As in all fields of medicine, management of the patient(s) can only be appropriately provided once the cause (s) of the problem is discovered, which requires:
Accurate history investigation
Imaging and laboratory investigation
When applying any of the available tests, the following need to be considered:
• Sensitivity (to minimize false-negatives)
• Specificity (to minimize false-positives)
• Usefulness (should results change treatment?)
• Positive and negative predictive values
Critical evaluation of various investigations for infertility was undertaken at a recent workshop of the European Society of Human Reproduction and Embryology (ESHRE) and the results published in the year 2000.
Accurate history investigation
Data that need to be recorded:
• Duration of infertility
• Frequency of intercourse
• Menstrual history
• Previous pregnancies
• Surgery and hospitalization
• If any drugs are being taken, and the presence of any drug sensitivity
• Previous fertility investigations and/or treatment
• Female body mass index (BMI) should be calculated (dividing weight/kg by the height/meter square [kg/m2]. Normal range is between 18.5 and 25).
Obese women should be advised to reduce their weight, stop smoking and reduce alcohol consumption.
A full physical examination should be routinely undertaken. This should include comments on the following:
Observation regarding presence of androgen excess (acne, facial hair, irregular abdominal and pelvic hair)
Palpation of the thyroid gland
Acanthosis nigricans (associated with insulin resistance)
“Buffalo neck” (associated with Cushing’s syndrome)
Turner’s syndrome (short stature, web-bed neck, shield chest, undeveloped breasts, and cubitus valgus, abdominal striae)
Secondary sexual characteristics (gonadotropin deficiency - androgen insensitivity syndrome, Kallmann’s syndrome, Turner’s syndrome)
Pelvic examination for:
• Absence of the vagina (Rokitansky–Küster–Mayer syndrome—the most frequent anatomic cause of primary amenorrhea)
• Imperforate hymen
• Vaginal septa (either transverse or longitudinal, or double cervices)
Microbiologic culture (possible as a routine for chlamydia or only if there is an abnormal discharge)
Rubella status, and, if seronegative, vaccination should be offered
Folic acid, 0.4mg, as a supplement to prevent neural tube defects is recommended (starting 3 months before initiation of treatment). Supplementation started >30 days after conception has no protective effect.
Uterine and size, shape, position, and mobility should be recorded
The adnexal and parametrial structures should be examined for the presence of large ovarian masses
Nodularity in the uterosacral ligaments on bimanual palpation or rectovaginal examination may indicate endometriosis
Vaginal Ultrasound Examination
Detection and exclusion of any abnormalities
The criterion for performing a test depends on whether the results would be of value in the management of the problem. Currently, there are no universally accepted standard protocols for investigation of subfertile couples, although there are guidelines produced by the World Health Organization (WHO) published by the Cambridge University Press in 1993, and the Royal College of Obstetricians and Gynaecologists published in London in 1998.
For a natural cycle IVF we need to know that the patient is ovulating.
A woman with regular menstrual cycles every 21–35 days is most likely to be ovulating. This can be confirmed by a midluteal serum progesterone measurement (above 18 nmol/L based on WHO standards, and between 16nmol/l and 32nmol/l according to ESHRE).
The basal body temperature (BBT) chart is no longer in use in most clinics.
Serial ultrasound scans that examine follicular growth, and the disappearance of the large follicle with the presence of fluid in the pouch of Douglas, may confirm that ovulation has occurred.
Endometrial biopsy can be performed during the luteal phase to confirm the presence of a secretory endometrium. Measurements should be taken to ensure that the women is not pregnant. The criteria for dating the endometrium were published by Noyes and colleague in 1950 and are still being used today. A discrepancy of 2 or more days after menstrual dating defines luteal-phase deficiency (LPD).
A baseline ultrasound scan is able to diagnose congenital anomalies, uterine fibroids, hydrosalpinges, ovarian cysts, endometriomas, and polycystic ovaries.
Normal uterus Contrast media in the uterus shows no pathology
Endometrium as seen in vaginal ultrasound examination:
A) Early follicular endometrium; B) Late follicular endometrium;
C) Midluteal endometrium
Bicornuate uterus Bicornuate uterus Unicornuate uterus
Uterine polyp Hydrosonography showing fibroids bulging into the uterine cavity Multicycstic ovary
Clear ovarian cyst Endometrioma polycystic ovary
A hydrosalpinxis a distally blocked fallopian tube filled with serous or clear fluid. The blocked tube may become substantially distended giving the tube a characteristic sausage-like or retort-like shape. The condition is often bilateral and the affected tubes may reach several centimeters in diameter. The blocked tubes cause infertility.A fallopian tube filled with blood is a hematosalpinx, and with pus a pyosalpinx.
The most common tool to assess the uterine cavity and opening of the fallopian tube is still the hysterosalpingogram
Uterine cavity defects such as fibroids, polyps, and synechiae can be clearly demonstrated with HSG
Normal examination Bicornuate uterus Sactosalpinx of right tube
A closed and dilated right ampullary end Septate uterus Bicornuate uterus
Bicornuate uterus Unicornuate uterus Uterus with fibroid Uterus with fibroid
In general, HSG is performed after cessation of menses, while the couple are requested to avoid intercourse from the time of menstruation to the time of examination, to prevent interference with an early pregnancy. Contrast media used are oil-based or water–based. It has been claimed that pregnancy rate after using oil-based media is higher. It is clear today that water-soluble media reduces inflammatory reactions, especially granulomatous inflammation, and the risk of oil embolism. A meta-analysis, published in 1995, demonstrated 65% sensitivity, and 83% specificity for diagnosing tubal obstruction.
Hysterosalpingo-Contrast Sonography (HyCoSy)
Tubal opening is assessed by using transvaginal ultrasound, and an injection of a solution containing gas microtubules stabilized on galactose microparticles. This procedure is lack of expose the patient to radiation exposure.
MRI(magnetic resonance imaging)
A procedure in which radio waves and a powerful magnet linked to a computer are used to create detailed pictures of areas inside the body.
Arcuate uterus Bicornuate uterus Uterine fibroids
Hysteroscopy is a simple procedure to visualize the cervical canal and the inside of the uterus using a thin, lighted, flexible tube designated a hysteroscope. The device is inserted through the vagina. It can be used as a diagnostic, as well as a therapeutic tool. The procedure can be performed with or without a local anesthetic, especially if it is used for a diagnostic procedure only. Occasionally this is performed under general anesthesia, usually to remove a polyp, fibroid, adhesions or for biopsy.
The hysteroscope inserted into the uterus through the cervix
Normal hysteroscopic view for comparison Fibroid in the uterine cavity Intrauterine adhesions
Uterine polyp observed during hysteroscopy Uterine septum at hysteroscopy Two bands of scar tissue (green Xs)
Uterine myoma at hysteroscopy
Risks of the Procedure
As with any surgical procedure, complications may occur. Some possible complications of hysteroscopy may include, but are not limited to, the following:
• Pelvic inflammatory disease
• Perforation of the uterus (rare)
This procedure is performed under general anesthesia, with tubal patency checked by the transcervical injection of methylene blue dye, and remains the “gold standard” for the accurate assessment of tubal patency. Visualization of the pelvic cavity by laparoscopy is necessary to ascertain tubal patency, adnexal adhesions, and ovarian mass. In the early days of IVF, oocytes were recovered using laparoscope under direct visualization of the ovaries.
IVF was established to bypass tubes that do not function properly, therefore unless there is a suspected pelvic pathologysuch as ovarian tumor, endometriosis, or endometrioma, there is no need for such a procedure.
In some of the cases GIFT and ZIFT are still being performed, however, for these procedures, in most of the cases HSG is adequate for investigation.
Some abnormalities detected at the time of diagnostic laparoscopy can be treated during the same procedure (for example, lysis of adhesions, salpingectomy, ovarian cystectomy, cauterization or vaporization of endometriotic implants).
Complications following laparoscopy
Due to general anesthesia, a 1–2% complication rate comprises postoperative infection, injury to bowel or blood vessels, and mortality of eight per 100,000.
Laparoscopy - the procedure Normal pelvis as seen through the laparoscope
Adhesions noted during laparoscopy Bicornuate uterus
Didelphys uterus Laparoscopic view of the left tube and ovary in a woman with severe pelvic adhesions.
A transparent band of adhesions between the ovary and the uterus and bowel (A)