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Approach to a case of female infertility dr monikha

obgy resident in AIIMS,new delhi

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Approach to a case of female infertility dr monikha

  1. 1. APPROACH TO A CASE OF FEMALE INFERTILITY Candidate: Dr Monikha Consultant Guide: Prof Neena Malhotra Sr Guide: Dr Swati Tomar
  2. 2. Introduction • Infertility: Disease of the reproductive system defined by failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse • Fecundability: Probability that a cycle will result in pregnancy • Fecundity: Probability that a cycle will result in live birth • Chance of conception in individual cycle -20% • Evaluation indicated-15% of couples • Lifetime risk of infertility- 6.6% to 32.6 % Hamilton et al The epidemiology of Infertility Human reproduction ,2009 85% of couples achieve conception by 1 year 92% of couples by 2 years NICE 2013
  3. 3. Causes of Infertility Speroff’s Clinical gynaecologic endocrinology and infertility 8th ed
  4. 4. Causes of female infertility ASRM 2017
  5. 5. When To Investigate? NICE 2013 1year: Unprotected sexual intercourse without any known cause of infertility 6 months: -Woman >35yrs -H/o Oligomenorrhea/ Amenorrhea, -Known Uterine/ Tubal/ Peritoneal disease/ Endometriosis -Known male subfertility
  6. 6. General Considerations 3 simple questions need to be addressed: 1. Is there evidence of normal sperm production and ejaculatory competence? 2. Is the woman ovulating? 3. Is the female pelvic anatomy normal and coital function adequate?
  7. 7. BASIC INFERTILITY EVALUATION PROTOCOL - AIIMS • History • Exam • TVS • Screening • FBC, ESR • MTx, X-ray chest • Rubella • Hep B, C, HIV EA Ovulation status Conventional molecular -ve for FGTB +ve molecular -ve vonventional +ve convention ATT Findings HSG Laparoscopy
  8. 8. Evaluation HISTORY •Duration of Infertility/ Contraceptive use •Fertility in previous/current relationships •Previous fertility investigations/ treatment MEDICAL HISTORY Menstrual History: •Menarche •Cycle length & duration of flow •Dysmenorrhea •Amenorrhea episodes •HMB/IMB Obstetric History: •No of previous pregnancies (MTP/miscarriage/ectopic preg) •Time to initiate previous pregnancies Drug History: •Agents causing ↑PRL/ CT/RT Surgical History •Previous abdominal/pelvic /gynaecological surgeries Occupational History: •Work patterns including separation from partner Sexual History: •Coital frequency, timing, knowledge of fertile period •Dyspareunia •Postcoital bleeding
  9. 9. Physical Examination General : • Height • Weight • BMI • Fat & Hair distribution • Acne • Galactorrhea • Acanthosis nigricans • Thyroid examination Abdominal : • Abdominal mass & tenderness Pelvis : • Assess state of hymen, clitoris and labia • Look for vaginal infection, septum, endometriotic deposits • Check for cervical polyps • Accessibility of cervix for insemination • Uterine size, position, mobility and tenderness • Cervical smear if needed
  10. 10. Investigations in Infertility Couple with infertility Female Investigations of suspected ovarian disorders Regularity of menstrual cycles Ovarian reserve testing Investigations of suspected uterine and tubal disorders Investigations of peritoneal factors male Semen analysis NICE 2013
  11. 11. Transvaginal Ultrasound • UTERUS – Size – morphology-fibroid, cong. abnormality, polyp • OVARY – Size – AFC – Morphology-PCOS, cysts – Outline – accessibility • FALLOPIAN TUBES • ENDOMETRIUM – ET, Pattern – Doppler
  12. 12. TVUS Dominant follicle Triple line endometrium Dermoid cyst Polycystic ovaryB/L hydrosalpinx
  13. 13. TVUS Adenomyosis Endometrioma Endocavitary leiomyoma Asherman syndrome
  14. 14. Infertility work up-Baseline TVS Patient Name …………………………. LMP.………… Date………….. Day…………... Uterus: size ……….. x ……….. x ……….. cm Myometrium: Normal / adenomyotic / calcification / fibroid Fibroids: Number- Size – Site – Endometrium: regular / irregular/calcification ET-……….. mm / TL / Diffuse Doppler: (Sub-endometrial) Right ovary: Size ……..x …….. x……..cm, vol- AFC …………… Outline: Hazy/well defined Proximity to uterus: Yes / No Accessibility : Yes/ No Endometrioma / Cyst / Others Left ovary: Size ……..x …….. x……..cm, vol- AFC …………….. Outline: Hazy/well defined Proximity to uterus: Yes / No Accessibility : Yes/ No Endometrioma / Cyst / Others Others: Hydrosalpinx: Rt- ……x …….. cm Left ……x…….. cm TO Mass: Rt- ……x …….. cm Left ……x …….. cm
  15. 15. Pre Conceptional Testing Rubella Chlamydia serology Cervical screening Vaccinate if not immune and avoid conception for one month HIV If compliant with HAART & if viral load <50 copies/ml for more than 6 months Timed unprotected intercourse Sperm washing and IUI HBSAg HCV + - Vaccinate if partner positive Treatment before conception IgG Antibodies testing Prophylactic treatment of both partners before any instrumentation if unable to investigate According to screening guidelines NICE 2013 TB screening, though not recommended by NICE, is necessary in India
  16. 16. Lifestyle Modifications Alcohol : • Women: 1-2U per week • Men: 3-4U per day Smoking: • Active & passive smoking decreases chances of conception Caffeinated beverages: no association Obesity : • BMI > 30 ↓ fertility • Weight loss ↑ conception chances Folic acid supplementation: • 0.4mg/day • 5mg /day if h/o NTD/antiepileptic drug intake/DM Frequency/timing of sexual intercourse: • Every 2-3 days ↑ chances of preg NICE 2013
  17. 17. Male Factor WHO LOWER REFERENCE LIMITS FOR SEMEN CHARACTERISTICS 2010 Criteria Lower reference values Vol (in ml) 1.5 Total sperm number(206 per ejaculate) 39 million Sperm concentration (106 per ml) 15 million Total motility (PR+NP,%) 40 Progressive motility(PR,%) 32 Vitality (live forms,%) 58 Morphology (normal forms,%) 4 NICE 2013
  18. 18. Tubal Patency Test AETIOLOGY: • Previous tubal infection C trachomatis infection- 50-70% Genital TB- 19% (India) • Previous surgery Post op adhesions after gynae surgeries: 50-70% • Endometriosis Distortion & blockage of FTs • Congenital abnormalities -Aplasia /Hypoplasia -Accessory ostia TESTS FOR TUBAL PATENCY: • Imaging -Hysterosalpingography (HSG) -Hysterosalpingo-contrast sonography (HyCoSy) -Saline infusion sonography (SIS) • Surgery -Laparoscopy + Dye test -Falloposcopy -Salpingoscopy • Indirect testing -Chlamydia serology
  19. 19. Historical techniques Diagnostic techniques Non surgical Ascending Tubal insufflation Pneumosalpingogram Phenolsulfonphthalein test Methylene blue test Tubal scan Descending China ink Starch Radioactive transportation Surgicall Partial evaluators Colpotomy Culdoscopy Complete evaluators Laparoscopy Laparotomy Amir et al,Fertility Sterility 1979
  20. 20. Tubal Patency Test: HSG PROCEDURE 2-5 days immediately following menses (follicular phase) 3 basic films  1st - Scout- preliminary film  2nd - To document uterine contours & tubal patency  3rd - Post-evaluation film to detect any areas of contrast loculation INDICATIONS: • Tubal patency- infertility/ post tubal Sx • Uterine factor in RPL • Staging & grading of uterine synaechiae • Preoperatively before myomectomy GENERAL CONSIDERATIONS: • Perform in proliferative phase • Irregular periods- rule out pregnancy • Exclude acute pelvic infection • Routine antibiotics in high risk cases PROCEDURE • Fluoroscopy table in lithotomy position • Parts painted and draped • P/s P/V examination • Karmans Cannula placed intracervically • Under fluoroscopic guidance inject 5- 10ml contrast agent over 1 min • Radiographs obtained • Procedure halted after adequate spill into peritoneal cavity Steinkeler et al.,Radigraphics,2009
  21. 21. Tubal Patency Test: HSG a)Early filling stage-small filling defects best seen b)Uterus fully distended-filling defects and uterine contour best seen c)Tubal filling phase-for tubal abnormalities d)Peritoneal spillage Steinkeler et al.,Radigraphics,2009
  22. 22. Beaded Tubes Convoluted tube, loculated spill Tobacco pouch appearance Stem pipe with beaded tube and IUA Normal HSG findings Tubal Patency Test: HSG
  23. 23. Tubal Patency Test: HSG COMPLICATIONS • Pain • Infection • Bleeding • Vascular /lymphatic intravasation • Vasovagal attack • Radiation exposure • Allergy to contrast • Uterine perforation CONTRAINDICATIONS • Suspected pregnancy • Acute pelvic infection • Active vaginal bleeding • Contrast sensitivity • Immediate pre and post menstrual phase • Tubal /uterine surgery within last 6 weeks THERAPEUTIC EFFECTS OF HSG • Expulsion of mucus plugs • Dilatation of fimbrial phimosis • Stimulation of tubal contractility • Enhanced fertility with oil based contrast
  24. 24. Oil vs Water Soluble Contrast? Oil soluble contrast significantly increased the likelihood of pregnancy compared to no intervention Jon Bosteel et al,Human Reproduction Update
  25. 25. Saline Infusion Sonography • Usually scheduled between day 5 – 10 of the menstrual cycle • No routine anesthesia or analgesia needed • Bimanual exam • Place speculum • Aseptic prep of the cervix • SIS – Flush catheter – Insert catheter • Fill balloon and snug catheter against the internal os • Remove speculum • Attach 10ml syringe of sterile saline • Insert TV U/S probe
  26. 26. Hysterosalpingo-Contrast-Sonography (HyCoSy) • Uses Sonoreflective echo contrast fluid (Echovist,SonoVue) • Good consistency with laparoscopic chromopertubation as the reference standard
  27. 27. Which one to choose: HSG/HyCoSy? HSG Pros: -Films available for review Cons: -X-ray exposure -Needs radiology set up -Radio-opaque contrast contains iodine (Risk of sensitivity) HyCoSy Pros: -USG at same time -Foam used is inert -100% sensitive -75% specific Cons: -No films,report only or video -Steep learning curve -Operator dependent -Not widely available
  28. 28. Hyfosy Hysterosalpingo-foam sonography: • Foam containing hydroxyethylcellulose & glycerol instilled • More accurate diagnosis of tubal patency compared with HyCoSy Newer modifications of sonography: • Pulse Doppler • Color Doppler • Combined air and saline • 3D saline SSG Hystsero-salpingo-lidocaine foam sonography-pulse doppler (HyLiFoSy-PD) • Contrast :Foam + 3-4 ml of 2% lidocaine gel+ saline + air • Flaming tube sign : This sign is result of the orange color of PD surrounding the contrast flowing into the patent tubes Emanuel et al.,USG Obs Gyn,2011 Arthur et al.,HiLiFoSy-PD,2016
  29. 29. Laparoscopy • Gold standard • Pelvic pathology concomitantly treated Hull and Rutherford Laparoscopic Classification of tubal disease GRADE 1-MINOR: •Tubal fibrosis absent even if tube occluded (proximally) •Tubal distension absent even if tube occluded (distally) •Mucosal appearances favourable •Adhesions flimsy GRADE 2-MODERATE: •U/L severe tubal disease ± C/L minor damage •“Limited” dense adhesions of tubes/ovaries GRADE 3-SEVERE: •B/L tubal damage •Extensive tubal fibrosis •Tubal distension > 1.5cm •Abnormal mucosal appearance •Bipolar occlusion •‘Extensive’ dense adhesions Significance : to predict the favourable ,fair and poor prognosis of live birth following tubal surgery Rutherford et al., BJOG,2004
  30. 30. Laparoscopy Beaded appearance in GTB Large hydrosalpinx in GTB Endometrioma Adhesions Fibroid uterus
  31. 31. Other Methods for Tubal Evaluation FALLOPOSCOPY: • To evaluate tubal mucosa • Endoscope introduced trans-cervically Techniques of Falloposcopy: 1. Coaxial technique 2. Linear everting catheter system(LEC) technique Success rate of cannulation by falloposcopy in ‘abnormal’ tubes of patients is >90% Wong et al HKMJ 1999
  32. 32. Salpingoscopy • Endoscope introduced via fimbrial end of FT during laparoscopy • Visualises internal tubal mucosa Brosens and Puttemans classification of salpingoscopic mucosal appearance: Grade I: Normal mucosal folds Grade II: Major folds separated & flattened, but otherwise normal/dye staining of mucosa/minimal flattening Grade III: Focal adhesions b/w mucosal folds & variable flattening Grade IV: Extensive adhesions b/w mucosal folds & disseminated flat areas Grade V: Complete loss of mucosal fold pattern Upto grade III-Compatible with fertility Higher grades-Counselled for IVF
  33. 33. Transvaginal Hydrolaparoscopy Transvaginal hydrolaparoscopy: • Endoscope introduced through posterior fornix after insufflation of pelvis with 0.4-0.6L of fluid • Outpatient procedure • 0.61% of rectosigmoid injury FERTILOSCOPY : • Hysteroscopy+transvaginal hydrolaparoscopy+ salpingoscopy • High concordance b/w Laparoscopy and Fertiloscopy Dutch healthcare authority,2009
  34. 34. Chlamydia Antibody Tests • As a pretest to select women who warrant earlier or more detailed evaluation • Micro immunofluorescence CAT preferred • Negative CAT: <15% likelihood of tubal pathology • Disadvantage : cross reactivity with C. pneumoniae may give false positive results • Does not differentiate b/w remote & persistent infection ASRM 2015
  35. 35. Tubal Assessment algorithm(NICE) Co-morbidities Previous surgeries,PID,Endometriosis Laparoscopy HSG/HyCoSy OVI +ve Non patent Patent -ve NICE 2013
  36. 36. Tubal surgery- Option for women with mild distal tubal disease Women with previous tubal sterilization Women with hydrosalpinges planning for IVF-laparoscopic salpingectomy or proximal tubal occlusion increases IVF success rate by 2-fold Fertility sterility 2015
  37. 37. Excision/Occlusion of Hydrosalpinges before IVF Both laparoscopic salpingectomy and tubal occlusion before IVF increases the odds of pregnancy Johnson et al. Cochrane review 2010 Laparoscopic salpingectomy before IVF increases the chances of live birth NICE 2013
  38. 38. Tests of Ovulation Menstrual history BBT: • 0.4-0.8 deg rise • Ideal BBT recording biphasic • Reveals a cycle b/w 25-35 days in length with menses beginning 12 days or more after temp rise • Not recommended Serum Progesterone levels: • <3ng/mL- anovulation • D21 S. progesterone is not always the best time • Best time: 1 week before expected menses TVUS: • Serial TVUS for size and number of preovulatory follicles • Most accurate estimate of ovulation Urinary LH secretion: • To predict midcycle LH surge in urine • LH kits/Ovulation predictor kits available • Sensitive to fluid intake and time of the day (4 to 10pm) • Interval of greatest fertility –day of surge and following 2 days Endometrial biopsy: • Secretory endometrium -ovulation • R/o hyperplasia in chronic anovulation Speroffs Clinical Gynaecologic Endocrinology 8th ed
  39. 39. Endometrial Biopsy/Aspiration • Routine work-up • Not to diagnose ovulation/LPD • Exclude FGTB – 40-80 % of FGTB presents with infertility (Bazaz-Malik,1983, Bhide A 1987, Tripathy S 2002, Jindal UN 2006) – 15-19% of infertile women in India have GTB (Deshmukh KK 1985, Parikh F 1997) • EB/EA – Conventional tests • AFB, HPE, solid culture – Molecular • DNA-PCR, RT-PCR, BACTEC
  40. 40. STATIC TESTS Basic hormone tests •Basal FSH levels •Anti Mullerian Hormone •Inhibin B •Estradiol levels Biophysical tests •Antral follicle count •Ovarian Volume and dimensions •Stromal blood flow DYNAMIC TESTS •Clomiphene citrate challenge test •GnRH agonist stimulation test(GAST) •Exogeneous FSH ovarian reserve test ( EFORT) OVARIAN RESERVE TESTS
  41. 41. Ovarian Reserve Test Ovarian reserve testing can best be justified for women with any of the following characteristics • Age over 35. • Unexplained infertility. • Family history of early menopause. • Previous ovarian surgery (ovarian cystectomy or drilling, unilateral oophorectomy),chemotherapy, or radiation. • Smoking • Demonstrated poor response to exogenous gonadotropin stimulation An ideal ovarian reserve test should yield consistent results and highly specific, to minimize the risk for incorrectly categorizing normal women as having a diminished ovarian reserve
  42. 42. Fertility with aging • Progressive follicular depletion • High abnormalities in aging oocyte • High prevalence of miscarriage • High prevalence of benign uterine pathology Speroffs Clinical Gynaecologic Endocrinology 8th ed
  43. 43. Ovarian Reserve Tests: Hormones Predicts response to ovarian stimulation with exogenous Gonadotropin Basal FSH concentration: • Day 2-4 • High levels 10-20IU/L- high specificity(80-100%) for predicting poor response to stimulation • Sensitivity is low (10-30%) Basal E2 level: • Little value as an ORT • Helps interpreting FSH levels • ↑E2/normal FSH or ↑E2/↑FSH-poor response to stimulation Inhibin B: • Little value as an ORT • Secreted during follicular phase and vary between cycles • 64-90% specificity • 40-80% sensitivity for poor response AMH • Granulosa cells- pre & small antral follicles • GnRH independent • Little variation within & b/w cycles • 40-97% sensitivity;78-92% specificity • Neither sensitive nor specific to predict PR • Very promising screening test for DOR Speroffs Clinical Gynaecologic Endocrinology 8th ed
  44. 44. •Increased risk of false positives when tests are used in low risk populations •Insufficient evidence to recommend that any ovarian reserve test to be used as a sole criterion for the use of ART. ASRM 2015
  45. 45. Hormonal evaluation PRL measurement: • Incidence of ↑PRL in infertile but ovulatory women-3.8% - 11.5% • Estimation of PRL levels should be reserved for women with ovulatory disorder/galactorrhea/pituitary tumour Thyroid function tests: • Abnormal TFT -1.3-5.1% of infertile women • 0.8-11.3% of women with ovulatory disorders have subclinical hypothyroidism NICE 2004
  46. 46. Biophysical Tests Antral follicle count: • AFC correlates to number of remaining follicles • Total no of antral follicles measuring 2– 10 mm in both ovaries • Performed on cycle days 2-5 • A low AFC has high specificity for predicting poor response to ovarian stimulation and treatment failure • Low sensitivity limits clinical utility Ovarian volume: • length × width × depth × 0.52=volume • A low ovarian volume(< 3mL) has high specificity (80–90%) but widely ranging sensitivity (11–80%) for predicting poor response to ovarian stimulation Speroffs Clinical Gynaecologic Endocrinology 8th ed
  47. 47. NICE Recommendations • Use one of the following measures to predict the likely ovarian response to gonadotrophin stimulation in IVF: 1. Total AFC 2. AMH 3. FSH Ovarian volume/ovarian blood flow/InhibinB/E2 are not used to predict fertility outcome
  48. 48. Dynamic tests of Ovarian Reserve Clomiphene citrate challenge test(CCCT) • 100mg Clomiphene citrate given from days 5-9 • Day 3 and day 10 FSH levels measured • Elevated day 10 FSH indicates DOR Mechanism : less negative feedback on clomiphene induced pituitary release d/t less inhibin B and E2 release by the smaller follicular cohort of aging women Speroffs Clinical Gynaecologic Endocrinology 8th ed
  49. 49. 1. Clomiphene citrate challenge test (CCCT) 2. GnRH agonist stimulation test (GAST) 3. Exogenous FSH ovarian reserve test (EFORT) • A positive test (abnormal CCCT) did not provide convincing evidence of non-pregnancy • Diagnostic accuracy of GAST and EFORT could not be calculated CONCLUSIONS-Inaccuracies in defining normality, dynamic ORT should be abandoned Maheshwari A et al,RBM 2009
  50. 50. Uterine factors Uterine factors in infertility 10-15% Congenital uterine anomalies: Defect in the development or fusion of paired mullerian ducts Acquired uterine abnormalities: Endometrial polyps Fibroids Adenomyosis Intrauterine adhesions
  51. 51. Evaluation of Uterine Factors HSG: • Identifies uterine anomalies/submucous polyps/intrauterine adhesions TVUS/SIS: • Identifies important uterine pathology but no useful measure about endometrial function/receptivity HYSTEROSCOPY : • GOLD STANDARD • Direct visualisation of uterine cavity MRI: • Non-invasive with 100% sensitivity • Added advantage of identifying urological abnormalities
  52. 52. UTERINE EVALUATION HSG Intrauterine filling defect Hysterographic USG Submucosal fibroid Adhesions Endometrial polyp Uterine contour abnormality Pelvic USG Pelvic MRI Fibroid Adenomyosis Mullerian duct anomaly
  53. 53. Hysteroscopy IU adhesions Uterine polyp Uterine septum
  54. 54. Congenital uterine anomalies • Associated with pregnancy loss and obstetrics complications • Not infertile • Prevalence 2-4% in fertile and infertile women • Septate(35%)> bicornuate(26%)> arcuate(18%) > didelphys(8%)> agenesis(3%) LBRs before hysteroscopic septal resection-10% & after resection 75-80% Joesph et al,Reproductive outcomes after septal resection,Journal of Obstetrics and Gynaecology,2014
  55. 55. Uterine Myomas • 5-10 % infertile women • Interferes with implantation • Submucous myomas reduce success rates in IVF by 70%, intramural myomas by 30% and subserosal myomas no effect Pritts et al.,Fertil-Steril 91:1215-23,2009
  56. 56. Submucosal Fibroids The European Society of Hysteroscopic classification of submucosal fibroids: Type 0: Complete protrusion of a pedunculated fibroid into cavity Type 1: sessile myomas with <50% of mass in the myometrium Type 2: >50% of fibroid within the myometrium Hysteroscopic myomectomy is the Gold standard treatment for submucosal fibroids Pritts et al.,Fertil-Steril 91:1215-23,2009
  57. 57. HSG-large intrauterine filling defect due to a large submucosal leiomyoma MRI demonstrates a region of heterogeneous increased signal intensity that represents a fundal intramural fibroid (arrow) with a submucosal component (arrowhead).
  58. 58. Endometrial Polyp • Prevalence- 6 to 32% in infertile women • Effect on embryo implantation &infertility is uncertain • Diagnostic modalities: TVUS:Appears hyperechoic Colour doppler shows feeder vessel Hysteroscopy: Gold standard SIS and Hysteroscopy are equally sensitive in terms of their diagnostic accuracy Lieng et al.,Trestment of endometrial polyps,Acta Obstet Gynecol Scand,2010
  59. 59. Endometrial Polyp (a) HSG- well-circumscribed ovoid IU filling defect (b) USG posterior fundal polyp (c) Color Doppler central feeding vessel
  60. 60. Adenomyosis • Poor reproductive outcomes due to disordered uterine peristalsis and disruption of endo-myometrial junction zone (JZ) EVALUATION  TVUS: • Specific feature: presence of myometrial cysts • Most sensitive feature:heterogenous myometrium  MRI: • Thickened JZ in adenomyosis
  61. 61. Adenomyosis HSG saccular contrast material protruding beyond normal contour of the endometrial cavity USG globular uterine enlargement with asymmetric thickening and poor definition of endomyometrial junction
  62. 62. Intrauterine Adhesions (a) HSG linear intrauterine filling defects (b) SIS- multiple uterine synechiae
  63. 63. Intrauterine Adhesions • Hysteroscopic adhesiolysis is the treatment of choice • Unmedicated IUDs and balloon catheters used in immediate post op period to maintain seperation • Best results with balloon catheter • Post op exogenous estrogen-efficacy not been established
  64. 64. Evaluation of Peritoneal factors ENDOMETRIOSIS : • 25-40% in infertile women • Distorted pelvic anatomy • Altered endometrial receptivity/ implantation • Altered peritoneal function Evaluation : • USG • MRI
  65. 65. Imaging Modalities TVS Adnexal masses : • Sensitivity: 64-89% • Specificity:89-100% • Can elicit probe tenderness and ovarian mobility - advantage over MRI Rectal endometriosis • sensitivity: 91% • specificity: 98% • Useful for identifying and ruling out rectal endometriosis Usefulness of 3D sonography not well established MRI • Sensitivity – 83% • Specificity- 98% • Usefulness of MRI not well established for diagnosis • Useful for detection of deep endometriosis; rectosigmoid, bladder endometriosis Hudelist et al., Ultrasound Obstet Gynecol 2011. 37:257-263 Benacerraf et al., J Ultrasound Med 2012. 31:651–653
  66. 66. Usg features of endometrioma • Ground glass echogenecity • 1-4 compartments • No papillary projections with detectable blood flow ESHRE Endometriosis Guideline Development Group,2013
  67. 67. Cervical Factor • Rarely the sole or principal cause of infertility Post coital test for the diagnosis of cervical factor is no longer recommended - NICE 2013
  68. 68. Unexplained infertility Includes : • Normal semen quality • Ovulatory function • Normal uterine cavity • Bilateral tubal patency More common in women >35 yrs Causes : Abnormalities in zona pellucida Genetic defects in centrosome Age of the female and duration of infertility affect pregnancy rates NO VALID DIAGNOSTIC TEST Speroffs clinical gynaecologic endocrinology 8th ed
  69. 69. Take home message • Evaluation of an infertile female depends on the resource settings of the country • Institution based standardized guidelines • Avoid aggressive treatment or inappropriate recommendations in women with normal ovarian reserve • History and physical examination –vital role • Baseline screening for general health and ANC • Tests of ovulation and tubal patency correlate with pregnancy outcome • Hormone assays are not recommended routinely • Tests for ovarian reserve not recommended • Endometrial biopsy/aspirate is done not to document ovulation but to rule out tuberculosis
  70. 70. THANK YOU!

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