Central Lakes Medical

Further investigations of female infertility

INVESTIGATIONS FOR ANOVULATION

Where the cycle length is either longer or shorter than 28 days a single day-21 progesterone level may be insufficient to pinpoint ovulation and serial progesterone checks may be needed (progesterone tracking). For example, in a 28-35 day cycle progesterone tracking could be started

Table 45.11 History taking in an infertile couple

General information

Male Fertility history

Medical

Occupational Sexual

Female Fertility

Menstrual history

Obstetric history

Medical history

Surgical history

Sexual history

Duration of infertility

Nature of infertility (primary or secondary)

Evidence of previous fertility with past partners

Previous investigations or treatment for infertility Sexually transmitted diseases Epidydimitis Mumps orchiditis Testicular maldescent Chronic disease or medication Drug/alcohol abuse Recurrent urinary tract infection (UTI) Surgical

Testicular torsion Orchidopexy Testicular injury

Vasectomy and vasectomy reversal Exposure to toxins Decreased libido Impotence

Anejaculation, premature ejaculation

Fertility in previous relationships

Time to previous conceptions

Previous fertility investigations or treatments

Length and type of previous contraceptive use

Cyclicity

Amenorrhoea

Dysmenorrhoea

Heavy menstrual bleeding

Intermenstrual bleeding

Previous pregnancy

Miscarriage, termination of pregnancy, ectopic pregnancy Chronic illnesses (diabetes, hypertension, renal disease) Known endocrine disorders, e.g. hypothyroidism, PCOS Previous STD's, e.g. Chlamydia Known endometriosis Galactorrhoea Cervical smear history Current medication including folate supplements Tubal surgery including salpingectomy and salpingostomy Ovarian surgery Pelvic surgery for endometriosis Previous laparoscopy Appendicectomy Coital frequency and timing from day 21 and continued weekly until the next period begins. Where periods are either very irregular or absent it may be impractical (and irrelevant) to estimate progesterone levels. Instead, additional biochemical investigations are indicated to establish a possible endocrine cause of oligo/anovulation (Fig. 45.2). These include early follicular phase FSH and LH, prolactin, TSH, and where PCOS is suspected, serum testosterone androstenedione and SHBG. Where an adrenal cause is to be excluded, DHEA and DHEAS, 17-OH progesterone need to be checked. FSH and LH levels should be checked in the early fol-licular phase (days 1-3) in order to avoid the normal midcycle surge which can lead to abnormally high values. Where accurate timing of the test is impossible (as in amenorrhoeic women), a serum sample can be obtained at any time and the results interpreted with reference to the following period.

TUBAL PATENCY TESTING

Once preliminary investigations suggest that a woman is ovulating and semen parameters are satisfactory, the next step should be assessment of tubal status. Tubal disease implies tubal block and pelvic adhesions due to infection, endometriosis or previous surgery. Laparoscopy and chromotubation (lap and dye) is the investigation of choice as it is able to demonstrate tubal patency as

Table 45.12 Examination of the infertile couple

	Female	Male
General	Height, weight, body	Height, weight,
examination	mass index (BMI)	BMI
	Blood pressure	Blood pressure
	Fat and hair distribution
	Acne and galactorrhoea
Local	Abdominal examination	Groin
examination	Scars	Hernia
	Abdominal masses
	Pelvic	Genitalia
	Inspection of external	Presence, location
	genitalia	and volume of
	Speculum examination:	testes
	vaginal assessment -	Epididymitis
	vaginal septa, infections	Vasa deferentia
	Cervix - ectopy, polyps	Varicocoele
	Accessibility of cervix for	Penis for any
	insemination	structural
	Bimanual palpation of	abnormalities,
	uterus: size, shape,	e.g. hypospadias
	position, mobility.
	Presence of adnexal
	masses and tenderness

Fig. 45.1 Investigation of infertility.

well as assess the pelvis for the presence of endometriosis and adhesions. Hysterosalpingogram (HSG) which involves a pelvic X-ray following the injection of a radio opaque iodine-based dye through the cervix is less invasive and can be helpful in cases where laparoscopy is contraindicated/hazardous or in women at low risk of pelvic pathology (Evers, 2002).

As a test of tubal obstruction, HSG has a sensitivity of 0.65 (95% CI 0.50-0.78) and a specificity of 0.83 (95% CI of 0.77-0.88) (Swart et al. 1995). This suggests that it is a reliable indicator of tubal patency but poor at identifying cases of tubal occlusion. A meta-analysis of 23 studies has found that the discriminative capacity of chlamydial antibody testing using enzyme-linked immunofluorescent assay is comparable to HSG in the diagnosis of tubal pathology (Mol et al. 1997). The use of ultrasound along with injection of a sonoreflective contrast medium through the cervix (HyCosy) has been described, but is yet to become part of standard care in most centres. Preliminary studies comparing it with lap and dye or HSG have shown good concordance (Dijkman et al. 2000). Further research is needed to ascertain the value of endoscopic tests such as fertiloscopy and falloposcopy. Routine assessment of tubal status is debatable in situations where knowledge of tubal patency is unlikely to change the proposed management plan - such as severe male factor infertility where intracytoplasmic sperm injection is indicated.

HYSTEROSCOPY AND PELVIC ULTRASOUND SCAN

Uterine pathology such as adhesions, polyps and submucous leiomyomas and septae have been found in 10-15% of women seeking fertility treatment. It is unclear whether hysteroscopy should be considered a routine investigation in infertile couples in addition to laparoscopy or HSG. While a causal relationship between uterine fibroids and infertility has been established (Donnez and Jadoul, 2002),

Pituitary imaging

Karyotype autoantibody

Pituitary imaging

BMI, ultra sound scan of ovaries Serum androgens, SHBG If required DHEA, DHEAS, 17-OH progesterone

Fig. 45.2 Investigations for anovulation.

the effectiveness of surgical treatment of uterine abnormalities to enhance pregnancy rate is unproven. Transvaginal pelvic ultrasound (TVS) enables pelvic structures to be visualized and provides more information than a bimanual examination. It can identify endometrioma, ovarian cysts, polycystic ovaries, fibroids and hydrosalpinges. However, the routine use of this investigation in women without a history of pelvic pathology has yet to be established.

POST-COITAL TEST

The role of the post-coital test (PCT) to detect the presence of motile sperm is the subject of ongoing debate. It is useful in predicting spontaneous conception in couples with a short duration of infertility (<3 years) where female causes of infertility have been excluded (Glazener et al. 2000). A systematic review of observational studies has failed to confirm the predictive power of this test. A randomized trial on 444 women has failed to demonstrate any advantages of routine PCT in terms of cumulative pregnancy rates. Intervention rates were higher in women subjected to the investigation (Oei et al. 1998).

OVARIAN RESERVE

Women have a finite number of primordial ovarian follicles, which show an age related decline. Tests for ovarian reserve have been used to predict ovarian response to stimulation as part of fertility treatment. Observational studies have demonstrated an association between factors such as day-3 FSH, serum inhibin and antral follicle count, and subsequent ovarian response to stimulation. Currently available tests of ovarian reserve do not possess adequate levels of sensitivity or specificity to justify their routine use in all women with infertility.

ENDOMETRIAL BIOPSY

The role of endometrial biopsy is not established in routine practice. While useful in cases where endometrial pathology is suspected on the basis of menstrual dysfunction, women should not be offered an endometrial biopsy to evaluate the luteal phase. There is no evidence that medical treatment of luteal phase defects improves pregnancy rates (Balasch et al. 1992).

SCREENING FOR CHLAMYDIA

Screening for chlamydia trachomatis can reduce the incidence of PID in women at increased risk of chlamydia (Scholes et al. 1996). Uterine instrumentation undertaken as part of investigation or treatment may reactivate upper genital tract infection. Hence women scheduled to undergo uterine instrumentation should be offered screening for chlamydia trachomatis.