An approach to infertility

—Evaluation Work up

—Management

The infertile couple should be investigated after one year of regular up protected intercourse with adequate frequency. The interval is however shortened to 6 months after the age of 35 of the woman and 40 year of man.

Both the partners should come for the initial interview and should be evaluated and treated together, as infertility is not the disease of only the woman. The causes with approximate percentages are :

                                            CAUSE                                               %

                                            Male                                                     30

                                            Female                                                 30

                                            Combined                                            30

                                            Idiopathic                                            10

TYPICAL SEQUENCE OF INFERTILITY WORK UP

STEP I

Initial Interview and Examination

·         Both partners should be present.

·         History and general physical examination of both partners.

·         Outline tests and investigations.

·         Answer questions.

·         Tests for Ureaplasma and chy madia.

STEP II

Laboratory Evaluations

MEN

Semen analysis (after suitable abstinence)

WOMEN (Beginning with next menstruation)

·         BBT

·         Ovulation detection kit

·         Hormone assays is indicated

·         Hysterosalpingography / Sonosalpigography

·         Follicular Ultrasonography

·         Post Coital Test

·         For ammenorhea / digomenorrhea begin with hormone studies.

·         After induction ofovulation proceed to above studies.

STEP III

Specialised Test

MEN

·         Abnormal semen analysis

·         Serum FSH, LH, TSH, Testosterone

·         Tructose content of semen

·         Prostatic massage and culture sensitivity of the fluid

WOMEN

·         Hysterosalpingogram shows comual patency

·         Laparoscopy (during luteal phase)

·         Endometrial biopsy

·         Above are done 9-12 days after LH surge

·         Hysterosalpingogram shows possible comeal block

·         Laparoscopy (during early follicular phase)

STEP IV

Continue investigations based on positive findings

MEN

·         Testicular biopsy

·         Sex chromatin study

·         Immunological tests

WOMEN

·         Hysteroscopy and Laparoscopy for pelvic or after pathology

·         Antisperm antibody test

·         CT scant and MRI for tumors of pituitary / hypothalmus / adrenal glands

Clinical Approach To Investigation

MALE

History

·         Age

·         Duration of Marriage

·         History of proven fertility if any

·         General medical history especially of

·         Sexually transmitted disease and treatment taken, of

·         Muneps orchetes after puberty, history of

·         Diabetes mellitus, tuberculosis.

·         Relevant surgery done eg herniorapply, operation on testis or any other genital operation.

·         Occupationae history towards exposure to radiation / excessive heat

·         Sexual history—frequency of intercourse, full penetration of penis inside the vagina, orgasm at the right time (premature ejaculation)

·         Social habits, heavy smoking, alcohol, drug abuse.

Examination

·         General Physical examination

·         Reproductive system examination

·         Inspection and palpation of genitalia

·         Presence ofvaricoupele

Special Investigation

Routine Investigations

Routine blood examination

·         Complete urine examination

                                    Fasting

·         B. Sugar   

                                    Post prandial

·         VDRL

·         Seminal fluid analysis collected by masturbation into a clean wide mouthed bottle preferably in thelaboratory with a prior abstinence for 2 days. A normal spermino gram is tabulated below :

Parameter                                         SOH 1912

Volume (ml)                                      >2.0

Density (x 106 / ml)                           >20

Motility (%)                                       >50

Viability (%)                                      >75

Normal Forms (%)                             >30

Leucocytes (x 106 / ml)                     <1.0

 

In case of abnormal seminal analysis we can follow the following routine of investigation.

 

 

 

 

 

 

 

 

Azoospermia Oligospermia

Hormonal Study

Fruestose content of Seminal fluid

Serum TSH

Testosterone

FSF

Absen Congenital absence of sperminal vesecle Partial duct obstruction *Botht

High

Low

High

Hypothyroid

Hypothalmo Pituitary dysfunction Leyding cell abnormality

Testicular Destruction

Normal/Low

Daily inj. HCG 5000 units x 4 such

Pus cells++

Puss cells absent

Prostatic message

Testicular biopsy

smear+culture

Spermatogcnesis absent

Spermatogcnesis present

Destruction of trbular epithelium

Vas obstruction

Vasogram

Responsive

Unresponsive

Hypogonadrotrophic hypogonadism

Sex chromatin study

Klienfilters syndrome

ABNORMAL SEMINOGRAM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Female

History

·         Age

·         Duration of Marriage

·         History of previous marriage with proven fertility

·         Medical history esp. of tuberculosis, sexually transmitted disease, diabetes

·         Surgical history especially of abdominal or pelvic surgery

·         Menstrual history in detail

·         Previous obstetric history

·         Contraceptive practice especially of IUCD insertions

·         Sexual history with problems such as dysparuenia, loss of libido

Examination

·         General Physical examination

·         Reproductive system examination

·         Distribution of hair

·         Development of secondary sexual characters

·         Per speculum examination

·         Per vaginal examination of evidence of vaginal infection, cervical tear or infection, uterine size, mobility, abnormality presence of adnexal masses, and presence of modules in pouch of Douglas.

·         Physical features pertaining to endrocrinopathies.

 

 

MANAGEMENT OF INFERTILITY COUPLE

Should be investigated and treated together

Ovulatory Dysfunction

Laparoscopy

Abnormal Semen analysis

Clomiphenic

Monitoring of ovulation

Gonadotrophins

No response

Endometriosis

Tubal disease obstrucion

Danazol or GnRH analog

Surgery

Pregnancy

No Pregnancy

Assisted Reproduction

Idiopathic seminiferous tubular failure

Varicocele

Infection

Testicular failure

Harmone Gonadotrophin

Surgery

Antibiotes

Doner sperm Adoption

 

HISTORY

 

 

PHYSICAL EXAMINATION

 

 

Semen analysis

Evidence of ovulation

Hormonal Profile

 

 

 

                                                                          

 

 

 

 

 

 

 

 

 

 

 

 

 

Identification of Factor	Methods Employed		Day of Cycle	Observation
	(1) BBT		Throughout cycle	Biphasic
OVULATION	(2) Endrometrial Biopsy		21-23	Secretary Endometrium
	(3) Cervical Mucus —Nature —Spimnbarkeit —Fern Pattern		12-14 and 21-23	12-24                           21-23 clear & watery            Thick & viscid +                                    — +                                    —
	(4) Vaginal cytology		12-14 and 21-23	12-14                           21-23 Discrete cells              Folded edges Pyknotic Nuclei          In clumps Background clear       Background dirty
	(5) Serum Progesterone		8 and 21	8                                 21 <I ng/ml                     >5 ng/ml
	(6) Serial sonar		12-14	Follicular measurement 18-20 mm
	(7) Laparoscopy		Secretory Phase	Recent couples luteum
TUBAL FACTOR	(1) Insufflation cycle		Proliferative phase-2 days after bleeding stops	(1) Dropin pressure when raised to 120 mm Hg (2) Hissing sound in iliat fossa (3) Shoulder pain
	(2) Hysterosalpingography		As above	Spillage of dye into the peritoneal cavity
	(3) Laparoscopy		Secretory phase	(1) Peritubal pathology (2) Pelvic pathology eg endometriosis (3) Evidence of ovulation (4) Evidence of potency tube by dye test
CERVICAL	Post Coital Test		12-14	Presence of >.20 sperm/high power field showing progression motility
HORMONAL ASSAY Done on day 2 of a spontaneous menstrual cycle		FSH (IU/1) LH (IU/1) E, (pg/ml) Testosterone (ng/ml)   0.24-0.89(0.59)		Normal Range / Mean 1.6-6.1(3.6) 2.0-10.5(6.1) 44-153(90)
Done on day 21 of a 28 - 30 day menstrual cycle		Prolactin (mIU/1)       150-500 Progesterone (ng/ml) >10
		T3, T4, TSH B. Sugar          —Fasting                         —Post prondial Evidence of sexually transmitted disease                         —VDRL                         —HIV Evidence of Tuberculosis                         —X-ray chest                         —IgA for active T.B. Sex chromatin study Evidence nuclerian —Buccal smear Evidence of pelvic inflammatory disease —Per vaginum examination —Culture sensitivity of high vaginal swab		Thyroid abnormality Abnormal Glucose tolerance test.   Syphilis AIDS