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CCCT should also be considered in women of any age with otherwise unexplained infertility, as approximately 30%will show abnormalities that adversely impact their prognosis with fertility treatment. A CCCT is performed as follows: After drawing a cycle day 3 FSH/E2, the patient begins taking 100mg of clomiphene per day on cycle days 5 through 9. On cycle day 10, the FSH only is repeated. The patient's prognosis is only as good as her worst FSH level. A level less than 10mIU/mL is normal. A level from10- 12.5mIU/mL predicts resistance to fertilitymedications and a diminished prognosis. At 12.5-15mIU/mL, the prognosis is poor but pregnancies do occur with aggressive treatment. Levels greater than 15mIU/mL indicate that fertility treatment with the patient's own eggs is not likely to succeed and that egg donation should be offered. Patients with any FSH level greater than 10mIU/mL should be referred to a reproductive endocrinologist for further evaluation. Othermarkers for ovarian reserve, such as antral follicle count, inhibin B levels and anti-mullerian hormone levels, are rarely indicated during the initial fertility work-up at the gynecologist's office. These tests are sometimes performed by reproductive specialists to clarify ovarian reserve status inmore complicated cases.


Tubal Patency The next step in the ovulatory patient is to confirm tubal patency. This has been done traditionally with the hysterosalpingogram(HSG) and nothing has really improved on this. This test should be done in the follicular phase of the cycle after bleeding has stopped and before possible ovulation. The ordering physician should personally review the films to confirmfindings of the study. Loculation of spill and tubal phimosis indicate that laparoscopymay be helpful. If large hydrosalpinges are identified, they should be clipped or removed laparoscopically prior to in vitro fertilization. Several large studies as well as a recentmetanalysis, have confirmed the pregnancy rates with IVF are reduced by half in the presence of hydrosalpinges and that the rates are normalized with salpingectomy. The exact etiology of the phenomenon is not known.


Confirmation of Ovulation Confirmation of ovulation is unlikely to be helpful in women when a careful history is consistent with ovulation. If there is doubt, a cycle day 21 progesterone with a level greater than 4 ng/mL is indicative of ovulation withmost conception cycles having levels greater than 10 ng/mL. Alternately, sonographic confirmation of follicle rupture with serial ultrasound can be performed.


Anovulatory Patients The apparently oligomenorrheic patient should have the cause of their anovulation evaluated thoroughly prior to the initiation of treatment. The initial physical examination should note the presence or absence of goiter, acanthosis nigricans, striae, normal secondary sexual characteristics, Turner's stigmata, galactorrhea, hirsuitismand abnormalities of the reproductive tract. Ultrasound should note the thickness of the endometrial lining as well as whether the ovaries are polycystic in nature. An endometrial biopsy should be considered if the uterine liningmeasures greater than 15mm.


Endocrine Evaluation In anovulatory patients, the initial laboratory evaluation should include randomlevels of FSH, LH, prolactin, TSH, DHEAS and testosterone. Insulin resistance should be considered in patients that have any of the following: obesity, hirsuitismor acanthosis nigricans on physical exam; polycystic ovaries on ultrasound;


N A N C Y K A U F M A N L C S W


THE RESOURCES LISTED IN THIS DIRECTORY ARE UNSCREENED AND SHOULD NOT BE VIEWED AS RECOMMENDATIONS OR ENDORSEMENTS, EITHER EXPRESS OR IMPLIED, BY THE AFA. 17


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