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INVESTIGATION OF INFERTILE COUPLE

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Title: INVESTIGATION OF INFERTILE COUPLE


1
INVESTIGATION OF INFERTILE COUPLE
In a climate of
Evidence Based Medicine
DR. JEHAD YOUSEF FICS , FRCOG ALHAYAT ART CENTRE
AMMN, JORDAN
2
  • ? Very long list of tests, have been advocated to
    assist in determining the cause of the
    infertility in the diagnostic evaluation of
    infertile couple.
  • The necessity and cost effectiveness of
  • performing many of these tests and
  • correcting the abnormalities found by
  • them have not been demonstrated.

3
Investigations of Male Factor
  • Conventional semen analysis
  • Computer- assisted sperm analysis (CASA)
  • Strict sperm morphology "Tygerberg strict
    criteria
  • A variety of sperm function tests
  • - The acrosome reaction test
  • - Hypo-osmotic swelling test
  • - Measurement of generation of Reactive
    oxygen species
  • - Sperm capacitation assays
  • - Hemizona-binding assay
  • - Hamster penetration test
  • - Human sperm-zona penetration assay
  • - etc.
  • A variety of imaging techniques for detection of
    varicocele

4
Assessment of ovulation
  • Basal body temperature
  • Urine LH kits
  • Mid luteal serum progesterone
  • Routine hormonal profile FSH, LH, Prolactin,TSH
  • Endometrial biopsy
  • Serial pelvic Ultrasonography.
  • A variety of tests for assessment of ovarian
    reserve such as D3 FSH E2, Inhibin B, Clomid
    challenge test, Gondotropin agonist stimulation
    test, TVS for ovarian volume, antral follicle
    count and Stromal blood flow.

5
Investigations of tubal factor
  • Hysterosalpingography (HSG)
  • Hysterosonography
  • Laparoscopy
  • Hydrolaparoscopy.
  • Falloscopy

6
Other investigations
  • PCT for assessment of the cervical factor.
  • Hysteroscopy and 3 D US for assessment of the
    uterine factor.
  • Laparoscopy for assessment of the peritoneal
    factors.
  • Chlamydia trachomatis antibodies for assessment
    of possible tubo-ovarian adhesions.
  • CA-125 blood testing for assessment of possible
    endomtetriosis.
  • Immunological factors are evaluated by a variety
    of special tests.

7
Controverses
  • Lack of agreement exists among trained
    infertility speicalists with regard to
    prognostic utility as well as criteria of
    normality of many of these tests?
  • There is no consensus on which tests are
    essential before reaching the exact diagnosis ?

8
Investigations of infertile couple Evidence
Medicine Based Era
National Evidence-Based Clinical Guidelines
Assessment and treatment for people with
fertility problems developed by the National
Collaborating Centre for Women and Children's
Health on behalf of the National Institute for
Clinical Excellence (NICE) February 2004
9
Grading Evidence Based Recommendations
  • GPP Good practice point The view of the
    Guideline Development Group

10
Semen analysisThe results of
semen analysis conducted as part of aninitial
assessment should be compared to the
followingWHO reference values
  • volume ? 2.0 ml
  • liquefaction time within 60 minutes
  • pH ? 7.2
  • sperm concentration ? 20 million per ml
  • total sperm number ? 40 million per ejaculate
  • motility ? 50 (grades a and b) or 25 or more
    with progressive motility (grade a) within 60
    minutes of ejaculation
  • vitality 75 or more live
  • white blood cells fewer than 1 million per ml
  • normal morphology 30 or 15 (based on strict
    morphological criteria)

11
Semen analysis
  • If the result of the first semen analysis is
    abnormal, a repeat confirmatory test should be
    offered. (Grade B)
  • Repeat confirmatory tests should ideally be
    undertaken 3 months after the initial analysis to
    allow time for the cycle of spermatozoa formation
    to be completed. However, if a gross spermatozoa
    deficiency (azoospermia or severe
    oligozoospermia) has been detected the repeat
    test should be undertaken as soon as possible.
    (GPP)

12
Semen analysis
  • CASA is not superior to conventional semen
    analysis (Grade A)
  • Screening for antisperm antibodies should not be
    offered because there is no evidence of effective
    treatment to improve fertility. (GPP)

13
Assessment of Ovulation
  • Women with fertility problems shouldbe asked
    about the frequency and regularity of menstrual
    cycles.
  • Women with regular monthly menstrual cycles are
    likely to be ovulating. (Grade B)
  • The use of basal body temperature charts to
    confirm ovulation does not reliably predict
    ovulation and is not recommended. (Grade B)

14
Assessment of Ovulation
  • Women with regular menstrual cycles and more than
    1 years infertility are offered a blood test to
    measure serum progesterone in the mid-luteal
    phase of their cycle (day 21 of a 28-day cycle)
    to confirm ovulation. (Grade B)

15
Assessment of Ovulation
  • Women with prolonged irregular menstrual cycles
    should be offered a blood test to measure serum
    progesterone. Depending on the timing of
    menstrual periods, this test may need to be
    conducted later in the cycle (for example day 28
    of a 35-day cycle) and repeated weekly thereafter
    until the next menstrual cycle starts. (GPP)
  • For such women direct or indirect measurement of
    progesterone is unnecessary until after therapy
    is initiated.

16
Assessment of Ovulation
  • Women with irregular menstrual cycles should be
    offered a blood test to measure serum FSH LH
    (GPP).
  • Blood test for prolactin should only be offered
    to women who have an ovulatory disorder,
    galactorrhoea or a pituitary tumour. (Grade C)

17
Assessment of Ovulation
  • Tests of ovarian reserve currently have limited
    sensitivity and specificity in predicting
    fertility. However, women who have high levels of
    gonadotrophins should be informed that they are
    likely to have reduced fertility. (Grade C)
  • The value of assessing ovarian reserve using
    Inhibin B is uncertain and is therefore not
    recommended. (Grade C)

18
Assessment of Ovulation
  • Women with possible fertility problems are no
    more likely than the general population to have
    thyroid disease and the routine measurement of
    thyroid function should not be offered.
    Estimation of thyroid function should be confined
    to women with symptoms of thyroid disease. (Grade
    C).

19
Assessment of Ovulation
  • Women should not be offered an endometrial biopsy
    to evaluate the luteal phase as part of the
    investigation of fertility problems because there
    is no evidence that medical treatment of luteal
    phase defect improves pregnancy rates (Grade B).

20
Assessment of tubal factor
  • The results of semen analysis and assessment of
    ovulation should be known before a test for tubal
    patency is performed.
  • Women who are not known to have co-morbidities
    (such as pelvic inflammatory disease, previous
    ectopic pregnancy or endometriosis) should be
    offered HSG to screen for tubal occlusion
    because this is a reliable test for ruling out
    tubal occlusion, and it is less invasive and
    makes more efficient use of resources than
    laparoscopy. (Grade B)

21
Assessment of tubal factor
  • Where appropriate expertise is available,
    screening for tubal occlusion using
    hysterosalpingo-contrast-ultrasonography should
    be considered because it is an effective
    alternative to HSG for women who are not known to
    have co-morbidities (Grade A)

22
Assessment of tubal factor
  • Women who are thought to have co-morbidities
    should be offered laparoscopy and dye so that
    tubal and other pelvic pathology can be assessed
    at the same time. (Grade B)

23
Screening for Chlamydia trachomatis
  • Before undergoing uterine instrumentation women
    should be offered screening for Chlamydia
    trachomatis using an appropriately sensitive
    technique. (Grade B)
  • If the result of a test for Chlamydia trachomatis
    is positive, women and their sexual partners
    should be referred for appropriate management
    with treatment and contact tracing. (Grade C)
  • Prophylactic antibiotics should be considered
    before uterine instrumentation (including HSG),
    if screening has not been carried out. (GPP)

24
Assessing uterine abnormalities
  • Women should not be offered hysteroscopy on its
    own as part of the initial investigation unless
    clinically indicated, because the effectiveness
    of surgical treatment of uterine abnormalities on
    improving pregnancy rates has not been
    established. (Grade B)

women with infertility and a normal HSG had no
abnormalities of the uterine cavity when
subsequently examined by hysteroscopy.
25
Post-coital testing of cervical mucus
  • The routine use of post-coital testing of
    cervical mucus in the investigation of fertility
    problems is not recommended because it has no
    predictive value on pregnancy rate. (Grade A)

. The post-coital test may be of value in the
diagnosis of sexual dysfunction and
ejaculatory problems. . Results of post-coital
testing may have little influence on treatment
strategy in the light of the widespread use of
IUI for fertility problems associated with
sperm-cervical mucus interaction. . The lack of
effective treatment for anti-sperm antibodies may
render PCT unnecessary.
26
CONCLUDING REMARKS
27
  • Until it is demonstrated conclusively that
    treatment of abnormalities diagnosed by any of
    infertility testing, results in a significantly
    better pregnancy rate than placebo or no
    treatment, the advisability of performing such
    test, remains unproven and should not be
    performed.

28
  • Conventional Semen analysis.
  • Assessment of utero-tubal status by HSG and
    indicated laparoscopy.
  • Mid luteal progesterone for the diagnosis of
    ovulation
  • Are useful tests, and correlate directly with the
    likelihood of conception.

29
  • Post-coital test.
  • ? Sperm penetration into cervical mucus.
  • ? Hysteroscopy.
  • ? Sperm antibody tests.
  • Varicocele assessment.
  • Endometrial biopsy.
  • ?The sperm penetration assay in the zona-free
    hamster oocyte.
  • Are less useful tests, as their results are not
    correlated with pregnancy.

30
  • It is not cost effective to perform a diagnostic
    laparoscopy as part of the initial infertility
    evaluation in women in whom, history, and
    physical examination, TVS, HSG, antibodies to
    Chlamydia trachomatis and CA-125 level are all
    normal.
  • Provided the woman is under age 35 and having
    ovulatory cycles and patent tubes, and there are
    more than 5 million motile sperm in the ejaculate
    of the male partner, 4-6 cycles of IUI ? COH
    should be undertaken before performing a
    diagnostic laparoscopy and resorting to ARTs.
  • Such approach has been shown to increase
    fecundability rates to 10 - 25 per cycle and is
    thus useful initial approach for subfertile
    couples.

31
  • Research could help improve treatment results in
    female infertility by discovering as-yet-unknown
    causes of infertility that coexist with
    recognized diagnoses.
  • Such unknown causes may include
    post-fertilization defects that cannot by
    definition respond to the pre-fertilization
    interventions that comprise many of the available
    treatments.

32
The diagnostic process of investigating
infertility has evolved more by discarding old
tests than by finding useful new ones
A simplified approach will lead to a significant
reduction in both the time and cost of
investigating an infertile couple.
  • Care must be taken to avoid exploitation of
    the infertile couple with expensive unnecessary
    tests

33
THANK YOU FOR YOUR ATTENTION
DR. JEHAD YOUSEF FICS, FRCOG E-mailramoamman_at_yaho
o.co.uk
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