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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.


3. HSG(HYSTEROSALPINGOGRAM)

  • a. What is a hysterosalpingogram?
  • b. What to expect during a hysterosalpingogram?
  • c. How painful is your HSG?
  • d. Can it done under anaesthesia?
  • e. How long will this procedure take?
  • f. When will you get the results?
  • g. Should you not try to get pregnant the month as HSG?
  • h. Will the radiation damage the ovaries and eggs?
  • i. Does having a dye test improve your chance for getting pregnant?
  • j. What next to do if I have blocked or damaged tubes on HSG?
    Is there another test to evaluate the tubes other than HSG?
  • k. Complications
  • l. What to expect after a HSG?

4. LAPAROSCOPY

  • What is a Diagnostic Laparoscopy?
  • Things you need to know before Diagnostic Laparoscopy?
  • What is operative laparoscopy?
  • Which conditions require operative laparoscopy?
  • When to resume Sexual activity
  • When to resume Sexual activity
  • How safe is laparoscopy?
  • How much does a laparoscopy cost?

5. HYSTEROSCOPY

  • What is Diagnostic Hysteroscopy?
  • What is Operative Hysteroscopy?
  • Which conditions require operative hysteroscopy?
  • How to prepare for a hysteroscopy?

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 > 15million/ml ANTIESTROGENS (TABLETS)
GONODOTROPHINS
(INJECTIONS)
IUI
Motility: Ability of sperm to move/swim 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
time of collection to time of testing H/O fever
  • How to Prepare for Semen Analysis?
  • How Is Semen Analysis Conducted?
  • Can semen collected at home be used for testing?
  • What factors can affect semen analysis?
  • How long will it take report a semen analysis;30-45 MTS

2. SEMEN CULTURE

Men with following conditions should get a semen culture

  1. If there is pain and burning feel in penis or scrotal sacs.
  2. If your semen is bloody or has abnormal view than normal
  3. If you have a problem in your testis like varicocele.
  4. If white blood cells are found in sperm analysis.
  5. 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.

http://www.sunfert.com/assisted-conception/