Ovulatory Function Evaluation:

Menstrual history:

• In most ovulatory women, menstrual cycles are regular every 25–35 days with consistent flow characteristics, and consistent pattern of moliminal symptoms. A degree of variation is entirely normal. In infertile women although a history of regular menstruation strongly suggests normal ovulatory function an objective measure is warranted.
• Women with abnormal uterine bleeding, oligomenorrhea (infrequent periods), or amenorrhea (no periods) generally do not require specific diagnostic tests to establish a diagnosis of anovulation.

Serial basal body temperature (BBT) measurements:

• Is a simple and inexpensive method to track ovulation. Your basal body temperature is your body’s temperature at rest. After ovulation, your basal body temperature will shift up by at least four-tenths of a degree. If your temperature remains elevated for at least three days, you can be pretty sure that ovulation has occurred on the day before the temperature rise. Because the shift in temperature is so small, it’s important to take your temperature at the exact same time every morning, before you get up or move. Before you go to bed at night, place a thermometer within your reach by your bed. It’s very important that you can reach this thermometer without needing to get up or move around when you wake up. Getting out of bed, or even sitting up, will throw off your temperature and skew the results. You should take your temperature at the same time every morning, with no more than a 30 minute difference from morning to morning. When you wake up, reach for your thermometer and take your temperature. Do not get up to go to the bathroom, and don’t get up to turn off your alarm (keep that near-by). You can take your temperature orally or vaginally. Choose one and stick with it day to day. Take your temperature vaginally if you sleep with your mouth open. Follow the directions for your thermometer to get the best reading. If you’re using a mercury thermometer, make sure you leave it in place four or five minutes to get a final reading. (Be sure to shake the mercury thermometer down before you go to bed at night). After you take your temperature, write it down. Some BBT thermometers have a memory function. Keep a pen and paper by your bed so you can jot down your temperature and the time you woke up, until you have time to fill this information into your chart. You need to have slept at least four straight hours for your temperature to be accurate. Basal body temperature charting does not work for everyone.
• If you don’t notice a sustained rise in temperature, it doesn’t necessarily mean that you are not ovulating.
• While basal body temperature charting can pinpoint when ovulation occurred, it isn’t a good way to predict ovulation. Since you need to have sexual intercourse before ovulation if you want to get pregnant, you should look for other signs of ovulation so you can time sexual intercourse better.
• One way to predict ovulation is by tracking your cervical mucus.
• In cycles monitored with BBT, the period of highest fertility spans the seven days prior to the mid-cycle rise in BBT.
• Ovulatory cycles generally are associated with clearly biphasic BBT recordings. Some ovulatory women cannot document clearly biphasic BBT patterns.
• An-ovulatory cycles typically result in monophasic patterns.
• Grossly short luteal phases (<10 days of temperature elevation) may identify women with more subtle ovulatory dysfunction.
• The test cannot reliably define the time of ovulation and can become tedious.
• BBT is no longer considered the best or preferred method for evaluating ovulatory function for most infertile women.

Serum progesterone level:

• Obtained at the appropriate time in the cycle provides a reliable and objective measure of ovulatory function. A serum progesterone measurement should be obtained approximately one week before the expected onset of the next menses. A progesterone concentration more than 9.54 nmol/L provides presumptive but reliable evidence of recent ovulation. Higher values have been used commonly as a measure of the quality of luteal function (=31.8 nmol/L). This criterion is not reliable because corpus luteum progesterone secretion is pulsatile and serum concentrations may vary up to 7-fold within an interval of a few hours.

Urinary luteinizing hormone (LH) tests:

• Using various over the counter ovulation predictor kits can identify the mid-cycle LH surge that precedes ovulation by one to two days. Urinary LH detection provides indirect evidence of ovulation. It helps to define the interval of greatest fertility i.e. the day of the LH surge and the following two days. Midday or Evening Urinary LH particularly correlates well with the peak in serum LH.
• Accuracy, ease of use, and reliability vary among ovulation predictor kits, and testing may yield false positive and false negative results.

Endometrial Biopsy and Histology:

• Can demonstrate secretory change in endometrium due to action of progesterone and thus implies ovulation.
• Endometrium Dating using histologic criteria was the gold standard for evaluating the quality of luteal function and for diagnosis of luteal phase deficiency (LPD). Now Endometrium Dating is not a valid diagnostic method because it lacks both accuracy and precision and the test cannot distinguish fertile from infertile women. It is no longer recommended for the evaluation of ovulatory or luteal function in infertile women. It is indicated only in women strongly suspected to have specific endometrial pathology e.g., neoplasia or chronic endometritis.

Transvaginal ultrasound:

• Determines the size and number of developing follicles
• Provides presumptive evidence of ovulation and luteinization by demonstrating progressive follicular growth, sudden collapse of the pre-ovulatory follicle, a loss of clearly defined follicular margins, the appearance of internal echoes, and an increase in cul-de-sac fluid volume.
• Because of the associated cost and logistical demands, the method generally should be reserved for women in whom simpler methods fail to provide the necessary information and those receiving ovarian stimulation for purposes of ovulation induction.

Other Evaluations may be Indicated for An-Ovulatory Infertile Women.

• Serum thyroid-stimulating hormone (TSH) and prolactin
• Tests can identify thyroid disorders and/or hyperprolactinaemia, which may require specific treatment.

In women with amenorrhea, serum follicle-stimulating hormone (FSH) and estradiol measurements can distinguish

• Women with ovarian failure (high FSH,low estradiol), who may be candidates for oocyte donation, from
• Women with hypothalamic amenorrhea (low or normal FSH, low estradiol), who will require exogenous gonadotropin stimulation for ovulation induction.
• In an-ovulatory infertile women, failure to achieve pregnancy after three to six cycles of successful ovulation induction should be viewed as an indication to perform additional diagnostic evaluation or, if evaluation is complete, to consider alternative treatments.