1. PROF.DR. SAMIR FOUAD KHALAF AL-AZHAR UNIVERSITY PRESIDENT WWW.ARABICOBGYN.NET Work up for infertility

2. Evaluation of infertility Couples should be evaluated together and brief idea about fertilization and causes of infertility to reassure the couple is given Investigations usually start after one year of unprotected intercourse in patients under the age of 35 years with no obvious cause of infertility After the age of 35 years it is better to start evaluation after 6 months if no obvious cause as fertility decreases by age History including sexual history and the use of jells or douching and physical examination for both should be detailed Female…evaluation of cervical, utrine, ovarian and tubal factors Male.. Semen analysis

3. Cervical Factor Stenosis: can be diagnosed during speculum examination. Complete cervical stenosis is confirmed by the inability to pass a 1-2mm probe into he uterine cavity Postcoital test (PCT) also known as Sims-Huhner test….consists of evaluating the amount of serpermatoza and its motility within the cervical mucus during the preovulatory period. It is no longer routinely used in he standard infertility work up because: - Has limited diagnostic potential -Poor predictive value -Increased testing without improvement in pregnancy rate -

4. Uterine Factor O/E defects such as vaginal septum, absence uterus, presence of fibroid can be found Detection of most defects require ancillary studies e.g Hystrosalpingograhy Ultrasonography Hysteroscopy

5. Hystrosalpingograhy _Performed during the early follicular phase *At his time the endometrium is thin &HSG provides better delineation of minor defects *in addition the possibility of pregnancy is eliminated -Use of water-based contrast media is preferable to oil- based media to avoid the risks of embolism and granuloma formation

6. Hystrosalpingograhy When used under Fluoroscopy it provides accurate information about: -Endocervical cavity -diameter and configuration of internal os -Endometrial cavity -Uterine/tubal junction (corneal ostium) Diameter, location and direction of fallopian tubes -Status of fimbriae

8. Ultrasonograhy It should be art of he routine examination in gynecology -It allows more precise evaluation of the position of he uterus within the pelvis -It provides more information about is size and regularity -It helps in detection of fibroids, endometrial polyp, ovarian cysts, adnexal masses and endometrioma -Assists in the diagnosis of PCO, persistent corpus luteum and monitoring ovulation

9. Ultrasonography Saline infusion sonography (SIS) It is well tolerated and can be performed in the office Should be performed during cycle days 6-12, thin endometrium allowing detection of intrauterine lesions - Provides simple inexpensive means to evaluate the uterine cavity and cases of tubal patency - Eliminates the risks associated with the dye and radiation required by HSG

11. Hysteroscopy A method for direct visualization of he endometrial cavity Used to treat synechia, polyp, and submucus fibroid, removal of uterine septum and foreign body Can be used to perform tubal canulation

13. Endometrial Biopsy Can detect ovulation and Luteal phase defects Dating of the endometrium by taking biopsy on day 21-22 of he cycle and matching with date of next period (assuming the cycle length=28dyas).. Lag +/- 2 days indicates LPD Multi-center prospective showed that dating of he endometrium does not discriminate between fertile and infertile coules

14. Tubal and Peritoneal Factors Laparoscopy Indicated when abnormalities are found on U/S, HSG, or suspected by symptoms and cases of unexplained infertility

16. Ovarian Factor Ovulation detection -Usually deferred when a woman report regular cycles If there doubt progesterone level greater than 4ng/ml is indicative of ovulation (day2-22 of the cycle) Sonograhic confirmation of follicle rupture with serial ultrasound can also be performed Basal body temperature chars can be used to predict ovulation Most prefer o use urinary ovulation predictor kits(detect LH) as they are more accurate and easier to use

17. Ovarian Factor Ovarian reserve Level of ovarian reserve and the age of he female are the most important prognostic factors in infertility Check FSH and E2 at cycle day 3…. Normal ovarian function is indicated when FSH is <10mIU/ml and E2 <65pg/ml Dynamic ovarian reserve Indicated in women >35 years old -Clomid 100mg from day 5-9 and measure FSH on day 10 if >10mIU/ml, it indicates decreased function -Other testes used for ovarian reserve evaluation..Antral follicle count, ovarian volume, Anti-mullirian Hormone level, Inhibin B level TSH and Prolactin assay should be checked since thyroid dysfunction and hyperprolactinemia can cause menstrual abnormalities and infertility

18. Evaluation of Male Previous paternity does not guarantee current fertility status Semen analysis -Sample should be collected in a sterile plastic container and delivered to the lab. at body temperature no longer than 30 minutes -Sample should be collected after a period of 3 days but no more than 5 days of sexual abstinence

19. Semen Analysis Volume 2-5ml pH level 7.2-7.8 Sperm concentration 20million or greater Motility 50% forward motility Morphology >4% normal sperm White blood cells fewer than million cells/ml

20. Interpretation Abnormal semen analysis can be attributed to various unknown reasons e.g: Incomplete collection of sample -Short period of sexual abstinence… Therefore repeating the semen analysis a least I month before a diagnosis made is important Azospermia…absence of sperm that could result from ----congenital absence or bilateral obstruction of he vasa deferens or ejaculatory ducts -spermatogenesis arrest -Sertoli cell syndrome -Postvasectomy Oligospermia… concenraion less than 20million/ml -Ejaculatory dysfunction such as retrograde ejaculation -Genetic condition Hormonal imbalance Asthenospermia.. Sperm motility of less than 50% may be due to excessive heat or delayed analysis of specimen Hypospermia…decrease of semen volume to <2ml er ejaculae Hyperspermia…Increase semen volume>8ml er ejaculate Teratospermia.. Increase number of abnormal morphology a head, neck or tail