Infertility Testing - Female Factor

Investigations

Correct diagnosis is a crucial step in determining appropriate therapy, and a variety of procedures can be used, ranging from simple blood tests to more complicated analytical methods. Furthermore, as infertility often has several causes, many factors must be considered. Once the diagnosis is established, treatment can be tailored specifically to the individual needs of the couple.

There is a very long list of investigations for diagnosis of infertility, however there is no consensus on which test is essential before reaching the exact diagnosis. Use of investigative test depends on sensitivity, specificity, positive and negative predictive value, invasiveness and possibility of harmfulness and cost.

Female Factor

  • Assessment of ovulation

  • Assessment of tubal factor

  • Baseline hormone levels

  • Immunological factor

  • USG

The only true proof of ovulation is recovery of an ovum or pregnancy. But confirmation of ovulation can be done by:

  1. BBT
  2. Estimation of LH
    There is no evidence that the use of BBT charts and LH hormones detection
    Methods to time intercourse improves outcome (Leader 1992/ Guermandi 2001)
  3. Midluteal serum progesterone- Day 21 to 25 - method of choice
  4. Endometrial biopsy: not a routine step in investigation of infertility except if tuberculosis endometritis suspected (Peters et al 1992 & Templeton 2001)


5. Ultrasound monitoring of ovulation: Trans vaginal sonography is the method of choice


Methods of evaluating ovulation

6. Antral follicle count – will tell about the ovarian reserve, and follicles recruited in that cycle

Assessment of tubal factor

HSG: Cheap and out patient procedure with low incidence of complications (RCOG 1999) . Although HSG is of low sensitivity, its high specificity makes it a useful screening test for ruling out tubal obstruction. In case of abnormal findings, diagnostic laparoscopy with dye transit is the procedure of choice (Swart et al 1995). HSG has a low prognostic value, the outcome of HSG adds little to predicting the occurrence of pregnancy. However when HSG shows bilateral obstruction, the chance of getting pregnant is only minimal (Maas et al 1997)

Laparoscopy:

Best method to evaluate the tubes as it not only proves its patency, but its gives us a clear picture about the quality & relationship with other structures like ovaries & tubes. Many times the tube may be anatomically patent but may not be functionally perfect i.e. capable of transporting the egg, sperms & the embryo formed. It also evaluates the uterus, ovaries & the pelvis, so that any other cause would be ruled out. It also has an advantage of treating the pathologies at the same sitting, so that it avoids a repeat anesthesia or surgery either laproscopy or laparotomy.

 

Falloscopy: To visualize the internal surface of the uterus

Hysterosonography: Done using ultrasound, where in fluid is instilled into the uterine cavity with the help of a catheter. & Passage of this fluid through the tubes looked for, along with the presence of free fluid in POD which signifies patency of tubes

Hydrolaproscopy: Gordts, 1999 – not used regularly, though specific as HSG, requires hysteroscopy, it is invasive and costly. Notsuperior to HSG, inferior to diagnostic laparoscopy. Its role still unclear (Templeton 2001)

Peritoneal factor by laparoscopy

Uterine factor evaluated by HSG and hysteroscopy. Before uterine instrumentation appropriate antibiotic prophylaxis against chlamydia should be given (RCOG 1999). Here again hysterosopy gives a more accurate diagnosis as we examine the uterine cavity directly using a hysteroscope. Moreover we could also rectify or treat pathologies like sub mucus fibroid, polyps, intrauterine adhesions, septum or foreign bodies in the cavity.

Baseline hormone levels on Day 2 or Day 3 – FSH, LH, Prolactin, Estradiol, progesterone

Androgen profile in presence of hirsuitism and PCO – DHEAS, testosterone, androstenedione, 17 OH progesterone

Fasting Insulin levels – in patients with PCO and obesity

Evaluation of thyroid status

Immunological factor by special test for antibodies
CA125 for endometriosis: The performance of serum CA 125 measurements in diagnosis of endometriosis grade I / II is limited, whereas its performance in diagnosis of endometriosis grade III / IV is better. It is better in predicting recurrence (Mol et al 1998)

Serum chlamydial antibodies – has comparable estimates of tubal pathology as compared to HSG, but it provides no details on the anatomy of the uterus and tubes (Mol et al 1997)

USG for endometrium and follicular growth – The prognostic value of endometrial thickness is not universally accepted (Schild et al 2001). Endometrial thickness of > 10 mm increases the chance of pregnancy.

3 D USG: As effective as 2 dimensional USG, bur very expensive with no diagnostic advantage in infertility evaluation over 2 D US. May be used to differentiate bicornuate from septate uterus.
Thus summarizing, serum progesterone for detection of ovulation, HSG for tubal patency and semen analysis are the basic essential test for diagnosis of infertility.
Laparoscopy reserved as further diagnostic procedure in combination with endoscopic surgery.
Other test may have a role in special situations.

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Dr. Patil’s Fertility and Endoscopy Clinic

Center for Assisted Reproductive Technology, Endoscopic Surgery and Andrology

No 1, Uma Admirality, First Floor, Bannerghatta Road, Bangalore - 560029
Ph: 080 - 41201357, 41462419 Mobile: 9945221622
E-Mail: drpatilsclinic@gmail.com

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