Definition
• Infertility is inability of a couple to
conceive after one year of sexual
intercourse without contraception
How frequently do people
conceive?
0 Natural pregnancy rates
0 (best rates at age 22-23 y.o., decline significantly after
35, abruptly after 40)
0 ART pregnancy rates
(try to) Look for the
diagnosis!
0 There is a very long list of investigations for the
diagnosis of infertility, however there is no consensus
on which tests are essential before reaching the exact
diagnosis
What are you looking for?
0 Is the woman ovulating? How is the fertility potential?
0 Is tere a mechanical factor? Are the tubes patent?
0 Is there a male factor? What is the quality of the
sperm?
(never forget the) Male Factor
0 Conventional semen analysis
0 A variety of sperm function tests such as in vitro
mucous penetration test, hamster egg penetration test
and post coital test.
0 Expensive and not realible
Assessment of ovulation
0 Basal body temperature
0 Mid luteal serum progesterone
0 Endometrial biopsy
0 Ultrasound monitoring of ovulation (detects timing).
Tubal factor
0 Hysterosalpingography
0 Laparoscopy
0 Falloscopy
0 Hysterosonography
0 Hydrolaparoscopy.
Others
0 The peritoneal factors are assessed by laparoscopy
0 The uterine factor by hysterosalpingography and
hysteroscopy.
0 Immunological factors are evaluated by a variety of
special tests.
Controverses
0 A lack of agreement exists among trained infertility
specialists with regard to the diagnostic tests to be
performed and their prognostic utility as well as
criteria of normality
Take Care
0 Care must be taken to avoid exploitation of the infertile
couple with expensive unnecessary tests
Concept to keep in mind
A simplified approach will lead to a
significant reduction in both the time
and cost of investigating an infertile
couple.
Diagnostic tests
0 Diagnostic tests for infertility should be categorized
into three categories based on the correlation with
pregnancy rates
The first category
includes tests which have an established correlation with
pregnancy as:
0 Semen analysis
0 Mid luteal progesterone for the diagnosis of ovulation.
0 Tubal patency by hysterography or laparoscopy
Semen analysis
0 Remains the mainstay in investigating male fertility
potential.
0 Serial semen samples (at least two) should be
assessed in the same laboratory
Criteria
According to the WHO the lower limit of the
normal semen testing is
> 20 million/mL.
>40% progressive motility
>30% normal forms
Collection of semen sample
• by masturbation
• after min 3 days abstinence, max 7 days
• temp (15C to 38C)
• deliver quickly
0 As many as 25% of proven fertile men have sperm
concentration
below 20 million/ml
CASA vs. conventional analysis
0 In a randomized controlled trial, the determination of
motility characteristics as obtained by CASA systems is
of limited value
0 CASA (computer assisted semen analysis) is not
superior to conventional semen analysis
(Krause ,1995 )
Testicular biopsy
0 For selected cases
0 Only in tertiary centers
0 Needs semen retrieval and cryopreservation facilities
Hysterosalpingography
Or pregnancy
Conception after HSG
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.
Some evidence that conception rates
increase during the 6 mths following HSG.
Confirmation of Ovulation
Serum progesterone in the mid-luteal phase on
day 22-26 is the method of choice
Endometrial biopsy is not a routine step in the
investigations of infertility .
However, Ultrasonography
0 US examination of the pelvis is useful
especially for the ovary.
0 Transvaginal sonography is the method of
choice for women who are having ovulation
induction
The second category
Includes tests which are not consistently
correlated with pregnancy as
0 zona-free hamster egg penetration tests
0 post coital test
0 antisperm antibodies assays.
Sperm function tests
0 should not be routine investigations
complex
expensive
not always provide clinically useful information)
Postcoital test
Diagnosis – laparoscopy
black- brown
Commonest appearance : round protruding vesicle which
shows a succession of colours from blue- brown- black
Endometriosis : Mild
. CONTROVERSY: ovarian
stimulation with IUI is more effective
for them than either no treatment or
IUI alone.
Endometriosis :
Moderate to Severe
Endometriosis :Moderate to
Severe
Surgical treatment may improve fertility
but controlled studies and comparisons
with assisted reproduction techniques are
required
Endometriosis-associated
infertility
Hormonal therapy for ovulation suppression cannot be
recommended as a standard therapy for
endometriosis-associated infertility.