The basic fertility work up in who class II anovulatory women; usefull or redundant? A systematic review

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OBJECTIVE: The first line treatment in WHO class II anovulatory patients is clomiphene citrate (CC). Once women become ovulatory after previous anovulation, there is a tendency to start a basic fertility work-up. However, one could hypothesize that in the presence of anovulation, which is an explanation per se for infertility, the prevalence of other causes of subfertility, may be decreased in comparison to patients suffering from subfertility for more than a year. DESIGN: We performed a systematic review to summarize the best available evidence regarding the value of a basic fertility work-up in WHO class II women once ovulatory on CC. MATERIALS AND METHODS: A literature search in MEDLINE, Embase and Cochrane library was performed to assess the potential value of basic fertility work up, including a semen-analysis, postcoital test, Chlamydia antibody titre, hysterosalpingography and diagnostic laparoscopy. RESULTS: We could identify only four studies. A prospective cohort study described the Chlamydia antibody titre. The sensitivity of the test to detect bilateral tubal pathology was 9% and the specificity 96%. A second and third study from 1983 and 1984 reported about the semen analysis, post coital test and tubal tests. Only a part of the population of interest was tested, follow up for pregnancy rates were lacking or total performed tests was unknown and the group size was small which made it impossible to draw conclusions. A fourth prospective follow up study was performed to identify parameters which could predict conception, but no significant predictors in the fertility work up were found. CONCLUSIONS: The present review shows there is no evidence to perform a basic fertility work up the women described and does not allow us to give firm recommendations. Routine use of these tests in these women might lead to unnecessary treatment. Effort should be focussed on studies on this subject, in stead of performing non-validated tests on a non-research setting.