Female Fertility Assessment Guidelines

Hormonal Assessment

The American College of Radiology recommends ovarian reserve testing using anti-Müllerian hormone (AMH) as the most reliable marker, which should be measured regardless of cycle day 1, 2
The Centers for Disease Control and Prevention recommends midluteal phase progesterone (day 21 of a 28-day cycle) to confirm ovulation 3
The American College of Radiology suggests follicle-stimulating hormone (FSH) and luteinizing hormone (LH) measured on cycle day 2-3 to assess ovarian reserve and pituitary function 2
The American Academy of Family Physicians recommends thyroid-stimulating hormone (TSH) to rule out thyroid disorders that can affect fertility 4, 5

The Centers for Disease Control and Prevention recommends testing for chlamydia, gonorrhea, syphilis, and HIV 3
The American Academy of Family Physicians recommends rubella seronegativity screening with vaccination if indicated 4
The Centers for Disease Control and Prevention suggests hepatitis B surface antigen testing 3

The American Academy of Family Physicians recommends a complete blood count (CBC) to identify anemia or other hematologic abnormalities that could impact fertility 4, 3

The American College of Radiology suggests that fertility assessment should include not only laboratory tests but also imaging studies such as transvaginal ultrasound to evaluate ovarian morphology and hysterosalpingography to assess tubal patency 1, 2
The American Academy of Family Physicians recommends consideration of additional testing for androgen levels, glucose tolerance, and insulin resistance in women with irregular cycles or suspected polycystic ovary syndrome (PCOS) 1
The American College of Radiology suggests that laparoscopy may be required for definitive diagnosis in women with suspected endometriosis 2
The American Academy of Family Physicians recommends consideration of karyotyping and thrombophilia testing in women with recurrent pregnancy loss 4

AMH levels may fluctuate throughout the menstrual cycle, particularly in women under 25 years, requiring cautious interpretation in younger patients 6

Transvaginal ultrasound can be used to evaluate ovarian morphology, measure ovarian volume, and perform antral follicle counts, with ovarian volume <3 cm³ and <5 antral follicles suggesting diminished ovarian reserve 7
The American College of Radiology recommends transvaginal ultrasound for evaluating ovarian morphology and measuring ovarian volume, with findings such as ovarian volume <3 cm³ and <5 antral follicles indicating diminished ovarian reserve 8
Laparoscopy may be required for definitive diagnosis in women with suspected endometriosis, as imaging may miss small implants, according to the Journal of the American College of Radiology 7

When ovarian volume is less than 3 cm³ and fewer than 5 antral follicles are present, this indicates diminished ovarian reserve, which is a significant concern for fertility potential 9, 10
A single follicle is a primary diagnostic consideration for diminished ovarian reserve, as it falls below the threshold of 5 antral follicles 9, 10
Diminished ovarian reserve is distinctly different from polycystic ovarian morphology, which requires 20 or more follicles per ovary or an ovarian volume greater than 10 mL 9, 10

Document the exact ovarian volume in cubic centimeters for both ovaries, as volume less than 3 cm³ combined with a low follicle count confirms diminished reserve 9, 10
Ensure the ultrasound was performed with an 8 MHz or higher frequency transvaginal transducer for accurate follicle detection 10, 11
Consider repeat ultrasound in the early follicular phase if the initial scan was performed at a suboptimal time in the cycle 9

Consider hysterosalpingography to assess tubal patency if the patient is actively pursuing pregnancy 9, 12
If ovaries cannot be adequately visualized by transvaginal ultrasound, obtain an MRI pelvis without IV contrast to accurately assess ovarian volume and follicle counts 9, 10

Do not assume a single follicle with low ovarian volume represents normal ovarian function during a particular cycle phase, as this is pathologic regardless of cycle timing 9, 10
The American College of Radiology recommends that a single follicle on transvaginal ultrasound in a reproductive-age woman suggests diminished ovarian reserve and requires immediate hormonal assessment 9, 10