INVESTIGATIONS
Regardless of the nature and type of infertility,
infertility investigations are considered basic to infertility management
because they can unfold the cause of infertility in 80-90% of causes. These
include semen analysis test, test of tribal potency (HSG, LG and adulatory
function test). Additional or secondary investigation could be performed there
is as immediate explanation for the cause of infertility from these basic test
or when one of these test is inconclusive /abnormal.
Also, conferee commencing
these investigations, endocrinal beuch microscopy culture and sensitivity is
adviced before proceeding to do HSG. Beselien pelne scan is also some an
denesing an appropriately sensitive technique is advisable but not usually
feasible in may done settings of Africa. Hence, prophylactic antibiotic may be
considered and before interne institution has (including HSG) if seceding has
not been carried out ancillary investigations like packed cell volume (PIV)
analysis (protein, glucose, mizroscoy) and other general investigation as might
be indicated by the general health
condition of the clients.
Basic Infertility Test
Seminal
fluid Analgesic (SFA)
The
semen sample for analysis is normally obtained from the male partner following
3-5days of sexual abstinence. The sample should be pregnable collected by the
saturation in a clear wide bore container. Collection by coitus interrupticus
or with a latex condom impregnated with a spermicidal agent is not recommended
ideally collection should take place in the hospital where analysis can be done
immediately or within 30 to 1hour of most for those bring their sample from
outside the hospital. The sample is then analyzed for volume count, mollify,
morphology cultured to exclude the presence of bacteria organisms the SFA
result (see table 3 & 4)
The standard semen analysis has a
sensitivity of about 90% (i.e 9 out of 10men with a genuine problem are
detected) It is not, however, particularly specific test and a single sample analysis
will falsely identify 10% of men as abnormal. Repeating the test reduces this
chance to 2%.
Marked fluctuations of the various
semen parameters have been observed in normal fertile men. It is therefore
important to repeat the semen analysis once any abnormality (interact of 2-3
mouths apart) is found with the first SAF. Repeat confirmatory test should
ideally be undertaken 2-3 months after the initial analysis to allow for the
cycle of spermatozoa formation to be completed (72days). However, if a gross
spermatozoa deficiency (Azosperma or severe digospermia) has been detected, the
repeat test should be undertaken earlier (i.e 4-6 weeks apart).
Test of Ovulation
Clinical indicators of ovulation include mid cycle
ovulatory pain (mittelschmerz), menstrual cycles in the range of 26-35 days.
Confirmatory ovulation test is an
important part of the basic infertility investigation and should be done
whether or not the woman is menstruating normally, since about 10% of women
with regular menstrual cycles may be anoovulatory.
Several tests of ovulation are
currently available but only few can be of practical evaluation of the
infertile woman these include:-
Producer
(using kaman’s syrup) and has the additional benefit of being able to diagnose
other abnormalities that may be associated with infertility such as lacteal
please defect and tuberculous endometritis. Semen progesterou:- ovulation can
be confirmed retrospectively by measurement of the semen progesterone in the in
lacteal phase, on approximately day 21 of a 28-day cycle.
Several tests of ovulation are
currently available (all dependent on the secretion of progesterone by the
corpus luteum) but only few appear to be practically utilized in the clinical
evaluation of the infertile women. These include:-
Endometrial
Biopsy: sampling the endometrium to access progesterone production by the
corpus luteum gives indirect evidence of the presence or absence of ovulation.
It consist of a histological assessment of endometrial biopsy taken (day 21
regualar 28 day cycle. Or late luteal phase preferable 1-3 days before menses)
normal ovulatory menstrual cycle would demonstrate a secretary endometrium with
maturity that is compatible with the day of endometrial sample which
non-ovulatory cycles would reveal pholiferative endometum. Endometrial biopsy
can also identify ovulatory abnormalities like luteal phase deficiency which is
presumptively diagnosed when there is a 3-days or more discrepancy in the
maturity of the sampled.
Its however, major available is
mainly from difficulty in interpreting the biopsy because precision and
accuracy vary greatly among individuals woman should not be offered an
endometrial biopsy to evaluate the luteal phase as part of the investigation of
infertility problems because there is no evidence that medial treatment of
luteal phase defect improves pregnancy rats moreover,
Endometrial biopsy (EB) is no longer
done routinely as part of infertility investigations except when endometrial
pathology (such as tuberculosis) is being considered, making it an indication
of Ep developed countries of Africa where this condition may be commonly
assisted with infertility.
Serum progesterone Estimation
Consist of the estimation of serum progesterone in the
mid leteal phase of their cycle on approximately nay 21 of a 28 day cycle) or a
progesterone index (mean value of samples taken on days 20, 21 ad 22) to
confirm ovulation retrospectively. Available evidence suggest that even within
the normal range, higher progesterone levels associated with higher conception
rate whole lower progesterone levels have lower pregnancy levels have lower
rates of conception.
The level needs to be interpreted in
the light of the date of the subsequent menses. For women with irregular cycle,
this test may need to be performed later in the cycle (for example day 28 of a
35 day cycle) or repeated weekly until the next menstrual cycle starts.
·
A level < 16
nmol/L suggest an ovulation
·
Levels >
30nmol/L is suggestive of ovulation, although WHO threshold is 18mmel/L (as
this represent the 2.5th centile in a large population study)
·
Levels between 16
and 30 nmol/L should be repeated further investigation of unovulation should
take place n tertiary care or specialized fertility clinics
However, hormone assay are often of available or
affordable to couples in many clinics in Africa as a tool for basic
investigation.
Ultrasound scan (USS)
Ussacn,
by contrast, is now available in increasing number of centres in Africa for the
assessment of ovulation. With a sector ultrasound scan and a vaginal probe, it
is now possible to visvalise the ovaries and ovarian follicles quite easily. An
ultrasound scan (baseline scan) done at the beginning of the menstrual cycle
usually reveals the follicles (as echoluscent circular spots within the more
echolgenic ovarian tissue) which are normally not more than 3-4 mn initially
paragraph with serial scans between day 8 and day 14, the follicles would be
seen to increase in size up to a maximum of 20-22 mm and ovulation is then
deferinched by the disappearance of the follicle and appearance of a distinct
corpus luteum.
Hence, ultrasound folliculagrphy
(follicular tracking) is very useful in monitoring ovulation during induction
of labour in specialized futility clinics worldwide. In addition, the thickness
and reflectively of the endometrial eaho can be assessed at the tune of
ultrasound folliculogrphy. However, the uss of the method for the assessment of
ovulation in Africa is limited by the high cost of ultrasound equipment.
Other methods that can be used for
assessment of ovulation include use of home ovulation test such as measurement
of daily basil body temperature (BBT) or use of lateralizing hormone (LH)
defection kits by the woman to track her ovulation at home. Basal body
temperature (BBT) tracing is not generally recommended for ovulation assessment
in Africa because the method stressful with is at fondant difficulties in
obtaining reliable temperature.. readings from the patients in addition,
neither method has been found useful in the practical management of the
infertile patient with respect to improving their conception rate.
Test of Tubal Potency
Test of tubal potency is an important investigation
that need to be carried out as part of basic infertility investigation in our
environment since tubal factor is a major infertility in Africa..
Hysterosalpingophry (HSG) and
laparoscopy with dye are the two most commonly used methods to test tubal
pathology.
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HSG
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laparoscopy toye
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Procedure
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done in follicular (day 10 or sule 1st days
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Done
in luteal phase profer phollizular phase to exclusive pregnancy.
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radiological setting/procedure
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surgical/theatre procedure
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Pain
relievers and/or antispatmedics to relax the tubes. (we please dales results
from corneal sperms)
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general anaestheisa allows better
assessment laparouspy (some gynecologist sometimes profer to use local anaesteis
with light sedation)
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-Dye/canola
oil based day or preferenably water
based sodium amidozoale (hypaque) or urographin preferably) instilled us the
cervix using either hilkohson’s or faco canula or foolery catuetor
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less invasive less expensive and eailsy accessible in Africa
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-Dye/canula
usually water based dye such as methylene blue or indigo carmine) preferred
by some because it does not stain) injected via a tightly fitted cauola
(sparkman/ nebin) expensive invasive and hence more complication prone
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Intratubal
and intrauterine factors such as asherman’s factors, such as asherman’s
syndrome subnucous fibrord, congerit a ulterine abnormalities, tubal
package
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Extriutnue
and partitioned factors such as pelux peritubal. Adhesions, subserous
fibroid) endonetrisis, ovarian cyst (which may be missed by HSG)
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i.e
mainly useful to establishing actual potency of the tubes where tubal
occlusion exist
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Clear
view of the several surface fo the tubes can be obtained, tubal potency
determined, peritoneal
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HSG
is a reliable indicator of tubal potency but poor at identifying cases of
tubal occlusion
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The
sensitivity, specificity and predictive value of laparoscopy for tubal
diseases is substantially greater than that of HSG
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-normal
HSG has compared to laparoscopy (with opening up of mocos plays and actuating
tubal cities)
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Normial
lap and dye is roles associated with a increased pregnancy rate/outcome but
usually allow the treatment of pathology at the same time such as
adherioslysis ablation of endometriosis or salping ostomy
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Indication
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used as screening procedure
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Gold
standard /confirmatory test for investigating the fallopian tube
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-low
risk group with no history of co-morbidities (such as PID /STD pestabortal/
puerperal surgeries etc)
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High
risk group with hx suggestive of reproduction pathology impairment
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six (6) months after normal HSG without conception
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Hysteroscal
pornography and laparoscopy are now regarded as being complementary in the
investigation of infertility. None of the procedures ont heir own, can fully
assess the extent of infertility. Women not known to have tubal disease should
be offered HSG or Hycosy to screen for tubal occlusion because they are
reliable tests for ruling out tubal occlusion, less invasive and make more
efficient use of resources than laparoscopy especially in developing courtiers
of Africa. However, if only one test can be done, the practical recommendation
is that this should by laparoscopy (+dye test) with the hope that if this is
normal it obviates the need for HSG in a large population of case.
Hysterocontiastsougrphy
(Hycosy) is a modern ultrasound based investigation which uses a son reflective
contrast media to outline the uterine country and fallopian tubes. It is a simple
test well tolerated, avoids exposure to x-rays and may be a suitable
alternative out patient procedure.
Hycosy has been shown to be
comparable to HSG demonstrated good concordance with lap and dye, but is yet to
become part of standard care in most centres especially in developing countries
of Africa.
Other techniques such as
fertiloscopy and fallopsoscopy require
further evaluation before incorporated into routine practice.
It must be noted that endceivcal
such should be done before any instrumentation of the literus to reduce the
risk of pelvic infections. Alternative by, prophylactic antibiotics may be
given.
Further/testing
final infertility investigation
These investigations become
necessary when the basic infertility evaluation are abnormal they are usually
carried in specialized secondary or tertiary centres and fertility clinics.
Inconclusive in determining the
cause or clinical evidence of hypogonaism or raricocele. Further investigation
of semen abnormalities a conclusion of normality or otherwise should be based
on at least 2-3 semen analysis 4 to 6 weeks apart. Three abnormal properly
collected semen specimen are indication for additional test to determine the achology of the deduced/ abnormal semen
parameten. These additional test include
1. Endocrine
test
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Hormonal assay (fsit, lit, frolactin,
testisterou)
·
Chromosomal (karyotyping, cystic
fibrosis gene screen, Y- chromosome micro deflection, ya,
deletion, FISH)
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Antisperm antibodies (Mixed agglotrmin reaction (MAR), immune
bead test)
2. Testicular Biopsy - is
no logner soul as routinely investigation in male fact infertility because of
feat of compromising
future microsurgical proaedures
expect where testicular carcinoma
in situ (CIS) is suspected.
Azosperma
Obstructure
azosperm FSH/normal
profile noral, testicular size – nonal
Cystic
Fibrosis Congenital
bilated aersense of vas defereus (CBAVD) po vasogrphy
Surgery
to gran, scrotum, mettra, vas deferens youngs synodame
Non
obstructive -FSH is increased, testicular volume/size small (<15mls)
Klinefelters
(r7xxx)
Testicular
atrphy
Hypogonadotrophiom
- FSIT 1) reduced/noral, testes small
Ejaculatory
failure
Retrograde
ejaculation - No post ejaculatory analysis for spernatzoa
Olispermia
fault thermoregulation - dopplar studies, thermogrpahy and venography for confirmation
-incomplete
descent - scrotal ussca
-hyohoceele
-
-clothing
Occupation
– baker
Infection
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chaandra - morphological studies
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Tb.
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Mrinps
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gonorrhea
In
azospermia or severe oligosperima (25million/ml), a hormonal assay and imaging
can help distinguish type of azospermia while genital studies should also be included
as any abnormality may have implications for resulting pregnancies.
b. drugs
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Alcohol
-Caner
chemotherapy
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sulpliasalazue
Irradiation
Sperm
immobilization (antisperion) antibodies in both semizel plasma and semen when
sperm mobility is persistently cow.
Prostatic
function test (zince, phosphates, fructose estimation) are not performed
routinely but only when there is abnormal semen specimen or clinical evidence
of discords of these glads.
Investigation
of anavulation/irregular cycles
If ovulation is confirmed, no
further endocrine test is one required. However, women fund to have low levels
of day 2, progesterone (i.e no ovulation) should have hormonal assoy/ students
dove.
Investigation for anoilelation
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Assessment
of uterine factor
Uterine abnormalities sufficient to cause infertility
are uncommon but should be investigated even through a direct casual
relationship between these abnormalities (fibroid, polyps, intrauterine
adhexous, septate) and infertility has not been established.
Assessment
of the utems and endometrial cavity is accomplished with ultrasound scan
(transvegica/abdominal), hysterosalpingogran (HSG) or saline-infusion
sonohysterogrphy (SHG0 hysteroscopy is not offered as part of the initial
investigation, it is usually reserved for evolution and treatment of
abnormalities identified by less invasive methods.
Assessment of cervical
factor
The proslcoital test (PCT) has been used to evaluate
the adequacy of the cervical music and its interaction with sperm.
Thus
test is normally performed at 1-2 piror to ovulation (on day 14 of a normal 28
day cycle) by obtaining a sample of the cervical mucus 2-12 hours after
intercourse. In the standard criteria (or a normal postcortal test the cervical
mucus is often profuse (volume) clear, presence of ferming, more than 5-20cm of
stretchanlity (spunnbarkeit effect) and at least 5 mobile 2 perm per high
powered filed. An abnormal postcoital test usually implies the absence of those
parameters and may be due to wrong towel of the test, abnormal tenvral micus
from chronic cervites and antisperm antibodies from the woman or her husband.
The utility validity of the PCT have been questioned because of the poor
reproducibility poor pregnancy outcome, difficulty a reading consensus or test
technique and interpretation. Again, contemporary fertility treatment with
intrauterine 1 ugeulation (FUT) or invitio fertilization (IVF) by passes any
abnormality of the cervox or cervical mucus. Due to limited diagnostic value,
the PCT is only usually mentioned to be condemned in practercal terms, but it
may be of some advantage (via Africa where the husband may evidently refuse to
submit himself to a formal semen analysis.