This document provides guidance for general gynecologists on evaluating and managing basic infertility. It highlights that a thorough history and physical exam should be done before starting any workup. The workup should generally start after 6 months of trying unless certain risk factors are present. Key parts of the initial workup include a semen analysis, confirming ovulation with a mid-luteal progesterone test, and checking tubal patency with HSG or sonohysterography. Empirical clomiphene citrate therapy is not recommended. IUI is only appropriate if the gynecologist understands patient selection and timing of referral for more advanced treatments. Lifestyle changes should be the first approach for overweight PCOS patients.

1. DIAGNOSIS AND
MANAGEMENT OF
BASICINFERTILITY

2. Rationale
Recorded malpractices
done by some general
gynecologists (GG) in
management of
infertility .

3. Objective
 To highlight practical messages
for GG regarding workup and
management of infertility.
 Are based on:
META-ANALYSIS
RCT
GUIDELINES AND PROTOCOLS.

4. Malpractice regarding the
workup?
 Negligence of history
taking, Examination before
starting workup:
Many problems can be
solved before
proceeding to
workup!!!!!!!!

5. When To start Workup
( investigations)?
 Three Era WHO)
 After one year ( Retrospective data ).
 After two years ( Retrospective data ).
 Recently After 6 months ( prospective data).
Provided That
 Absence of known reproductive pathology.
 Regular and frequent marital relationship

6. Why duration becomes 6
month only ( WHO )?
Reduction in both
the time and cost of
investigating an
infertile couple.

7. WHAT IS AFTER WORKUP earlier than 6 month ?
 If workup normal…….leave
couple till one year passed
or become pregnant……
 If any workup is
abnormal……proceed the
treatment

8. Message 1 :Workup earlier than 6 month
•Female
Factor
•Irregular
menses
•PID
•Abdominal
surgery
•Dyspareunia
•Age > 35
•BMI >29

9. Workup Before 6 months ..cont
•Male factors
 Impotence.
 A partner known to be sub fertile.
 Testicular surgery/injury
 Outflow abnormalities (hypospadias) .
 Traveling abroad for working leaving
wife
•Social problems
•Second marriage

10. Workup which have an established
correlation with pregnancy
1- Semen analysis.
2- ovulation Assessment (Mid luteal
progesterone= MLP).
3-Tubal patency (HSG ,
sonohysterography or laparoscopy)

11. Messages regarding
Semen Assessment

12. Message 2
 Laboratories that
perform semen
analysis should follow
WHO methodology.

13. Message 3 : CASA or Conventional Semen
Analysis!!!?
CASA is not
superior to
conventional
semen analysis
(Grade A).

14. Message 4 :What To Do if
Semen analysis Is Abnormal?
 Repeat confirmatory test ( 3
months after the initial analysis
& ttt). (Grade B).
 If azoospermia or severe
oligozoospermia , repeat test as soon
as possible. (GPP)
(GPP =Good practice point )

15. Message 5: Where & When
Testicular Biopsy (TB) be done In
Azoospermia?
TB should be performed only
in a tertiary service where
there are facilities for sperm
recovery ,cryopreservation
and ART( C )

16. Messages regarding
Ovulation Assessment

17. Message 6: Regular menstruation
not indicate absolute ovulation
 Ovulation, should be
confirmed by MLP
Although regular
menstruation is strongly
suggestive of ovulation.

18. Message 7: Midluteal
Progesterone
 Pulsatile release, thus single level
may not be useful unless elevated.
 Values of > or = 10ng/ml are
suggestive of normal progesterone
production.
 In irregular cycles:
 the test may be performed later in
the cycle and repeated weekly until
the next menstruation.

19. Messages regarding Tubal
Patency tests

20. Message 8:No : Ranking of Tubal Patency
tests
The results of semen
analysis and assessment of
ovulation should be known
before a test for Tubal
Patency is performed.

21. Message 9 :precautions Done Before Tubal Patency
Tests?
 Prophylactic antibiotics should
be considered before uterine
instrumentation (including HSG),
if screening for Chlamydia
trachomatis has not been carried
out. (GPP)

22. Messages
Regarding HSG
Technique

23. Message 10 :
HSG should
be
performed
Under
Fluoroscopy
( Grade :d)

24. Removal of the
speculum
before
scanning
Application of
traction by the
tenaculum during
filling of the uterus
often results in
improved uterine
visualization.
Message 11:
. A complete view of
the endometrial
cavity and
cervical canal
should be the
aim.
Grade D

25. Flushing of the tubes with oil-soluble
media increases subsequent
pregnancy rates (It may flush tubal
"plugs" ).
The Cochrane Library, Issue 2 2004.
Message 12 : Oil-soluble # Water Soluble Media
for HSG

26. Message 13 : sonohysterography # HSG?
The use of sonohysterography
should be considered as an
effective alternative to HSG
(Grade A).
 TVS can add evaluation of
pelvis.

27. Hycosy using contrast agent (Infoson®)
HYCOSY using contrast agent
appears to be more efficient than
saline solution in detecting tubal
obstruction. (Grade A).

28. Messages regarding Doing
Unnecessary Workup

29. Message 14: Unnecessary laparoscopy!!!
It is not cost effective to do
diagnostic laparoscopy as part of
the initial infertility evaluation
when:
history, and physical
examination, TVS, HSG, and
Midluteal progesterone are all
normal (Grade B)

30. Message 15 :When To Do Laparoscopy For tubal evaluation?
 When associated pelvic co
morbidities (PID, previous Ectopic,
endometriosis ..etc) :evaluation of
the pelvis is required.
(Grade B)

31. Message 16:
:Hysteroscopy has NO
role in routine
evaluation
of infertility

32. Message 17: Indications of Hysteroscopy as
workup of infertility?
 Abnormal HSG
 When Laparoscopy is indicated as
in Unexplained infertility ?
 Before IVF in cases of
unexplained infertility ?!!!!
 After Failed IVF ?

33. Message 18: No Role
for...
1. Postcoital test.
2. Endometrial biopsy
3. Antisperm antibodies
4. Routine cervical cultures
5. Thyroid function ( in absence of
symptoms suggestive of of thyroid disease)
6.Prolactin (in absence of
galactorrhoea)

34. Why PCT Not Recommended?
 It has no predictive value on pregnancy
rate. (Grade A)……… Why?
. PCT may be of value in the diagnosis of sexual
dysfunction and ejaculatory problems.
. Results of PCT may have little effect on treatment
strategy in the light of the widespread use of IUI for
fertility problems.
. The lack of effective treatment for anti-sperm
antibodies may render PCT unnecessary.

35. Why PEB Not Recommended?
• Controversies regarding the
accuracy of diagnostic criteria.
• Controversies regarding the value
of LPD, as a cause of infertility.
• No evidence that medical treatment
of LPD improves pregnancy rate.
(ASRM, 2004 &Grade C NICE Guidelines 2004).

36. Message 19: The Role Of 3-D US In
workup?
No role in routine
infertility workup
Is effective as two-
dimensional US

37. Messages Regarding
Management

38. General Rules
 Both partners should be
considered as a one unit (couple)
 Timed intercourse to coincide
with ovulation causes stress
and not to be recommended
( e out COH).
 Smoking reduces both,
women’s fertility as well as
semen quality

39. 1. Anti E (cx & endometrium)
2. long lasting (till 14-22 day of cycle)
3. sub clinical pregnancy loss
4. LH sec > FSH miscarriage
5. (LUF) syndrome (unexplained infertility)
6. Ectopic ( Sluggish tubal transport)
Message 20: Disadvantages Of empirical CC

40. Conclusion
 It is more better to start
workup of infertility earlier
(6 month) and proceed….
than to waste time in
empirical CC therapy, with
its side effects.

41. Message 21: Pre requisites For Practicing IUI:
The gynecologist should be aware of:
1. IUI workup.
2.Prevention of complication of super
ovulation.
3.The optimal time for referral the case
to ART centers ( not do IUI)

42. Optimum Time For Referral To ART Centers
1. Age > 35 Y.
2. Failed 3 IUI.
3. Severe male subfertility.
4. Number of mature follicles >4 (not give HCG).
5. Number of follicles (>12 mm) >8 (not give HCG).
6. Extensive endometriosis.
7. Need for cryopreservation of semen.
8. Non optimized office.

43. Male Subfertility
Count Motility Morphology
Million/ml (G1+G2%) (N%)
Mild 15-20 40-50 30-40
Moderate 10-15 20-40 10-30
Severe <10 <20 <10
WHO

44. Message 22 Targets For Treatment PCOS
IR None IR
( Traditional)
Causative ttt
+or- Adjunctive
Symptomatic ttt :
Anovulation ,Acne,Hirsutism,
Insulin sensitizers :
prevent Hyperandrogenemia – IR
Vicious circle .
Adjunctive
PCOS

45. Message 23 :RCOG 2007 Guidelines
All overweight
PCOS should be
provided with
dietary and
lifestyle advice.

46. Message 24: LOD
• Not rush
towards LOD
as first line of
ttt PCOS.

47. Indications Of LOD In PCOS
1) IR PCOS (OBESE)
 Failure of :
 Change of life style.
 Insulin sensitizing agents.
 CC +/- HMG.
 2) Non insulin R (Lean
PCOS)