What initial investigations should I perform for a woman presenting with primary infertility?

Initial investigations for a woman presenting with primary infertility include:

• Taking a detailed history including menstrual cycle frequency and regularity to assess ovulation status. Women with regular cycles are likely ovulating but should still have confirmation.
• Offering a blood test to measure serum progesterone in the mid-luteal phase (day 21 of a 28-day cycle) to confirm ovulation, even if menstrual cycles are regular.
• For women with prolonged or irregular menstrual cycles, serum progesterone should be measured later in the cycle and possibly repeated weekly until the next period.
• Women with irregular cycles should have serum gonadotrophins measured, specifically follicle-stimulating hormone (FSH) and luteinising hormone (LH).
• Routine prolactin measurement is not recommended unless there is an ovulatory disorder, galactorrhoea, or pituitary tumour.
• Routine thyroid function tests are not recommended unless symptoms of thyroid disease are present.
• Hysterosalpingography (HSG) should be offered to screen for tubal occlusion in women without known comorbidities such as pelvic inflammatory disease, previous ectopic pregnancy, or endometriosis.
• Where expertise is available, hysterosalpingo-contrast-ultrasonography may be considered as an alternative to HSG.
• Women with suspected comorbidities should be offered laparoscopy and dye to assess tubal and pelvic pathology.

These investigations should be performed alongside assessment of the male partner, including semen analysis, as part of the initial infertility workup.

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