Investigations for diagnosing cause of infertility
1. BLOOD TESTS
TEST
ASSESSES
EFFECT of AbnormaL levels ON FERTILITY
WHEN IS DONE
TSH,FT3,FT4, TPO antibodies
Thyroid function
effect the growth & quality of oocyte and impair the possibility of pregnancy
ANY DAY OF CYCLE ON FASTING
SERUM PROLACTIN
Prolactin function
effect the growth & quality of oocyte and impair the possibility of pregnancy
DAY 2 OF CYCLE ON FASTING
S. TESTOSTERONE/ S.DHEA-S/S.ANDROSTENIDIONE
Androgen function
Impairs the growth of follicle
DAY 2 OF CYCLE ON FASTING
FBS/ HbA1C/GTT
Sugar levels
Increases abortion chances and defects in the baby
ANY DAY OF CYCLE ON FASTING
FSH/LH/AMH
Ovarian Reserve & Function
Decides the method of treatment required
DAY 2 OF CYCLE
E2/P4
Ovarian function
Decides the method of treatment required
DAY 2 OF CYCLE
CA 125
Endometriosis or other ovarian cyst activity
ANY DAY OF CYCLE ON FASTING
Vit D3, HOMOCYSTEINE
Micronutrients
Impairs oocyte quality & Recurrent abortions
ANY DAY OF THE CYCLE
APLA, ANA, PT, APTT
Immunological status
Recurrent abortions
ANY DAY OF THE CYCLE
Bhcg
Pregnancy status
ANY DAY AFTER MISSING CYCLE.
2. ULTRASONOGRAPHY
Baseline scan: A vaginal scan done on the second day of the cycle to assess the uterine size, position, ovaries and number follicles (potential eggs)-antral follicle count in the ovary. Done onempty bladder.
Follicular scan: Vaginal scan done during the first half of the periods to assess the growth of the follicle.
Obstetric scan: vaginal or abdominal scan done to assess the growth of your baby. Only abdominal scans aredone on full bladder till 12 weeks of pregnancy.
Quick fact: Ultrasound waves are harmful neither to you nor to your baby. So getting multiple scans is very safe.
You will have to change into the clinic gown so that your dress doesn’t get soiled during the procedure.
You might be given a mild sedative in the form of tablet or injection before the procedure
Once you lie down on the X ray table, a vaginal examination is done(level of discomfort is similar to that of a vaginal scan) and a small catheter is passed through the cervix(mouth of your uterus). Dye that is pushed through the catheter fills the uterus and spills through the tubes into the abdomen. You will experience mild to moderate cramping experience as the dye spills into your abdomen.
Contrary to the popular belief, HSG is not a very painful procedure when it is performed correctly. The pain experienced is similar to or slightly more than that of your period pain. You may experience more pain only if the tubes are blocked or if the mouth of the uterus-cervix is tightly closed.
Though it is routinely not done under anaesthesia, if you are very sensitive to pain you may request your doctor well in advance to get the HSG under anaesthesia.
You can ask your doctor performing the HSG and know immediately if your tubes are blocked or not. The reporting might take a couple of hours to couple of days based on individual centre.
The dose of radiation used for X ray in HSG is very minimalRadiation exposure from these small doses is not known to injure ovarian tissue and there have been no demonstrated ill effects, even if conception occurs in the same month.
Pregnancy rates in several studies have been reported to be very slightly increased in the first months following a HSG. This could be due to the flushing of the tubes with the dye and opening a minor blockage or cleaning out some debris that was preventing the couple from conceiving.
The negative findings on a HSG are not always 100% accurate. Hence all abnormal HSGs should be followed up with a Diagnostic Laproscopy.
Other methods for assessing tubes include HyCoSy or SIS(Saline Infusion Sonosalphingography) which are done using the same technique as a HSG, but a Ultrasound imaging is done instead of an X Ray. HyCoSy or SIS are traditionally considered less painful than a HSG, however HSG is the most accepted testing method.
There can be a possibility of an allergic reaction to the dye, which is uncommon. This usually causes a rash, but can rarely be more serious. So do make it a point to inform your doctor performing the HSG if you have had a history of allergic reactions.
Diagnostic laparoscopy is a day care surgical procedure during which we can directly visualize a woman's reproductive organs. A laparoscope, a thin telescope, is passed through a small incision (cut) in the abdomen(usually umbilicus). Using the laparoscope, the doctor can look directly at the outside of the uterus, ovaries, fallopian tubes, and nearby organs.
A female pelvic laparoscopy is often recommended when other diagnostic tests, such as ultra soundand X-ray, cannot confirm the cause of a condition.
Laparoscopy is done under General anaesthesia and you will completely lose consciousness. Anaesthesia is given as an injection to your hand.
You are required to come to the clinic 2 hour before the scheduled surgery time on empty stomach. (Not to consume even water on the day of the surgery).
The surgery may take about 30-90 minutes.
A DL is usually combined with a diagnostic hysteroscopy to assess the insides of the uterine cavity.
The cuts on the abdomen are just about 5mm and hence don’t leave big scars.
You may leave the clinic 3-6 hours after the procedures. Mild giddiness and discomfort is common post procedure. Hence it is advised that you take off from work that day.
All regular activities can be resumed from the next day. (No need of prolonged rest)
Endometriosis: An Ovarian endometriotic cyst larger than 4 cm needs to be removed surgically before trying for pregnancy. Endometriotic spots seen in the abdominal cavity should be burnt or removed to prevent the release of substances (cytokines) that are toxic to the egg, sperm and embryo.
Fibroids: Fibroids that are protruding into the uterine cavity or those forming the base of uterine lining should be removed as they form a not only a hostile environment for the embryo trying to attach to the womb, but also can cause recurrent abortions by interfering with the blood supply to the baby.
Hydrosalphinx: Toxic fluid is collected inside the tubes. The opening of the tubes into the uterus is blocked and the both tubes are separated from the uterus. results in decrease in chance of pregnancy.
Adhesiolysis: adhesions between various organs in the abdominal cavity may prevent the natural release of egg and the decrease the ability of tube to pick up the egg and transfer the embryo into the uterus. Removing these adhesions may not only improve the natural conception possibilities, but also decrease the abdominal pain routinely noticed in women having adhesions.
Laparoscopy is very safe. About three out of every 1,000 women who have laparoscopy have some form of complications. Women undergoing an operative laparoscopy should keep in mind that indifficult cases the operating surgeon may decide to convert the laparoscopy into an open surgery.
A Hysteroscope is a thin telescope that is passed through the cervix (opening of the uterus) to directly visualize the interior aspect of uterus. As this is the site of attachment for the embryo, it is of utmost importance to ensure that the cavity is normal and adequate to support pregnancy.
Septum: The septum is cut either using a hysteroscopic scissors or using electric hook.
Fibroids: Fibroids that are protruding into the uterine cavity should be removed as they form a not only hostile environment for the embryo trying to attach to the womb, but also can cause recurrent abortions by interfering with the blood supply to the baby. They can be removed using an electric loop that slices the fibroid into multiple bits and removes it.
Adhesions: adhesions are released using a hysteroscopic scissors to improve the possibility of embryo implantation.
The preparation is similar to that of a laparoscopy, the only difference being that hysteroscopy might take much lesser duration.
6. ENDOMETRIAL BIOSPY
At the time of hysteroscopy the lining of the uterus is sent for testing infections like tuberculosis (TB-PCR, TB culture) and histopathology examination (HPE) to assess if there are any underlying microscopic factors that can possibly effect the pregnancy chances.
INVESTIGATIONS FOR DIAGNOSING CAUSE OF INFERTILITY- MALE FACTOR
1. SEMEN ANALYSIS
The single most important test to evaluate male fertility. The following factors are assessed:
PARAMETER
EFFECT ON FERTILITY
NORMAL VALUES
TREATMENT FOR ABNORMALITIES
Sperm count
Low sperm count decreases the chances of pregnancy
If the motility of the sperms is low, they might not be able to travel across the partner’s womb to fertilize the egg. This decreases the chances of pregnancy
Motile sperms(Progressive+Non-Progressive) >40%
ANTIOXIDANTS MICRONUTIENTS IUI
Morphology Size and shape of the sperm
Sperms of abnormal shape and size can’t fertilize an egg. Even if they fertilize the pregnancy thus resulted can end up in a miscarriage
> 4%
NO EFFECTIVE MEDICAL TREATMENT. ICSI
Total semen volume
Decreases the total number of sperms.
> 1.5ml
HYDRATION ZINC SUPPLEMENTATION
Liquefaction of the semen - Ability to go from normal gel-like state at ejaculation to a liquid state)
If the semen is too thick, the sperms in the semen can’t move freely and eventually die without fertilizing the egg.
< 30 minutes
MUCOLYTICS IUI
White Blood cells
Excessive WBC suggest inherent infection.
This can affect the motility and morphology of the sperms.
May also cause cross infection in the female partner.
< 1 million/ml
ANTIBIOTICS BASED ON THE TYPE OF INFECTION
Duration of abstinence
Seasonal Temperature:
Motility decreased during winter, increased during summer
Two main factors are crucial to have a good testing sample. First, the semen must be kept at body temperature. If it gets too warm or too cold, the results will be inaccurate. Second, the semen must be analysed within 30 to 60 minutes of leaving the body. If both these parameters are fulfilled, you may collect the sample at home after prior intimation to your doctor and the diagnostic centre.
Medications: Certain medications like steroids, Selective serotonin reuptake inhibitors (SSRIs), ketaconazole, spironolactone, cimetidine, nifedipine, sulfasalazine, viagracan affect the semen parameters. Make it a point to let your doctor know of any medications that you are on currently or have taken in the past 3 months.
Illness: Any kind of fever or illness you have suffered in the past 3 months can affect the report.
Stress: Severe stress or depression can result in an abnormal report.
You may have the report in 2-24 hours based on the centre policy.
VIDEO OF NORMAL SEMEN N ABN SEMEN
2. SEMEN CULTURE
Men with following conditions should get a semen culture
If there is pain and burning feel in penis or scrotal sacs.
If your semen is bloody or has abnormal view than normal
If you have a problem in your testis like varicocele.
If white blood cells are found in sperm analysis.
If you have genital (penile discharge).
This identifies any specificmicroorganisms in the semen fluid and to determine which antibiotics are effective against it.Semen culture test usually takes 2-3 days to report.
3. DFI (DNA FRAGMENTATION INDEX):
The most important role of the sperm is to carry genetic material (DNA) from the male partner to the female partner. Research suggests that sperms with a high percentage of DNA (genetic material) fragmentation or damage are less likely to give a healthy pregnancy or may cause recurrent pregnancy loss.
Sperms with high DFI, look normal in a routine semen analysis. Hence testing for DFI is recommended.
DFI > 30% is abnormal.
We may minimize the effect of high DFI by using antioxidants, correcting varicocele or by opting for ICSI.
DFI can be done as a separate test using the same sample given for semen analysis
Conditions that can raise DFI:
Abstinence (infrequent ejaculations)
Age (DFI rises considerably after the age of 46)
Smoking
Exposure to high levels of pollutants
Exposure of testicles in high temperatures (e.g. professional drivers)
Trauma of the testicles or testicular cancer
Exposure to chemicals or radiation
Read the scientific article:
http://www.sciencedirect.com/science/article/pii/S1110569013000137
The place of sperm DNA fragmentation testing in current day fertility management. Middle East Fertility Society Journal Volume 18, Issue 2 June 2013, Pages 78–82
4. ULTRASOUND:
SCROTAL ULTRASOUND: A scrotal or testicular ultrasound is a diagnostic test that obtains images of the testicles and the surrounding tissues in your scrotum.The scan is absolutely pain free and doesn’t require any prior preparations.A scan is advised incase of abnormal semen analysis or DFI and helps in diagnosing the following conditions:
assess the causes of infertility
assess lump in your scrotum or testicles either solid or cystic.
detect for and evaluate varicoceles, which are dilated spermatic veins
identify sources of pain or swelling in your testicles
find the location of an undescended testicle
The procedure takes about 15-20 minutes and is reported immediately.
TRANSRECTAL ULTRASOUND: A scan done to check your prostate, and look for blockages of the tubes that carry semen (ejaculatory ducts and seminal vesicles). As these structures are located more posteriorly, a thin scan probe is inserted into your rectum to assess these structures.
5. BLOOD TESTS
The following blood tests may be advised to further evaluate the hormonal status of the male partner: FSH. LH, S.TESTOSTERONE.
6. GENETIC TESTS.
Genetic defects maybe the cause behind absent or extremely low sperm concentration.
Genetic testing on DNA obtained from blood samples can reveal signs of abnormality.
Y chromosome micro deletions, cystic fibrosis, Klinefelter’s syndrome, Kartagener syndrome are certain genetic conditions that result in male infertility and maybe carried on to next generation.
7. URINE ANALYSIS AFTER EJACULATION:
In certain conditions (prior prostate or urethral surgery, uncontrolled diabetes, anti-hypertension drugs and some mood-altering drugs), semen enters the bladder instead of going out through the urethra during ejaculation. This is called Retrograde ejaculation.
This may be suspected when there is little or no semen discharged from the urethra during ejaculation or cloudy urine after sexual climax.
A urine analysis after ejaculation will confirm the diagnosis.
Stopping the medications responsible for retrograde ejaculation and starting epinephrine-like drugs helps in improving it.
SPERM RETREIVAL TECHNIQUES:
When the male partner is diagnosed with azoospermia (absence of sperm in the ejaculate) certain microsurgical techniques maybe employed to obtain sperms directly from the epididymis or testis. This is done by an andrologist or an urologist under anaesthesia.This maybe done on the day of the egg pick up to obtain a fresh sample for ICSI or prior to assess for presence of sperms.
TESA: Testicular sperm aspiration: Sperms obtained from aspirating the testis using a special syringe.
PESA: Percutaneous epididymal sperm aspiration: Sperms obtained from aspirating the epididymis.
TESE: Testicular sperm Extraction: A small portion of the testis is removed or biopsied to see for presence for sperms.
The sperm cells from the tissues are extracted by the embryologist and are processed for ICSI.
Two causes for azoospermia are non-obstructive and obstructive. Non-obstructive azoospermic males have either Sertoli-cell-only syndrome or development arrest of the sperm cells. On the other hand, obstructive azoospermic males generally have reasonable sperm production capacity but the sperm could not be deposited in vagina due to obstruction in the tubes that transport sperm into the penis. Success rates for ICSI with non-obstructive azoospermia are generally lower than ICSI with obstructive azoospermia.
IN azospermic patients sperm is extracted byanyone of the abve mentioned methods.
