infetility-Investigations for female partner.pptx

Investigations to be done in case of infertility of the female partner

1. Investigations for female partner

2. 1. Test of ovulation.(5) 2. Assessment of tubal patency. (4) 3. Hysterosalpingography. (4) 4. Semen analysis. (4) 5. Ovulation induction. (2) 6. Causes and treatment of male infertility. 7. Intrauterine insemination. (1) 8. Management of anovulation. (1) 9. Causes of infertility. (1) 10. Tubal factors in infertility. (1) 11. Evaluation of primary infertility. (1) Short Answers Long questions(10 marks) Previous year questions 1. Infertility x 7 2. Male infertility x 1

3. 1.Objectives to investigate1 2.History taking 3.Examination 4.Investigations- ovarian factors Tubal factors Uterine factors Cervical factors Index

4. „„ To detect the etiological factor(s) „„ To rectify the abnormality in an attempt to improve the fertility „„ To give assurance with explanation to the couple if no abnormality is detected . Objectives

5. When to investigate As per the definition, the infertile couple should be investigated after one year of regular unprotected intercourse with adequate frequency. The interval is however, shortened to 6 months after the age of 35 years of the woman and 40 years of the man. What to investigate? The basic investigations to be carried out are: (a) Semen analysis; (b) Confirmation of ovulation; (c) Confirmation of tubal patency.

6. History Age, duration of marriage, history of previous marriage with proven fertility if any, are to be noted. The surgical history should be directed especially towards abdominal or pelvic surgery. Menstrual history should be taken in details. Wide spectrum of abnormalities ranging from hypomenorrhea, oligomenorrhea to amenorrhea are associated with disturbed hypothalamo-pituitary ovarian axis. This may be either primary or secondary to adrenal or thyroid dysfunction.

7. Obstetric history Details of previous pregnancies, if any (indicates secondary infertility) H/o complications such as severe postpartum hemorrhage (PPH) and postabortal/puerperal sepsis (severe PPH can lead to Sheehan syndrome-postpartum pituitary necrosis) H/o any curettage done Personal history H/o alcohol, smoking and drug addiction Family history H/o infertility in siblings Family history of congenital anomalies and early menopause

8. Examination General, systemic and gynecological examinations are made to detect any abnormality which may hinder fertility. General examination must be thorough—special emphasis being given to obesity or marked reduction in weight (BMI). Hirsutism, acne, acanthosis nigricans or underdevelopment of secondary sex characters are to be noted. Physical features pertaining to endocrinopathies are carefully evaluated to detect features of polycystic ovary syndrome (PCOS) and galactorrhea. Systemic examination may accidentally detect such abnormalities like hypertension, organic heart disease, thyroid dysfunction, and other endocrinopathies.

9. „„ Speculum examination may reveal abnormal cervical discharge. The discharge is to be collected for Gram stain and culture. Cervical smear is taken as a screening procedure as a routine or in suspected cases. „„ Gynecological examination includes adequacy of hymenal opening, evidences of vaginal infections (C. trachomatis, Mycoplasma), uterine size, position and mobility, presence of unilateral or bilateral adnexal masses—tenderness and presence of nodules in the pouch of Douglas (POD).

10. (A) Diagnosis of ovulation (B) Diagnosis of tubal and peritoneal factors (C) Diagnosis of uterine pathology (D) Diagnosis of cervical pathology Investigations of the Female Partner

11. Ovarian dysfunctions (dysovulatory) commonly associated with infertility are: „„ Anovulation or oligo-ovulation (infrequent ovulation). „„ Luteal phase defect (LPD). „„ Luteinized unruptured follicle (LUF) . „„ Ovarian failure Ovarian factors:

12. The various methods used in practice to detect ovulation are grouped as follows „„ Indirect „„ Direct „„ Conclusive Diagnosis of Ovulation

13. Indirect

14. Menstrual history The following features in relation to menstruation are strong evidences of ovulation. „„ Regular normal menstrual loss between the age of 20–35. „„ Midmenstrual bleeding (spotting) or pain or excessive mucoid vaginal discharge (Mittelschmerz syndrome). „„ Features suggestive of premenstrual syndrome or primary dysmenorrhea .

15. Basal body temperature (BBT) Evaluation of peripheral or endorgan changes

16. Cervical Mucus Study Typical fern pattern appearance of cervical mucus. Disappearance of fern after 22nd day of the cycle is suggestive of ovulation. Persistence of fern pattern even beyond 22nd day suggests anovulation. Progesterone causes dissolution of the sodium chloride crystals. Following ovulation, there is loss of stretchability (spinnbarkeit), which was present in the midcycle.

17. Vaginal cytology Maturation index shifts to the left from the midcycle to the mid second half of cycle due to the effect of progesterone. Single smear on day 25 or 26 of the cycle reveals features of progesterone effect, if ovulation occurs. If ovulation has occurred, under the influence of progesterone, the epithelial cells are predominantly intermediate cells If ovulation has not occurred, under the effect of estrogen, the epithelial cells are predominantly superficial cells.

18. Hormone estimation „„ Serum progesterone : Estimation of serum progesterone is done on day 8 and 21 of a cycle (28 days). An increase in value from less than 1 ng/ml to greater than 6 ng/ml suggests ovulation. „„ Serum LH: Daily estimation of serum LH at midcycle can detect the LH surge. Ovulation occurs about 34–36 hours after beginning of the LH surge. It coincides about 10–12 hours after the LH peak. „„ Serum estradiol attains the peak rise approximately 24 hours prior to LH surge and about 24–36 hours prior to ovulation. The serum LH and estradiol estimation is used for in vitro fertilization.

19. „„ Urinary LH: LH kits are available to detect midcycle LH surge. Ovulation usually occurs within 14–24 hours of detection of urine LH and almost always within 48 hours. (The test should be done on a daily basis. It is started 2–3 days before the expected surge depending upon the cycle length)

20. Endometrial biopsy Endometrial tissues to detect ovulation (endometrial sampling) can easily be obtained as an outpatient procedure using instruments such as Sharman curette or Pipelle endometrial sampler. When to do? Biopsy is to be done on 21st–23rd day of the cycle. Barrier contraceptive should be prescribed during the cycle to prevent accidental conception. Findings: Evidences of secretory activity of the endometrial glands in the second half of the cycle give not only the diagnosis of ovulation but can predict the functional integrity of the corpus luteum. Subnuclear vacuolation is the earliest evidence appearing 36–48 hours following ovulation.

21. Sonography (follicular monitoring) Serial transvaginal sonography (TVS) during midcycle can precisely measure the Graafian follicle just prior to ovulation (18–20 mm). It is particularly helpful for confirmation of ovulation following ovulation induction, artificial insemination, and in vitro fertilization. The features of recent ovulation are: Collapsed follicle and fluid in the pouch of Douglas. TVS can detect endometrial thickness. Trilaminar endometrium with a thickness >8 mm is favorable for implantation. Posterior Acoustic enhancement due to presence of secretions in glands.

22. Laparoscopy Laparoscopic visualization of recent corpus luteum or detection of the ovum from the aspirated peritoneal fluid from the pouch of Douglas is the only direct evidence of ovulation. Direct Conclusive Pregnancy is the surest evidence of ovulation.

23. Diagnosis of LPD is difficult. However, it is based on the following: „„ BBT chart: (a) Slow rise of temperature taking 4–5 days following the fall in the midcycle; (b) Rise of temperature sustains less than 10 days. „„ Endometrial biopsy—biopsy done on 25–27th day of the period reveals the endometrium at least 3 days out of phase (Example: If the biopsy is done on 25th day of cycle, the endometrial changes observed correspond to the day 22). This lag phase endometrium must be proved in two consecutive cycles. However, it is not conclusive. „„ Serum progesterone estimated on 8th day following ovulation is less than 10 ng/ml. Luteal Phase Defect

24. Luteinized Unruptured Follicle Luteinized unruptured follicle (LUF) syndrome refers to an infertile woman with regular menses and presumptive evidences of ovulation without release of the ovum from the follicle (trapped ovum). The features of ovulation, formation of corpus luteum and its stigma are absent. It is often associated with pelvic endometriosis. Diagnosis : In the presence of biologic effects of progesterone in the early luteal phase: „„ Sonography: Persistence of echo-free dominant follicle beyond 36 hours after LH peak. „„ Laparoscopy: Failure to observe a stigma of ovulation. „„ Ovarian biopsy: Conclusive proof is determination of ovum amidst the structure of corpus luteum

25. Test for ovarian reserve Indications: Age ≥ 35y: As age increases, reserve decreases. Chronic smoker. H/o premature menopause in family. Personal history of surgery, radiotherapy/ chemotherapy. Case of unexplained infertility.

26. Tubal Factors

27. Insufflation Test (Rubin’s Test) Principle: The underlying principle is that the cervical canal is in continuity with the peritoneal cavity through . As such, entry of air or CO2 into the peritoneal cavity when pushed transcervically under pressure, suggests oftubal patency (it is not commonly done these days). Observations: The patency of the tube is confirmed by: (1) Fall in the pressure when raised beyond 120 mm Hg; (2) Hissing sound heard on auscultation on either iliac fossa (3) Shoulder pain experienced by the patient (irritation of the diaphragm by the air). Limitation: It should not be done in the presence of pelvic infection.

28. Hysterosalpingography (HSG) Principle: The principle is the same like that of insufflationtest. Instead of air or CO2, dye is instilled transcervically. When to be done?: D7–D10 of the cycle. Limitation: As in D&I. Advantages: It has got distinct advantages over insufflation test. It can precisely detect the side and site of block in the tube. It can reveal any abnormality in the uterus (congenital or acquired like synechiae, fibroid). As such, insufflation of the tubes has largely been replaced by HSG.

29. Histosalphingography proceaure: · urographin is a radiopaque, lodine based, water soluble dye. · The dye is inserted into the uterus via Leech Wilkinson Cannula · Serial x-rays are done to see the spillage of the dye from the fallopian tubes. . HSG is done in the pre ovulatory phase : Day 6 to Day 11 Abnormal findings on HSG : · Straight lead pipe liketubes are seen in Genital TB. · Hydrosalpinx Contraindications of HSG : · Pregnancy. · Genital TB. · Active PID.

30. Findings on a HSG : Tube blockages : Proximal / midsegmental or distal. Distal block - the dye collects behind the block leading to dil- atation of the tube - hydrosalpinx. mullerian malformations (accidental finding) : I0C 3D USE Gold standard is MRI. Filling defects : Seen in 3 conditions I. Submucosal Fibroids : Smooth and regular filling defect (broad base). a. Polyps : Smooth and regular filling defect (narrow base). 3. Asherman syndrome : multiple irregular filling defects (moth eaten appearance).

31. Laparoscopy and Chromopertubation Laparoscopy is the gold standard (definitive method) For evaluation of tubal factors of infertility. Drawbacks: Laparoscopy is more invasive than hysterosalpingography (HSG). It cannot detect abnormality in the uterine cavity or tubal lumen. Thus, the two procedures (HSG and laparoscopy) should be regarded as complementary to each other and not a substitute to the other procedure. When to be done? It is commonly done in the proliferative phase.

32. Sonohysterosalpingography Principle: Normal saline is pushed within the uterine cavity with a pediatric, Foley catheter. The catheter balloon is inflated at the level of the cervix to prevent fluid leak. Ultrasonography of the uterus and fallopian tubes are done. Ultrasound can follow the fluid through the tubes up to the peritoneal cavity and in the pouch of Douglas. Advantages: It is a noninvasive procedure. It can detect uterine malformations, synechiae, or polyps (superior to HSG). Tubal pathology could be detected as that of HSG. There is no radiation exposure.

33. Falloposcopy It is to study the entire length of tubal lumen with the help of a fine and flexible fiberoptic device. It is performed through the uterine cavity, using a hysteroscope. It helps direct visualization of tubal ostia, mucosal pattern, intratubal polyps, or debris. Salpingoscopy Tubal lumen is studied introducing a rigid endoscope through the fimbrial end of the tube. It is performed through the operating channel of a laparoscope.

34. Uterine factor Uterine factors commonly associated with subfertility are submucous fibroids, congenital malformations and intrauterine adhesions (Asherman’s syndrome). They are more likely to cause recurrent pregnancy loss rather than primary infertility. Ultrasonography, HSG, hysteroscopy, and laparoscopy are needed in the evaluation of uterine factor for subfertility. Hysteroscopy It is the gold standard for visualizing the uterine cavity and the tubal ostia. Besides diagnosis, therapeutic benefits of hysteroscopy are: (a) Polypectomy for endometrial polyp; (b) Submucous resection of myoma; (c) Hysteroscopic adhesiolysis; and (d) Resection of uterine septum.

35. The cervix functions as a biological valve. This is because in the proliferative phase, it permits the entry of sperm and in the secretory phase, hinders their penetration. As such, dysfunction at this level should be carefully evaluated. Principle: PCT is to assess the quality of cervical mucus and the ability of sperm to survive in it. PCT is rarely done these days. Postcoital test (PCT) (Sims-Huhner test) Cervical factor Sperm cervical mucus contact test (SCMCT) not done presently.

36. DC Dutta’s Textbook of gynaecology Shaw’s Textbook of Gynaecology References

37. Thank you for your attention