Definition of Infertility
According to American Society of Reproductive Medicine (ASRM) Infertility Is defined as
An infertility evaluation may be offered to any patient who
a) By definition has Infertility
b) Is at high risk of infertility
Indications for immediate evaluation include:-
Basic Infertility Evaluation
Both partner should be evaluated.
Evaluation of an infertile couple depends on thorough history and physical evaluation of the couple.
Who is Responsible?
We see that male and female partners both are approximately equally responsible for infertility. So Couple has to be treated together as a unit.
A very important aspect of infertility management is Counselling, Counselling and Counselling!!!. The role of counselling in the management of infertile couple cannot be underestimated, rather it is of utmost importance. Counselling at all the steps is important, starting from the first visit to each step and even at failure. The best counselor is the treating Doctor herself, but other counsellors can be hired and trained. Counsel the patient thoroughly by Audio Visual methods (Charts).
Evaluation of Infertile female - Over the period of time the evaluation of infertile couple has reduced to certain basic and concrete tests as compared to earlier long list of tests, haunting and confusing both doctor and patient. Start with a thorough History…History should be protocol based so that no aspect remains untouched
Duration of infertility, Menstrual history (Age at menarche, Cycle length, Severity and type of dysmenorrhea), Obstetric history (parity, previous pregnancy outcome, and associated complications), Coital frequency, Sexual dysfunction, dyspareunia, Previous methods of contraception, PID, STD, pelvic or abdominal pain, Thyroid disease, Galactorrhoea, Hirsutism, Past surgery, Results of any previous evaluation and treatment, Family history (Birth defects, mental retardation, Early menopause, Reproductive failure or compromise), Life style hazards (Exposure to known environmental hazards, History of Smoking, alcohol and drugs(SAD))
Obesity and Infertility has a very strong correlation, so much so that many patients conceive spontaneously after weight reduction. BMI Cut-off for Asians <18.5-underweight, 18.5-22.9-normal, 23-26.9-overweight, >=27-obese (WHO guidelines, 2010).
Investigations: Screening tests and Specific tests
Three ‘MUST KNOW’ skills for ART specialist- for Doctors aspiring to take infertility management as specialty, it is mandatory to be equipped with these three basic armamentarium
The art of learning transvaginal sonography is so much important that it is said that if you enter the field of infertility without the knowledge of this art it is almost like “walking in the dark without a torch”
Role of Ultrasound in Infertility
Trans vaginal Ultrasound, Basal D2/D3 Scan-Size and Shape of Uterus, Congenital uterine anomaly, Fibroid mapping, Adenomyosis, Preexisting cyst, Intra Uterine adhesions /synechia/ polyp
TVS & Endometrium - Endometrial thickness, Endometrial Pattern in different phases of menstrual cycle (Proliferative phase, Secretary Phase, Endomyometrial junctional zone- discrete/hazy, Endometrial Volume, 56-98% sensitivity to detect intrauterine lesion
Ultra Sound Doppler blood flow studies
Uterine and endometrial arteries resistance decreases significantly during the midluteal phase, i.e. in the period of embryo implantation (PI, less than 3.0). Endometrial blood flow evaluation is done by means of analyzing flow velocity waveforms of sub endometrial and endometrial arteries
Applebaum zones of Blood flow:
zone 1 - vessels penetrating the outer hypoechogenic area
zone 2 - vessels penetrating the hyperechogenic outer margin of the endometrium
zone 3 - vessels entering the hypoechogenic inner area of endometrium
zone 4 - up to the middle echo . Blood flow up to Zone 3 and 4 are good
USG & Ovaries- Ovarian masses, Ovarian Cyst & Endometrioma, Polycystic Ovaries, Ovarian blood flow, Antral Follicular Count (AFC) on D2/D3, Serial Folliculometry and ovulation studies-Size and number of developing follicles, Rate of follicular growth.
Folliculometry (TVS) - USG signs of ovulation, Sudden collapse of follicle, Loss of clear margins, Appearance of internal echoes in the follicle, Increase in cul-de-sac fluid volume
Ovarian Reserve Tests (ORTs)? What is ovarian Reserve? - Ovarian reserve relates to the quantity and quality of the remaining primordial follicle pool in both the ovaries at a given age. Ovarian reserve is a term that is used to determine the capacity of the ovary to provide eggs that are capable of fertilization, resulting in a healthy and successful pregnancy.
Difference between Ovarian response and ovarian reserve- Ovarian reserve may be good but ovarian response may be poor or vice versa may be true. It depends on many factors specific to the patient herself and may be due to genetic predisposition of difference in receptor responsiveness to various gonadotropins doses. So response is more important than reserve.
Ovarian reserve tests!!!
1) Age > 35 years Poor reserve
2) Basal D2/ D3 Hormones
3) Sonographic parameters
4) Dynamic tests
Hysterosalpingography (HSG) - HSG should be done under strict aseptic conditions by a trained person only, along with the tubal patency we can assess the Uterine cavity (septate, bicornuate, unicornuate, didelphys uterus, Endometrial Polyp, submucosal fibroid, intrauterine adhesions.
Laparoscopy- What information Laparoscopy can give? Uterus (shape, size any adhesions, Fibroids) Tubes (Architecture, Tubo-ovarian relation, Patency) Ovaries (size, Ovarian cyst, Free/Adherent) Pelvis (Endometriosis and its staging, Adhesions, Findings suggestive of tuberculosis, POD-free /obliterated).
Hysteroscopy- Gold standard for uterine cavity pathology.
Diagnostic: Uterine cavity (Normal cavity/T-shape uterine cavity, normal ostia, Polyp/submucous fibroid/adhesions, any congenital defect especially septa and its extent, Endometrial lining (strawberry type -in TB).
Therapeutic: correction of uterine malformation, septal resection, adhesiolysis, myomectomy, polypectomy, tubal cannulation.
Role of MRI in infertility- Fibroid mapping and adenomyosis, Mullerian duct anomalies and associated renal anomalies, pituitary adenoma in cases of hyper prolactinemia.
Male factor Evaluation
History- (Age, occupation, previous seminal analysis, smoking, alcohol and drug (SAD) Tobacco), Sexual history (Erectile dysfunction or ejaculatory problems, loss of libido) Medical history (Diabetes, hypertension, TB), Surgical (Hydrocele, hernia, Varicocele, Undescended testis, Appendicectomy), Family history (diabetes, hypertension, male infertility), History of consanguinity.
Physical examination - If semen analysis abnormal or sexual dysfunction
Single most important test for male factor evaluation is good Semen Analysis (Semen Qualitative Examination -SQE) by pre and post semen processing method. SQE is different from semen analysis done in a pathology laboratory.
In an infertility centre, Semen collection is done in a clean, hygienic and separate collection room meant for the purpose.
Commonly used semen processing techniques-Swim-Up Technique and Density Gradient Method.
Advantages of Processing Semen.
Additional advanced analyses need to be carried out in case of subnormal semen parameters.
Infertility tests in special situations
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