Nov;142(5):310–4.
Burger HG, Hale GE, Robertson DM, Dennerstein L. A review of hormonal changes during the menopausal transition: focus on findings from the Melbourne Women’s Midlife Health Project. Hum Reprod Update. 2007 Nov–Dec;13(6):559–65.
Burger HG. Diagnostic role of follicle-stimulating hormone (FSH) measurements during the menopausal transition–an analysis of FSH, oestradiol and inhibin. Eur J Endocrinol. 1994 Jan;130(1):38-42.
Coutifaris C, Myers ER, Guzick DS, Diamond MP, Carson SA, Legro RS, et al; NICHD National Cooperative Reproductive Medicine Network. Histological dating of timed endometrial biopsy tissue is not related to fertility status. Fertil Steril 2004 Nov;82(5):1264-72.
Murray MJ, Meyer WR, Zaino RJ, Lessey BA, Novotny DB, Ireland K, Zeng D, Fritz MA. A critical analysis of the accuracy, reproducibility, and clinical utility of histologic endometrial dating in fertile women. Fertil Steril. 2004 May;81(5):1333–43.
Batista MC, Cartledge TP, Merino MJ, Axiotis C, Platia MP, Merriam GR, Loriaux DL, Nieman LK. Midluteal phase endometrial biopsy does not accurately predict luteal function. Fertil Steril. 1993 Feb;59(2):294–300.
Gibson M. Clinical evaluation of luteal function. Semin Reprod Endocrinol. 1990;8:130–41.
Dockery P, Li TC, Rogers AW, Cooke ID, Lenton EA, Warren MA. An examination of the variation in timed endometrial biopsies. Hum Reprod. 1988 Aug;3(6):715–20.
Kasius JC, Fatemi HM, Bourgain C, Sie-Go DM, Eijkemans RJ, Fauser BC, Devroey P, Broekmans FJ. The impact of chronic endometritis on reproductive outcome.Fertil Steril. 2011 Dec;96(6):1451–6.
Haggerty C, Ness RB, Amortegui A, Hendrix SL, Hillier SL, Holley RL, Peipert J, Randall H, Sondheimer SJ, Soper DE, Sweet RL, Trucco G. Endometritis does not predict reproductive morbidity after pelvic inflammatory disease. Am J Obstet Gynecol. 2003 Jan;188(1):141–8.
Glazener CM, Kelly NJ, Hull MG. Prolactin measurement in the investigation of infertility in women with a normal menstrual cycle. Br J Obstet Gynaecol. 1987 Jun;94(6):535–8.
Kostrzak A, Warenik-Szymankiewicz A, Meczekalski B. The role of serum PRL bioactivity evaluation in hyperprolactinaemic women with different menstrual disorders. Gynecol Endocrinol. 2009 Dec;25(12):799–806.