What is infertility ?

Inability of a couple to conceive after a

minimum of a year of unprotected sex.
Diagnostic testing should be done only
after 1 yr.

When to investigate within a year ?
When there is a female >35
History of male factor infertility
Endometriosis
A tubal factor
DES exposure
PID
Pelvic surgery
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Goals Of Conducting Investigations
To identify and correct the cause
contributing to infertility
Provide accurate information
Counseling about alternatives if pregnancy
fails or is not possible

Evaluation includes:
History
Clinical Examination
Specific Investigations
Investigations for male infertility

Semen analysis
Post Coital test
Sperm penetration test
Testicular biopsy
Ultrasound
FSH level
Chromosomal study
Immunological study

Investigations for
male infertility
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Semen Analysis
Cornerstone of the male infertility workup.
A specimen is collected by masturbation in a
clean,dry,sterile container or during coitus using
special condoms(which have no spermicidal
lubricants).
Patient should be abstinent for 2-3 days prior.
Sample should be processed within 1 hr of
production.
2-3 samples at a minimum of 2-3 days apart
should be taken.
WHO criteria

Volume :- 2-5ml
PH :- 7.2-7.8
Sperm concentration :- > 20 million/ml
Count:- > 40 million
Motility :- >50% forward progressive
Morphology :- At least 4% normal using
Tygerberg Criteria
WBC :- Fewer than 1 million cells /microL





Compare with normal values to
detect :
Azoospermia( no sperm in semen)
Asthenospermia(sperm motility of <50%)
Necrospermia (dead sperm)
Teratospermia (abnormal morphology)
Oligospermia (<20 million sperm/ml)
Ejaculatory failure
Hypospermia(<2mL/ejaculation)
Hyperspermia(>8mL/ejaculation)

Spermatogenesis takes around 72 days.
Abnormal semen analysis results can be
attributed to various unknown reasons(short
period of abstinence, incomplete collection,
poor sexual stimulus).
Therefore, repeating the semen analysis at least 1
month later is important before a diagnosis is
made.
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Post Coital Test
Intercourse close to ovulation preferably in
early hours of morning.
The female presents herself at a clinic within
two hours of intercourse.
Cervical mucus is aspirated and spread over a
glass slide.
<10 motile sperm ~abnormal (Range10-50)
Abnormal results may
indicate
Poor timing
Hostile cervical mucus related to cervicitis (eg,
bacteria/yeast)
Low pH
Sperm antibodies
Poor technique during intercourse (eg, premature
ejaculation)
Undiagnosed male factor infertility
Anatomical defects (cervical cone
due to DES exposure in utero)

Sperm
Penetration Test
Used to study the
physiological profile
of the sperm.
It is studied in vitro by
using Zona free
hamster egg.

Testicular Biopsy
Indicated in case of
azoospermia to
distinguish between
testicular failure and
an obstruction in vas
deferens

USG
The scanning of
scrotum detects
scrotal volume and
presence of
hydrocoele, and is
useful for ultrasound
guided biopsy

FSH LEVELS:
High FSH - primary
gonadal failure
Low FSH - pituitary
or hypothalamic failure
Normal level but
azoospermic ~
obstruction in vas


CHROMOSOMAL STUDY:

Done in case of azoospermic men
15 to 20% of them have chromosomal
disorders
Most common disorder is Klinefelters
syndrome(47 XXY)

Immunological testing
Required in abnormal post coital test ,
abnormal sperm profile and
unexplained infertility
Used to detect sperm antibody in
seminal plasma and cervical mucus
Sperm agglutination test ,
immunoglobulin specific assays are
available to detect immunological
defects in semen.

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Stepwise approach to male
infertility
History and physical
Semen analysis
Assess Testosterone, LH, FSH
Consider Prolactin and TSH if LH,FSH
low/normal
Image pituitary if testosterone low and LH/FSH
low
Consider karyotyping if testosterone low and
FSH high

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Consider blockage of vas if testosterone is
normal and FSH normal and azoospermic
Consider special semen tests, genetic tests if
semen analysis normal and still infertile
Some will have normal evaluations and still have
unexplained infertility.
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Investigations for
female infertility
Investigations for female infertility
Assessment of ovarian function
Basal body temperature
Hormonal study
Endometrial biopsy
Fern test
Ovarian Reserve
Tubal and peritoneal factors
Laparoscopy
Hysterosalpingogram

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Cervical factors-Post Coital Test
Uterine Factors
Hysterosalpingogram
Ultrasongraphy
Saline Infusion Sonography
MRI
Hysteroscopy
Endometrial Biopsy

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Confirmation Of
Ovulation
The definitive proof is either
recovery of an ovum or pregnancy
itself.
1) Basal Body Temperature
It falls at time of ovulation by F.
In progesteronal half of cycle it slightly
raised above the preovulatory level(due
to its thermogenic action).
Oral temperature is considerably more
accurate.

2) Endometrial biopsy:
Involves curetting small pieces of endometrium
preferably 1 or 2 days before the onset of
menstruation
The material should be fixed immediately in
formalin /saline and submitted for histological
scrutiny.
Secretary changes prove that cycle is ovulatory
Corpus luteal phase defects can also be
diagnosed by this.

3) FERN TEST:

Cervical mucus is obtained by
platinum loop and spread
on a glass slide .
During oestrogenic phase it
shows characteristic pattern
of fern formation .
This ferning is due to
presence of NaCl in the
mucus secreted under effect of estrogen.

4) HORMONAL STUDY:

PROGESTERONE:
Its concentration rises after ovulation and
reaches a peak of 15 ng/ml.
<5 ng/ml indicates luteal phase defect.
LUTEINIZING HORMONE:
LH surge occurs 24 hours prior to
ovulation
LH >10 IU/L suggests polycystic ovaries

Ovarian Reserve
Most important indicator for prognosis along with age
of the female partner.
Most commonly evaluated by checking a cycle day 3
FSH(<10mIU/mL is normal) and estradiol level(<65
pg/mL is normal).
Others tests of ovarian reserve include antral follicle
counts,ovarian volume,inhibin B and antimullerian
hormone.
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Tests for tubal patency
These are done in preovulatory phase of
the menstrual cycle.
The tests are-
1. Hysterosalpingography
2. Laparoscopic Chromotubation
3. Sonosalpingography
4. Sonohysterogram

Hysterosalpingography
This is visualization of uterine cavity and fallopian
tube with the use of image intensifier in an x-ray
room using Acron tip catheter
It is performed between the end of menstural
period and ovulation(usually the 5 to 9 day of
cycle)
In this technique Radiopaque dye is injected
through cannula into uterine cavity
15 ml of medium is adequate to visualize the
uterine cavity and the tubes.
This examination also excludes congenital
abnormalities of the uterus.
This test should not be performed in :
Post ovulatory period
Presence of genital infection
Patients sensitive to iodine should use a
dye with a different base
Although HSG is of low
sensitivity(50%), its high specificity
makes it a useful screening
test for ruling in tubal obstruction.
In case of abnormal finding,
diagnostic laparoscopy with
dye transit is the procedure
of choice
Advantages
HSG is cheaper
Can be performed as an outpatient procedure
Although often painful has a low incidence of
complications
Laparoscopic chromotubation
In this we can visualize the pelvis ,fallopian tube and
ovaries
Here methylene blue is injected through the cervix
to visualize the free spill or absence of spill.
Helps to establish the patency of fallopian tube.
This also demonstrates the external condition of the
fallopian tube.
Peritubal adhesions and unusual endometriosis can
also be diagnosed.
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Laparoscopy is indicated as the last test
in the evaluation of infertility because of
the risks, the need for anesthesia, and
the operative cost.
The only exception is when a known
medical history directs attention to a
pelvic factor as the cause of infertility.
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Hysteroscopy

It is a method of direct visualization of the
endometrial cavity with help of optical devices,
video camera-enhanced images, and television
monitors
It is the definitive method for diagnosis and
treatment of intrauterine pathology
However, cost factor makes it second choice
after saline infusion sonography

Ultrasonography
USG of the pelvis is useful especially for ovary.
Transvaginal sonography is the method of choice
for women who are having ovulation induction

Sonosalpingography
(Sion test)
Used to evaluate tubal patency
200ml of saline is injected into the uterine
cavity under USG visualization
Then the flow of saline along the fallopian
tube is observed as it issues out as a shower at
the fimbrial end.
This scan also shows the presence of any free
fluid in the pouch of Douglas

Sonosalpingography should be performed
during cycle days 6-12 so that the endometrial is
thin, allowing better detection of intrauterine
lesions. This also ensures that an ongoing
pregnancy is not interfered with.
In case of a history of PID or genital tract
infection, antibiotics may be given before the
procedure.
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Stepwise evaluation Of
Female Infertility
(1)History and Examination
(2)Tests for ovulation-LH, Basal Temp,Serum
progesterone, TVS
(3)Uterus cavity and tube patency: TVS,HSG,Sion
Test,3-D USG,Laparoscopy
(4)Others: TSH,Prolactin
(5)Pregnancy is the only conclusive proof for
fertility.
References
Williams Textbook Of Gynecology
Dewhursts Textbook of Gynecology
WHO Laboratory Manual for The Examination of
Human Semen and Sperm Cervical Mucus
Interaction, Cambridge University Press
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