1. Infertility Work-up: Take Home Messages by Prof. Mohammad Emam Mansoura Faculty Of Medicine Mansoura Integrated Fertility Center EGYPT-2011

2. Objective: To highlight practical messages for general gynecologist regarding workup of infertility. To highlight practical messages for general gynecologist regarding workup of infertility. Based on: Based on:META-ANALYSISRCT GUIDELINES AND PROTOCOLS.

3. Grading – Evidence Based Recommendations A recommendation I evidence B recommendation II evidence C recommendation III evidence D recommendation IV evidence I a- meta-analysis of RCTs trials, I b- at least one RCT. II a - at least one controlled study without randomization II b - at least one other type of quasi- experimental study non-experimental descriptive studies, such as comparative studies, correlation studies and case control studies from expert committee reports or opinions and/or clinical experience of respected authorities GPP Good practice point: The view of the Guideline Development Group

4. Message 1: Do not neglect history and examination, before starting workup. Many problems can be solved before proceeding to workup. Do not neglect history and examination, before starting workup. Many problems can be solved before proceeding to workup.

5. Message 2: When to start your workup? TWO Era (WHO) TWO Era (WHO) After one year After one year Recently after 6 months Recently after 6 months Provided that: Absence of known reproductive pathology Absence of known reproductive pathology Regular and frequent marital relationship Regular and frequent marital relationship

6. Why duration becomes 6 month only (WHO)? 1. 1. Reduction in both the time and cost of investigating an infertile couple. 2. 2. It is better to start a workup of infertility earlier and proceed, than to waste time in empirical clomiphene citrate therapy, with its side effects.

7. Workups that have an Established Correlation with Pregnancy 1- Semen Analysis 2- Ovulation Assessment (mid luteal progesterone) 3- Tubal Patency (HSG, sonohysterography or laparoscopy if indicated)

8. WHAT is AFTER the 6 Month WORKUP? If the workup is normal, give the couple one year or if they become pregnant… If any workup is abnormal, proceed the treatment.

9. Message 3: Workup Earlier than 6 months if Female Factors Irregular menses Irregular menses PID PID Abdominal surgery Abdominal surgery Dyspareunia Dyspareunia Age > 35 Age > 35 BMI >29 BMI >29

10. Workup before 6 months continued Male factors Impotence Impotence A partner known to be sub fertile A partner known to be sub fertile Testicular surgery/injury Testicular surgery/injury Outflow abnormalities (hypospadias) Outflow abnormalities (hypospadias) Traveling abroad for extended period of time, (i.e. working, leaving wife in his country) Traveling abroad for extended period of time, (i.e. working, leaving wife in his country) Social problemsSocial problems Second marriage with no living offspring from first and known history of infertilitySecond marriage with no living offspring from first and known history of infertility

11. Messages Regarding Semen Assessment

12. Message 4 Laboratories that perform semen analysis should follow WHO methodology.

13. Message 5: CASA or Conventional Semen Analysis Message 5: CASA or Conventional Semen Analysis CASA is not superior to conventional semen analysis, (Grade A).

14. Message 6: If Semen Analysis is Abnormal Repeat confirmatory test 3 months after the initial analysis and treat. (Grade B) Repeat confirmatory test 3 months after the initial analysis and treat. (Grade B) If Azoospermia or severe oligoathenozoospermia, repeat test as soon as possible. GPP If Azoospermia or severe oligoathenozoospermia, repeat test as soon as possible. GPP ) (GPP = Good practice point)

15. Male Sub fertility Count Motility Morphology Million/ml (G1+G2%)(N%) Mild 15-20 40-50 30-40 Moderate 10-15 20-40 10-30 Severe <10 <20 <10 WHO

16. Message 7: Where and When Testicular Biopsy (TB) should be done in Azoospermia? Message 7: Where and When Testicular Biopsy (TB) should be done in Azoospermia? TB should be performed only in a tertiary service where there are facilities for sperm recovery, cryopreservation and ART. (C) TB should be performed only in a tertiary service where there are facilities for sperm recovery, cryopreservation and ART. (C)

17. Messages Regarding Ovulation Assessment

18. Message 8: Midluteal Progesterone Pulsatile release, thus single level may not be useful unless elevated. Pulsatile release, thus single level may not be useful unless elevated. Values of > or = 10ng/ml are suggestive of normal progesterone production. Values of > or = 10ng/ml are suggestive of normal progesterone production. In irregular cycles: In irregular cycles: Perform test later in the cycle and repeated weekly until the next menstruation. Perform test later in the cycle and repeated weekly until the next menstruation.

19. Messages Regarding Tubal Patency Tests

20. Message 9: Ranking of Tubal Patency Tests (TPT) Primary Infertility: The results of semen analysis and assessment of ovulation should be known before a test for Tubal Patency is performed..Why ?..As decision of treatment depend on all 3 parameters and tubal factor is ranked the third. Secondary Infertility:TPT should be done first…..Why?... As the most common cause of secondary infertility is tubal factor. Secondary Infertility: TPT should be done first…..Why?... As the most common cause of secondary infertility is tubal factor.

21. Message 10: Precautions Done Before Tubal Patency Tests? Prophylactic antibiotics should be considered before uterine instrumentation (including HSG), if screening for Chlamydia T has not been carried out. (GPP) Prophylactic antibiotics should be considered before uterine instrumentation (including HSG), if screening for Chlamydia T has not been carried out. (GPP)

22. Message 11: HSG is better to be done Under Fluoroscopy HSG is better to be done Under Fluoroscopy

23. Message 12 Sonohysterography HSG? Message 12: Sonohysterography HSG? With experience, the use of sonohysterography should be considered as an effective alternative to HSG (Grade A). With experience, the use of sonohysterography should be considered as an effective alternative to HSG (Grade A). TVS can add evaluation of pelvis. TVS can add evaluation of pelvis.

24. Messages Regarding Doing Unnecessary Workup

25. Message 13:Unnecessary laparoscopy Message 13: Unnecessary laparoscopy It is not cost effective to do diagnostic laparoscopy as part of the initial infertility evaluation. When: history, examination, TVS, HSG, and MLP are all normal (Grade B) (Grade B)

26. Message 14 : When to do Laparoscopy? For women who are thought to have pelvic co morbidities (PID, previous ectopic or endometriosis), evaluation of the pelvis is required. (Grade B)

27. Message 15 Two schools of thought: 1) Hysteroscopy has No role in routine Evaluation of infertility. 2) Some recommend office hysteroscopy as routine.

28. Message 16: SolidIndications of Hysteroscopy as Workup in Infertility Message 16: Solid Indications of Hysteroscopy as Workup in Infertility Abnormal HSG hen Laparoscopy is indicated When Laparoscopy is indicated After Failed IVF ? After Failed IVF ?

29. Message 17:No Role for… Message 17: No Role for… Postcoital test Endometrial biopsy Antisperm antibodies Routine cervical cultures Thyroid function in absence of symptoms suggestive of thyroid disease Prolactin in absence of galactorrhoea

30. Message 18: The Role of 3-D US in workup? Message 18: The Role of 3-D US in workup? No role in routine infertility workup It is no more effective than two dimensional ultrasound

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