Infertility one year or longer Initial evaluation , history ,physical examination Irregular Unilatera or Structural Abnormal Normalmenses,no bilateral endometria semen evaluationovulation tube block abnormality analysis Uterine MaleAnovulation Tubal factor Unexplained factor 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 Done on day 12 or 13 of menstrual cycle. Report to clinic within 8 hours of intercourseEndocervical mucus is collected and placed on a slideNumber and motility of sperms seen under microscope
MILLER KURZROK TESTCervical mucus of the wife at the time of ovulation is placed on slide Semen of the husband is placed alongside Penetration of the sperms is studied under microscope
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 Abnormal Abnormal NormalsemenHusband’s semen+ Abnormal Normal Abnormaldonor mucusInference Problem in Wife’s Immunologic both mucus problem in abnormal male
INVESTIGATIONS TODETECT 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 Atropine is Clean the lower genital tract given 30 min before Radiopaque dye injected procedure through cannula Radiographic pictures taken
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 .
Ovarian disordersInfrequent menses Signs ofSigns of decreased High day 3 FSH hyperandrogenism estrogenization Abnormal CCCT Oligomenorrhoea High FSH , LH Advanced age AnovulationPremature ovarian Decreased ovarian Polycystic ovarian failure reserve syndrome Assess for and Brief trials of Ovulation treat secondary superovulation or induction causes IVF ART ART