INVESTIGATIONS

Infertility one year or longer

Initial evaluation , history ,physical

examination

Irregular menses,no ovulation

Unilatera or bilateral

tube block

Normal evaluation

Structural endometria abnormality

Abnormal semen

analysis

Anovulation Tubal factor Unexplained Uterine factor

Male factor

Counselling and psychosocial support Multiple factors – investigate and manage

HISTORY• Age• Duration of marriage• Menstrual history• Past obstetric history – PROM , puerperal sepsis • Previous use of contraceptives and its type • Medical History - tuberculosis , pelvic infection ,

STD ,diabetes , thyroid dysfunction .• Surgical history

CLINICAL EXAMINATION

• Height and weight• Blood pressure• Features of hirsuitism • Galactorrhoea• Palpation of thyroid • Breast and lymph nodes• Abdominal examination

GYNAECOLOGICAL EXAMINATION

• Examination of perineum• Speculum examination

INVESTIGATIONS FOR CERVICAL FACTORS

• POST COITAL TEST / SIMS TEST / HUHNERS TEST

• MILLER - KURZROK TEST• SEMEN CERVICAL MUCUS CONTACT TEST

POST COITAL TEST

Number and motility of sperms seen under microscope

Endocervical mucus is collected and placed on a slide

Report to clinic within 8 hours of intercourse

Done on day 12 or 13 of menstrual cycle.

MILLER KURZROK TEST

Penetration of the sperms is studied under microscope

Semen of the husband is placed alongside

Cervical mucus of the wife at the time of ovulation is placed on slide

MILLER KURZROK TEST

SEMEN CERVICAL MUCUS CONTACT TEST

• A test for anti sperm antibodies .• The sperm and mucus are mixed and sperms

viewed under microscope for characteristic shaky movement.

Wife’s mucus+ donor semen

Abnormal Abnormal Normal

Husband’s semen+ donor mucus

Abnormal Normal Abnormal

Inference Problem in both

Wife’s mucus abnormal

Immunologic problem in male

INVESTIGATIONS TO DETECT TUBAL PATENCY

• HYSTEROSALPINGOGRAPHY• LAPROSCOPIC CHROMOTUBATION• SONOSALPINGOGRAPHY• HYSTEROSCOPY AND FALLOSCOPY• AMPULLARY AND FIMBRIAL

SALPINGOSCOPY

HYSTEROSALPINGOGRAPHY• To visualize uterine cavity and fallopian tubes• Done on day 10 of menstrual cycle PROCEDURE

Clean the lower genital tract

Radiopaque dye injected through cannulaRadiographic pictures taken

Atropine is given 30 min before procedure

LAPAROSCOPIC CHROMOTUBATION

• To visualize pelvis , fallopian tubes and ovaries and to verify HSG findings.

• Peritubal adhesions and unsuspected endometriosis can be diagnosed.

• Indicated in patients with blocked fallopian tubes prior to tubal microsurgery.

• Advantage – can proceed with therapeutic procedure.

SONOSALPINGOGRAPHY

• Less side effects.• Good technique to detect submucous fibroid

polyp and intrauterine lesions. PROCEDURE Under ultrasound scanning slow injection of 200ml of physiological saline through Foleys catheter.

HYSTEROSCOPY AND FALLOSCOPY

• To study the interstitial end of fallopian tube.• ADVANTAGES - Mucus plug or inspissated material can be flushed out. - Polypus can be removed. - Synechiae can be broken.

AMPULLARY AND FIMBRIAL SALPINGOSCOPY

• To study the mucosa of fallopian tube.

DILATATION AND INSUFFLATION

• Also known as RUBINS TEST• Performed 2days after menstruation stops.• PROCEDURE – air or carbondioxide is pushed

transcervically under pressure .• Not commonly done now.

TESTS OF OVULATION• BASAL BODY TEMPERATURE• ENDOMETRIAL BIOPSY• FERN TEST• ULTRASOUND• HORMONAL STUDY

BASAL BODY TEMPERATURE• Falls at time of ovulation by 0.5 F. • In progestational half temperature is raised

above preovulatory level by 0.5 – 1 F.• Presumptive evidence of functional corpus

luteum.• Has now become obselete .

ENDOMETRIAL BIOPSY• Curetting small pieces of endometrium 1 or 2

days before onset of menstruation.• Histological scrutiny done after fixation in

formalin saline• Subjected to culture – rule out genital TB• Not done routinely

FERN TEST • Specimen of cervical mucus spread on slide and

viewed under low power microscope .• Oestrogenic phase – fern formation.• After ovulation ferning disappears.• At ovulation – ovulation cascade and

spinnbarkeit or thread test .• Secretory phase – spinnbarkeit disappears and

tack appears.• Insler scoring system

ULTRASOUND• Standard procedure for monitoring

maturation of graafian follicle .• ADVANTAGES Non invasive accurate and safe. Pelvic pathology can be picked up . Endometrial thickness can be measured .

HORMONAL STUDY• PLASMA PROGESTERONE• LUTEINIZING HORMONE • HYPERPROLACTINAEMIA• FOLLICLE STIMULATING HORMONE • THYROID TESTS

Ovarian disorders

Infrequent menses Signs of decreased estrogenization

High FSH , LH

High day 3 FSH Abnormal CCCT Advanced age

Signs of hyperandrogenism Oligomenorrhoea

Anovulation

Premature ovarian failure

Decreased ovarian reserve

Polycystic ovarian syndrome

Assess for and treat secondary

causes

Brief trials of superovulation or

IVF

Ovulation induction

ART ART

INVESTIGATIONS FOR UTERINE FACTORS

THANK YOU

A presentation by - Athira P.A (final year: JUGGERNAUTS)