▸ Hysterosalpingogram. Schedule the test for day 6–12 to assess the structure and patency of the fallopian tubes.
▸ Midluteal serum progesterone levels. Timing is everything with this test, said Dr. Miller. “I see clinic after clinic after clinic … getting a day 21 progesterone [in a] patient with a 35-day cycle. You want to get that progesterone level a week after ovulation and a week prior to menstruation. Time it based on cycle length.”
▸ Clomiphene challenge test. Draw a day 3 FSH and estradiol, and order clomiphene citrate, 100 mg daily on days 5–9. Draw FSH again on day 10. A poor prognosis is associated with either an abnormal day 3 FSH or day 10 FSH, or if the sum of the day 3 and day 10 FSH is less than 26.
▸ Surgery. Consider with caution performing minimally invasive surgery to correct anatomic problems, scarring, adhesions, endometriosis, or fibroids, although the cost of surgery and the potential advantages of in vitro fertilization should be considered.
▸ Fertility drugs with insemination. If the woman's follicles do not develop to a mature size or her estrogen or progesterone levels are low, Dr. Miller considers several courses of clomiphene citrate at low doses (50 mg for 5 days on days 3–7 or days 5–9.) Ovulation will occur in 80%–85% of women, and over four cycles, 40% of women will become pregnant.
However, pregnancy rates are much lower in older patients.
“I can tell you that [40% pregnancy rate] does not happen in my 38-year-olds. I do not use this medication in women over 40. I feel that we are just wasting time.”
However, in well-selected young patients, the strategy is worth a try, since it is inexpensive, easy, and not associated with an unacceptable rate of multiple births.
“For a generalist, this is a safe drug to use for 3–4 cycles, particularly in younger patients. Then move that patient on,” Dr. Miller said.