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.