2. Definition
•Infertility is inability of a couple to
conceive after one year of sexual
intercourse without contraception

3. Which Investigations!!
• There is a very long list of investigations for the diagnosis of
infertility, however there is no consensus on which tests are
essential before reaching the exact diagnosis

4. Male Factor
• conventional semen analysis
• A variety of sperm function tests such as in vitro mucous
penetration test, hamster egg penetration test and post coital
test.

5. Assessment of ovulation
• Basal body temperature
• Mid luteal serum progesterone
• Endometrial biopsy
• Ultrasound monitoring of ovulation.

6. Tubal factor
• Hysterosalpingography
• Laparoscopy
• Falloscopy
• Hysterosonography
• Hydrolaparoscopy.

7. Others
• The peritoneal factors are assessed by laparoscopy
• The uterine factor by hysterosalpingography and hysteroscopy.
• Immunological factors are evaluated by a variety of special
tests.

8. Controverses
• A lack of agreement exists among trained infertility speicalists
with regard to the diagnostic tests to be performed and their
prognostic utility as well as criteria of normality

9. Opinion Based Practice
• consulting senior colleagues or by
• reading text books with lack of sufficient time available for
searching the specialized journals.
• Little is paid to evidence derived from research “the Scientific
Factor”.

10. Evidence-based medicine
(EBM)
• EBM brings the best available evidence from clinical research to
clinical practice.
• gets our knowledge up to date by tracking the recent clinical
research results.

11. Sources of Evidence Based
Infertility investigations
• Cochrane Library
• Journal of Evidence Based Obstetrics and
Gynecology
• Evidence based recommendations of the Royal
College of Obstetrics & Gynecology

12. Take Care
• Care must be taken to avoid exploitation of the infertile couple
with expensive unnecessary tests
( ESHRE Capri Workshop 1996)

13. Concept to keep in mind
A simplified approach will lead to a
significant reduction in both the time and
cost of investigating an infertile couple.
(Strandell 2000)

14. So what EBM tells us?!!
• Diagnostic tests for infertility should be categorized into three
categories based on the correlation with pregnancy rates

15. The first category
includes tests which have an established correlation with pregnancy
as:
• semen analysis
• Tubal patency by hysterography or laparoscopy
• Mid luteal progesterone for the diagnosis of ovulation.

16. Semen analysis
• Remains the mainstay in investigating male fertility potential.
• Serial semen samples (at least two) should be assessed in the
same laboratory
(WHO,1999)

17. WHO criteria
• According to the WHO the lower limit of the
normal semen testing is
> 20 million/mL.
>40% progressive motility
>30% normal forms
WHO,1999

18. Collection of semen sample
• by masturbation
Temp (15C to 38C)
deliver quickly
• As many as 25% of proven fertile men have sperm
concentration
below 20 million/ml

19. CASA vs. conventional analysis
• In a randomized controlled trial, the determination of motility
characteristics as obtained by CASA systems is of limited value
• CASA is not superior to conventional semen analysis
(Krause ,1995 )

20. Hysterosalpingography
• Although HSG is of low sensitivity, its high
specificity makes it a useful screening test for
ruling in tubal obstruction.
• In case of abnormal finding, diagnostic
laparoscopy with dye transit is the procedure
of choice
(Swart et al, 1995)

21. Advantages
• HSG is cheaper
• Performed as an outpatient procedure
• Although often painful has a low incidence of complications
RCOG, 1999

22. Conception after HSG
• HSG has a low prognostic value, the outcome
of HSG adds little to predicting the occurrence
of pregnancy.
• However, when HSG shows bilateral
obstruction, the chance of getting pregnant is
only minimal.
(Maas et al, 1997)

23. Serum chlamydial antibodies vs HSG
Chlamydia antibody testing has comparable
estimates of tubal pathology but
provides no details on the anatomy of uterus
and tubes.
(Mol et al, 1997)

24. Confirmation of Ovulation
The only true proof of ovulation is the recovery of an ovum
Or
pregnancy .

25. Confirmation of Ovulation
Serum progesterone in the mid-luteal phase on day
22-26 is the method of choice
Endometrial biopsy is not a routine step in the
investigations of infertility .
(Peters et al,1992 / Templeton,2001)

26. However, Ultrasonography
• US examination of the pelvis is useful
especially for the ovary.
• Transvaginal sonography is the method of
choice for women who are having ovulation
induction
(Templeton 2001)

27. The second category
Includes tests which are not consistantly
correlated with pregnancy as
• zona-free hamster egg penetration tests
• post coital test
• antisperm antibodies assays.

28. Sperm function tests
• should not be routine investigations
complex
expensive
not always provide clinically useful information)
(Oehninger et al 2000)

29. Postcoital test
• Comparing impact of infertility investigations
with and without the postcoital test showed
closely similar cumulative pregnancy rates at 24
months, the postcoital test is not an essential
procedure
(Oei et al, 1998)

30. The third category
Includes tests which seem not to correlate with
pregnancy as:
• endometrial dating
• varicocele assessment
• chlamydial testing.
(ESHRE Capri workshop 2000)

31. Endometrium
• The prognostic value of endometrial thickness is not
universally accepted
(Schild et al 2001)

32. Thyroid / Prolactin assay
• There is no value in measuring thyroid
function or prolactin in women with a regular
menstrual cycle, in the absence of
galactorrhoea or symptoms of thyroid disease
(Templeton,2001)

33. BBT/LH
• There is no evidence that the use of BBT
charts and luteinizing hormone detection
methods to time intercourse improves
outcome.
(Leader,1992 / Guermandi,2001)

34. Hysteroscopy
• HSC is not a routine investigation of infertile
couples as there is no evidence linking
treatment of uterine abnormalities with
enhanced fertility.
(RCOG,1999)

35. Precaution
• Before uterine instrumentation (as HSG or HSC) appropriate
antibiotic prophylaxis against chlamydia should be given
RCOG,1999

36. CA-125 in endometriosis
•The performance of serum CA-125
measurement in the diagnosis of
endometriosis grade I/II is limited, whereas its
performance in the diagnosis of endometriosis
grade III/IV is better.
• Better in predicting recurrence
(Mol et al, 1998)

37. How to judge a new diagnostic test
• Sensitivity: to produce few false negatives.
• Specificity: to produce few false positives.
• Positive predictivevalue.
• Negative predictive value.
• Invasiveness: with the possibility of harmfulness
• Cost

38. Hydrolaparoscopy as a model
• Specific as HSG
• Invasive
• Costy
• In unexplained infertility
• Require hysteroscopy
Gordts,1999

39. Thus
• More difficult than HSG
• Not superior to HSG
• Inferior to D.L
Its role is still unclear
Templeton,2001

40. 3-D US: another model
• As effective as two-dimentional US
• Very expensive
• No specific advantage in infertility over 2-D
No role in infertility yet
N.B: Bicornuate ut. Vs septate ut

41. Summary
• From the above data, it seems that serum progesterone for
detection of ovulation, hysterography for tubal patency and
semen analysis are the basic essential tests for diagnosis of
infertility.

42. • Other tests may have a role in special situations or as a part of
clinical trials
• Laparoscopy should be reserved as a further diagnostic
procedure or in combination with endoscopic surgery

43. Testing until
uncertainty vanishes
may delay treatment
AGINGprocess