Definition
• Infertility is inability of a couple to
conceive after one year of sexual
intercourse without contraception
Which Investigations!!
There is a very long list of investigations
for the diagnosis of infertility, however
there is no c...
Male Factor
conventional semen analysis
A variety of sperm function tests such
as in vitro mucous penetration test,
hamste...
Assessment of ovulation
Basal body temperature
Mid luteal serum progesterone
Endometrial biopsy
Ultrasound monitoring of o...
Tubal factor
Hysterosalpingography
Laparoscopy
Falloscopy
Hysterosonography
Hydrolaparoscopy.
Others
The peritoneal factors are assessed by
laparoscopy
The uterine factor by
hysterosalpingography and
hysteroscopy.
Im...
Controverses
A lack of agreement exists among
trained infertility speicalists with regard
to the diagnostic tests to be pe...
Opinion Based Practice
consulting senior colleagues or by
reading text books with lack of sufficient
time available for se...
Evidence-based medicine (EBM)
EBM brings the best available evidence
from clinical research to clinical
practice.
gets our...
Sources of Evidence Based
Infertility investigations
Cochrane Library
Journal of Evidence Based Obstetrics and
Gynecology
...
Take Care
Care must be taken to avoid
exploitation of the infertile couple with
expensive unnecessary tests
( ESHRE Capri ...
Concept to keep in mind
A simplified approach will lead to a
significant reduction in both the time
and cost of investigat...
So what EBM tells us?!!
Diagnostic tests for infertility should be
categorized into three categories based
on the correlat...
The first category
includes tests which have an established
correlation with pregnancy as:
semen analysis
Tubal patency by...
Semen analysis
Remains the mainstay in investigating
male fertility potential.
Serial semen samples (at least two)
should ...
WHO criteria
According to the WHO the lower limit of the
normal semen testing is
> 20 million/mL.
>40% progressive motilit...
Collection of semen sample
by masturbation
Temp (15C to 38C)
deliver quickly
As many as 25% of proven fertile men
have spe...
CASA vs. conventional analysis
In a randomized controlled trial, the
determination of motility characteristics
as obtained...
Hysterosalpingography
Although HSG is of low sensitivity, its high
specificity makes it a useful screening test
for ruling...
Advantages
HSG is cheaper
Performed as an outpatient procedure
Although often painful has a low
incidence of complications...
Conception after HSG
HSG has a low prognostic value, the
outcome of HSG adds little to predicting
the occurrence of pregna...
Serum chlamydial antibodies vs HSG
Chlamydia antibody testing has
comparable estimates of tubal pathology
but
provides no ...
Laparoscopy
Is the gold standard
Invasive
Costy
Incidence of complications 1-2%
Confirmation of Ovulation
The only true proof of ovulation is the
recovery of an ovum
Or
pregnancy
Confirmation of Ovulation
Serum progesterone in the mid-luteal phase on
day 22-26 is the method of choice
Endometrial biop...
However, Ultrasonography
US examination of the pelvis is useful
especially for the ovary.
Transvaginal sonography is the m...
The second category
Includes tests which are not consistantly
correlated with pregnancy as
zona-free hamster egg penetrati...
Sperm function tests
should not be routine investigations
complex
expensive
not always provide clinically useful
informati...
Postcoital test
Comparing impact of infertility investigations
with and without the postcoital test showed
closely similar...
The third category
Includes tests which seem not to correlate
with pregnancy as:
endometrial dating
varicocele assessment
...
Endometrium
Premestrual Endometrial biopsy does
not correlate with pregnancy:-
Pathologist: interobserver variation
type o...
Endometrium
The prognostic value of endometrial
thickness by US is not universally
accepted
(Schild et al 2001)
Thyroid / Prolactin assay
There is no value in measuring thyroid
function or prolactin in women with a
regular menstrual c...
BBT/LH
There is no evidence that the use of BBT
charts and luteinizing hormone detection
methods to time intercourse impro...
Hysteroscopy
HSC is not a routine investigation of
infertile couples as there is no evidence
linking treatment of uterine ...
Precaution
Before uterine instrumentation (as HSG
or HSC) appropriate antibiotic
prophylaxis against chlamydia should
be g...
CA-125 in endometriosis
• The performance of serum CA-125
measurement in the diagnosis of
endometriosis grade I/II is limi...
How to judge a new diagnostic
test
Sensitivity: to produce few false negatives.
Specificity: to produce few false positive...
Hydrolaparoscopy as a model
Specific as HSG
Invasive
Costy
In unexplained infertility
Require hysteroscopy
Gordts,1999
Thus
More difficult than HSG
Not superior to HSG
Inferior to D.L
Its role is still unclear
Templeton,2001
3-D US: another model
As effective as two-dimentional US
Very expensive
No specific advantage in infertility over
2-D
No r...
Summary
From the above data, it seems that
serum progesterone for detection of
ovulation, hysterography for tubal
patency ...
Other tests may have a role in special
situations or as a part of clinical trials
Laparoscopy should be reserved as a
furt...
Testing until uncertainty
vanishes may delay treatment
AGING process
Investigation of infertility modified
Investigation of infertility modified
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how to investigate infertile couples? there are endless number of tests: How evidence based diagnosis would help us in this issue? this talk try to answer such questions?

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Investigation of infertility modified

  1. 1. Definition • Infertility is inability of a couple to conceive after one year of sexual intercourse without contraception
  2. 2. Which Investigations!! 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
  3. 3. Male Factor conventional semen analysis A variety of sperm function tests such as in vitro mucous penetration test, hamster egg penetration test and post coital test.
  4. 4. Assessment of ovulation Basal body temperature Mid luteal serum progesterone Endometrial biopsy Ultrasound monitoring of ovulation.
  5. 5. Tubal factor Hysterosalpingography Laparoscopy Falloscopy Hysterosonography Hydrolaparoscopy.
  6. 6. Others The peritoneal factors are assessed by laparoscopy The uterine factor by hysterosalpingography and hysteroscopy. Immunological factors are evaluated by a variety of special tests.
  7. 7. Controverses A lack of agreement exists among trained infertility speicalists with regard to the diagnostic tests to be performed and their prognostic utility as well as criteria of normality
  8. 8. Opinion Based Practice consulting senior colleagues or by reading text books with lack of sufficient time available for searching the specialized journals. Little is paid to evidence derived from research “the Scientific Factor”.
  9. 9. Evidence-based medicine (EBM) EBM brings the best available evidence from clinical research to clinical practice. gets our knowledge up to date by tracking the recent clinical research results.
  10. 10. Sources of Evidence Based Infertility investigations Cochrane Library Journal of Evidence Based Obstetrics and Gynecology Evidence based recommendations of the Royal College of Obstetrics & Gynecology
  11. 11. Take Care Care must be taken to avoid exploitation of the infertile couple with expensive unnecessary tests ( ESHRE Capri Workshop 1996)
  12. 12. 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. (Strandell 2000)
  13. 13. So what EBM tells us?!! Diagnostic tests for infertility should be categorized into three categories based on the correlation with pregnancy rates
  14. 14. The first category includes tests which have an established correlation with pregnancy as: semen analysis Tubal patency by hysterography or laparoscopy Mid luteal progesterone for the diagnosis of ovulation.
  15. 15. Semen analysis Remains the mainstay in investigating male fertility potential. Serial semen samples (at least two) should be assessed in the same laboratory (WHO,1999)
  16. 16. WHO criteria According to the WHO the lower limit of the normal semen testing is > 20 million/mL. >40% progressive motility >30% normal forms WHO,1999
  17. 17. Collection of semen sample by masturbation Temp (15C to 38C) deliver quickly As many as 25% of proven fertile men have sperm concentration below 20 million/ml
  18. 18. CASA vs. conventional analysis In a randomized controlled trial, the determination of motility characteristics as obtained by CASA systems is of limited value CASA is not superior to conventional semen analysis (Krause ,1995 )
  19. 19. Hysterosalpingography Although HSG is of low sensitivity, its high specificity makes it a useful screening test for ruling in tubal obstruction. In case of abnormal finding, diagnostic laparoscopy with dye transit is the procedure of choice (Swart et al, 1995)
  20. 20. Advantages HSG is cheaper Performed as an outpatient procedure Although often painful has a low incidence of complications RCOG, 1999
  21. 21. 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. (Maas et al, 1997)
  22. 22. Serum chlamydial antibodies vs HSG Chlamydia antibody testing has comparable estimates of tubal pathology but provides no details on the anatomy of uterus and tubes. (Mol et al, 1997)
  23. 23. Laparoscopy Is the gold standard Invasive Costy Incidence of complications 1-2%
  24. 24. Confirmation of Ovulation The only true proof of ovulation is the recovery of an ovum Or pregnancy
  25. 25. 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 . (Peters et al,1992 / Templeton,2001)
  26. 26. However, Ultrasonography US examination of the pelvis is useful especially for the ovary. Transvaginal sonography is the method of choice for women who are having ovulation induction (Templeton 2001)
  27. 27. The second category Includes tests which are not consistantly correlated with pregnancy as zona-free hamster egg penetration tests post coital test antisperm antibodies assays.
  28. 28. Sperm function tests should not be routine investigations complex expensive not always provide clinically useful information) (Oehninger et al 2000)
  29. 29. Postcoital test Comparing impact of infertility investigations with and without the postcoital test showed closely similar cumulative pregnancy rates at 24 months, the postcoital test is not an essential procedure (Oei et al, 1998)
  30. 30. The third category Includes tests which seem not to correlate with pregnancy as: endometrial dating varicocele assessment chlamydial testing. (ESHRE Capri workshop 2000)
  31. 31. Endometrium Premestrual Endometrial biopsy does not correlate with pregnancy:- Pathologist: interobserver variation type of curette used debate on timing Karamardian & Grimes,1992
  32. 32. Endometrium The prognostic value of endometrial thickness by US is not universally accepted (Schild et al 2001)
  33. 33. Thyroid / Prolactin assay There is no value in measuring thyroid function or prolactin in women with a regular menstrual cycle, in the absence of galactorrhoea or symptoms of thyroid disease (Templeton,2001)
  34. 34. BBT/LH There is no evidence that the use of BBT charts and luteinizing hormone detection methods to time intercourse improves outcome. (Leader,1992 / Guermandi,2001)
  35. 35. Hysteroscopy HSC is not a routine investigation of infertile couples as there is no evidence linking treatment of uterine abnormalities with enhanced fertility. (RCOG,1999)
  36. 36. Precaution Before uterine instrumentation (as HSG or HSC) appropriate antibiotic prophylaxis against chlamydia should be given RCOG,1999
  37. 37. CA-125 in endometriosis • The performance of serum CA-125 measurement in the diagnosis of endometriosis grade I/II is limited, whereas its performance in the diagnosis of endometriosis grade III/IV is better. • Better in predicting recurrence (Mol et al, 1998)
  38. 38. How to judge a new diagnostic test Sensitivity: to produce few false negatives. Specificity: to produce few false positives. Positive predictivevalue. Negative predictive value. Invasiveness: with the possibility of harmfulness Cost
  39. 39. Hydrolaparoscopy as a model Specific as HSG Invasive Costy In unexplained infertility Require hysteroscopy Gordts,1999
  40. 40. Thus More difficult than HSG Not superior to HSG Inferior to D.L Its role is still unclear Templeton,2001
  41. 41. 3-D US: another model As effective as two-dimentional US Very expensive No specific advantage in infertility over 2-D No role in infertility yet N.B: Bicornuate ut. Vs septate ut
  42. 42. Summary From the above data, it seems that serum progesterone for detection of ovulation, hysterography for tubal patency and semen analysis are the basic essential tests for diagnosis of infertility.
  43. 43. Other tests may have a role in special situations or as a part of clinical trials Laparoscopy should be reserved as a further diagnostic procedure or in combination with endoscopic surgery
  44. 44. Testing until uncertainty vanishes may delay treatment AGING process

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