Others• The peritoneal factors are assessed by laparoscopy• The uterine factor by hysterosalpingography and hysteroscopy.• Immunological factors are evaluated by a variety of specialtests.
Controverses• A lack of agreement exists among trained infertility speicalistswith regard to the diagnostic tests to be performed and theirprognostic utility as well as criteria of normality
Opinion Based Practice• consulting senior colleagues or by• reading text books with lack of sufficient time available forsearching the specialized journals.• Little is paid to evidence derived from research “the ScientificFactor”.
Evidence-based medicine(EBM)• EBM brings the best available evidence from clinical research toclinical practice.• gets our knowledge up to date by tracking the recent clinicalresearch results.
Sources of Evidence BasedInfertility investigations• Cochrane Library• Journal of Evidence Based Obstetrics andGynecology• Evidence based recommendations of the RoyalCollege of Obstetrics & Gynecology
Take Care• Care must be taken to avoid exploitation of the infertile couplewith expensive unnecessary tests( ESHRE Capri Workshop 1996)
Concept to keep in mindA simplified approach will lead to asignificant reduction in both the time andcost of investigating an infertile couple.(Strandell 2000)
So what EBM tells us?!!• Diagnostic tests for infertility should be categorized into threecategories based on the correlation with pregnancy rates
The first categoryincludes tests which have an established correlation with pregnancyas:• semen analysis• Tubal patency by hysterography or laparoscopy• Mid luteal progesterone for the diagnosis of ovulation.
Semen analysis• Remains the mainstay in investigating male fertility potential.• Serial semen samples (at least two) should be assessed in thesame laboratory(WHO,1999)
WHO criteria• According to the WHO the lower limit of thenormal semen testing is> 20 million/mL.>40% progressive motility>30% normal formsWHO,1999
Collection of semen sample• by masturbationTemp (15C to 38C)deliver quickly• As many as 25% of proven fertile men have spermconcentrationbelow 20 million/ml
CASA vs. conventional analysis• In a randomized controlled trial, the determination of motilitycharacteristics as obtained by CASA systems is of limited value• CASA is not superior to conventional semen analysis(Krause ,1995 )
Hysterosalpingography• Although HSG is of low sensitivity, its highspecificity makes it a useful screening test forruling in tubal obstruction.• In case of abnormal finding, diagnosticlaparoscopy with dye transit is the procedureof choice(Swart et al, 1995)
Advantages• HSG is cheaper• Performed as an outpatient procedure• Although often painful has a low incidence of complicationsRCOG, 1999
Conception after HSG• HSG has a low prognostic value, the outcomeof HSG adds little to predicting the occurrenceof pregnancy.• However, when HSG shows bilateralobstruction, the chance of getting pregnant isonly minimal.(Maas et al, 1997)
Serum chlamydial antibodies vs HSGChlamydia antibody testing has comparableestimates of tubal pathology butprovides no details on the anatomy of uterusand tubes.(Mol et al, 1997)
Confirmation of OvulationThe only true proof of ovulation is the recovery of an ovumOrpregnancy .
Confirmation of OvulationSerum progesterone in the mid-luteal phase on day22-26 is the method of choiceEndometrial biopsy is not a routine step in theinvestigations of infertility .(Peters et al,1992 / Templeton,2001)
However, Ultrasonography• US examination of the pelvis is usefulespecially for the ovary.• Transvaginal sonography is the method ofchoice for women who are having ovulationinduction(Templeton 2001)
The second categoryIncludes tests which are not consistantlycorrelated with pregnancy as• zona-free hamster egg penetration tests• post coital test• antisperm antibodies assays.
Sperm function tests• should not be routine investigationscomplexexpensivenot always provide clinically useful information)(Oehninger et al 2000)
Postcoital test• Comparing impact of infertility investigationswith and without the postcoital test showedclosely similar cumulative pregnancy rates at 24months, the postcoital test is not an essentialprocedure(Oei et al, 1998)
The third categoryIncludes tests which seem not to correlate withpregnancy as:• endometrial dating• varicocele assessment• chlamydial testing.(ESHRE Capri workshop 2000)
Endometrium• The prognostic value of endometrial thickness is notuniversally accepted(Schild et al 2001)
Thyroid / Prolactin assay• There is no value in measuring thyroidfunction or prolactin in women with a regularmenstrual cycle, in the absence ofgalactorrhoea or symptoms of thyroid disease(Templeton,2001)
BBT/LH• There is no evidence that the use of BBTcharts and luteinizing hormone detectionmethods to time intercourse improvesoutcome.(Leader,1992 / Guermandi,2001)
Hysteroscopy• HSC is not a routine investigation of infertilecouples as there is no evidence linkingtreatment of uterine abnormalities withenhanced fertility.(RCOG,1999)
Precaution• Before uterine instrumentation (as HSG or HSC) appropriateantibiotic prophylaxis against chlamydia should be givenRCOG,1999
CA-125 in endometriosis•The performance of serum CA-125measurement in the diagnosis ofendometriosis grade I/II is limited, whereas itsperformance in the diagnosis of endometriosisgrade III/IV is better.• Better in predicting recurrence(Mol et al, 1998)
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
Hydrolaparoscopy as a model• Specific as HSG• Invasive• Costy• In unexplained infertility• Require hysteroscopyGordts,1999
Thus• More difficult than HSG• Not superior to HSG• Inferior to D.LIts role is still unclearTempleton,2001
3-D US: another model• As effective as two-dimentional US• Very expensive• No specific advantage in infertility over 2-DNo role in infertility yetN.B: Bicornuate ut. Vs septate ut
Summary• From the above data, it seems that serum progesterone fordetection of ovulation, hysterography for tubal patency andsemen analysis are the basic essential tests for diagnosis ofinfertility.
• Other tests may have a role in special situations or as a part ofclinical trials• Laparoscopy should be reserved as a further diagnosticprocedure or in combination with endoscopic surgery