BASIC INVESTIGATIONS FOR MALE AND FEMALE FERTILITY.
1)To detect the etiological factor(s).
2) To rectify the abnormality in an attempt to improve the fertility.
3)To give assurance with explanation to the couple if no abnormality is detected.
When to investigate: 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 man.
What to investigate : The basic investigations to be carried out are:
(i) Semen analysis.
(ii) Confirmation of ovulation
(iii) Confirmation of tubal patency.
It is important that both partners should come at the first visit. Detailed general and reproductive history should be taken in presence of both. However, the clinical examination of each partner is carried out separately.
clinical approach to investigation
duration of marriage
history of previous marriage proven fertility if any, are to be noted.
A general medical history should be taken with special reference to sexually transmitted diseases, mumps orchitis after puberty, diabetes, recurrent chest infection or bronchiectasis. Enquiry about relevant surgery such as herniorrhaphy, operation on testes, also about the sexual history, social habits, particularly heavy smoking and
alcohol are of importance and to be made.
A full physical examination is performed to determine the general state of health.
Examination of the reproductive system includes—inspection and palpation of the genitalia. Attention should be paid to the size and consistency of the testicles. Testicular volume (measured by an orchidometer) should be at least 20 mL. Presence of varicocele should be elicited in the upright position. Investigations
1) Routine investigations include urine and blood examination including postprandial sugar.
2) Semen analysis: This should be the first step in investigation because, if some gross abnormalities are detected (example being absence of sperm), the couple should be counseled for the need of assisted reproductive technology.
• Aspermia: failure of emission of semen (no ejaculate).
• Oligospermia / Oligozoospermia: Sperm count is less than 20 million per ml.
• Polyzoospermia: count is more than 350 million/ ml.
• Azoospermia : no spermatozoan in the semen.
• Asthenozoospermia : Reduced sperm motility. leucocytospermia: Increased white cells in semen.
• Necrozoospermia : Spermatozoa are dead or motionless.
• Teratozoospermia : > 70% spermatozoa with abnormal morphology.
• Oligoasthenoteratozoospermia : Disturbance of all 3 variable.
3)Testicular biopsy: is done to differentiate primary testicular failure from obstruction as a cause ofazoospermia or severe oligospermia. The biopsy material is to be sent in Bouin’s solution and not in formol saline. Testicular tissues may be cryopreserved for future use in IVF/ICSI. transrectal ultrasound (truS): is done to visualize the seminal vesicles, prostate and ejaculatory ducts obstruction. Indications of TRUS are:
(i) Azoospermia or severeoligospermia with a normal testicular volume,
(ii) Abnormal digital rectal examination,
(iii) Ejaculatoryduct abnormality (cysts, dilatation or calcification),
(iv) Genital abnormality(hypospadias). vasogram is a radiographic study done to evaluate the ejaculatory duct obstruction. It is mostly replaced by TRUS.
4) Karyotype analysis: This is to be done in cases with azoospermia or severe oligospermia and raised FSH. Klinefelter’s syndrome (XXY) is the commonest. Micro deletions of the long arm of Y chromosome can also cause severe seminal abnormalities.
5) Immunological tests: Two types of antibodies have been described—sperm agglutinating and sperm immobilizing; the latter is probably related to infertility. The antibodies are produced following infection (orchitis), trauma or vasectomy. These antibodies can be detected from the serum by the sperm immobilizing test.
History: Age, duration of marriage, history of previous marriage with proven fertility if any, are to be noted.
1)A general medical history should be taken with special reference to tuberculosis, sexually transmitted disease, pelvic inflammation or diabetes.
2)The surgical history should be directed especially towards abdominal or pelvic surgery. This may be related to peritubal adhesions.
3)Menstrual history should be taken in details. Wide spectrum of abnormalities ranging from hypomenorrhea—oligomenorrhea to amenorrhea are associated with disturbed hypothalamopituitary ovarian axis which may be either primary or secondary to adrenal or thyroid dysfunction.
4)Previous obstetric history—It is including number of pregnancies, the interval between them and pregnancy related complications are to be enquired. In the case of secondary infertility, the obstetric history is important. The history of puerperal sepsis may be responsible for ascending infection and tubal damage. Uterine synechiae may be due to
5)Contraceptive practice should be elicited. IUCD use may cause PID. Sexual problems such as dyspareunia, and loss of libido are to be enquired. It should be born in mind that the female orgasm is not essential for fertility and loss of semen from the vaginal orifice following coitus is normal. examinations
6)General, systemic and gynecological examinations are made to detect any abnormality which may hinder fertility.
7)General examination must be thorough—special emphasis being given to obesity or marked reduction in weight (BMI). Hirsutism, acne, acanthosis nigricans (p. 459) or underdevelopment of secondary sex characters are to be noted. Physical features pertaining to endocrinopathies are carefully evaluated to detect features of PCOS and
8)Systemic examination may accidentally detect such abnormalities like hypertension, organic heart disease, chronic renal lesion, thyroid dysfunction, and other endocrinopathies.
9)Gynecological examination includes adequacy of hymenal opening, evidences of vaginal infections, cervical tear or chronic infection, undue elongation of the cervix, uterine size, position and mobility, presence of unilateral or bilateral adnexal masses —fixed or mobile with or without tenderness and presence of nodules in the pouch of
10)Speculum examination may reveal abnormal cervical discharge. The discharge is tobe collected for Gram stain and culture. Cervical smear is taken as a screening procedure as a routine.
Diagnosis of ovulation
indirect Menstrual history
evaluation of peripheral or endorgan changes
• cervical mucus study
• Vaginal cytology
• Hormone estimation
− Serum progesterone − Serum lH
− Serum estradiol
− Urine lH
• endometrial biopsy ,Sonography (TVS)
Detection of abnormality of one factor does not negate investigation for another defect elsewhere. Multiple defects may be present in the same case, e.g. tubal defects may be associated with anovulation. Pregnancy following laparoscopy and dye test or hysterosalpingography is not uncommon. It is presumed that small flimsy adhesions or any mucus plug obstructing the tubal lumen is removed during such procedures. The cervical spasm may be
relieved during dilatation.
Ovarian factors: Ovarian dysfunctions (dysovulatory) commonly associated with infertility are:
Anovulation or oligo-ovulation (infrequent ovulation).
Luteal phase defect (LPD).
Luteinized unruptured follicle (LUF).
Diagnosis of ovulation
• Indirect • Direct
The indirect or presumptive evidences of ovulation are commonly used in clinical practice. These are inferred from :
Evaluationofperipheralorendorganchangesdue to estrogen and progesterone.Direct assays of gonadotropins or steroid hormones preceeding, coinciding or succeeding the ovulatory process.
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 (Mittel-
schmerz syndrome). basal body temperature (bbt)
BBT indicates ovulation retrospectively.
It cannot predict ovulation precisely with time. Rarely, ovulation has been observed though BBT is monophasic.
It should not be continued for more than 3–4 months for investigation purpose. However, it has to be maintained for longer periods during management of ovulation induction. Cervical mucus study Alteration of the physicochemical properties of the cervical mucus occurs due to the effect of estrogen and progesterone. Disappearance of fern pattern beyond 22nd day of the cycle, which was present in the midcycle is suggestive of ovulation. Persistence of fern pattern even beyond 22nd day suggests anovulation. Progesterone causes dissolution of the sodium chloride crystals.
Vaginal cytology Maturation index shifts to the left from the midcycle to the mid second half of cycle due
to the effect of progesterone . However, a single smear on day 25 or 26 of the cycle reveals features of progesterone effect, if ovulation occurs. Hormone estimation Serum progesterone.
The serum LH and estradiol estimation is used for in vitro fertilization.
Urinary LH :
sonograPhy: Serial sonography (TVS) during mid cycle 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.
Direct 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
In the presence of biologic effects of progesterone in the early luteal phase:
i. Sonography: Persistence of echo-free dominant follicle beyond 36 hours after LH peak.
ii. Laparoscopy: Failure to observe a stigma of ovulation.
iii. Ovarianbiopsy: Conclusiveproofisdetermination of ovum amidst the structure of corpus luteum. Dilatation and insufflation test Hysterosalpingography laparoscopy and chromopertubation Sonohysterosalpingography falloposcopy Salpingoscopy. insUfflation test (rUbin’s test).