1. Dr H Rahmanpour Infertility specialists

2. Definition Infertility is defined as 1year of unnon-conception with unprotected intercourse in the fertile phase of the menstrual cycles (Evers,2002).

3. In normal couples the fecundity, or the chance to pregnancy with in one cycle is 20%(Evers,2002). On this Basis it is assumed that 85% of women should be pregnant in 1 year.

4. Common causes of infertility include male factor (25-45 %), ovulation disorders (30-40 %) and tubal damage (30-40 %). A combination of several factors is found in approximately 10-20 % of all couples.

5. Un explained infertility 10-15%of in whom standard investigations – Including semen analysis,tests of ovulation and tubal patency have failed to detect any gross abnormality

6. Initial Consultation Infertile couples are usually advised to start their investigations after 12 months of trying to conceive or after 6 months.

7. Earlier evaluation Earlier evaluation is warranted for couples wherein the male partner has known or suspected poor semen quality or the female partner has irregular or infrequent menses, a history of pelvic infection or endometriosis, or is over 35 years of age.

8. basic infertility evaluation should include tests aimed at the 4 most important causes of infertility (1) ovulatory dysfunction, (2) abnormalities of semen, (3) abnormalities of the uterus and fallopian tubes, (4) reproductive aging.

11. tubal obstructions Proximal tubal obstructions prevent sperm from reaching the distal fallopian tube where fertilization normally occurs. Distal tubal occlusions prevent ovum capture from the adjacent ovary.

12. Whereas proximal tubal obstruction is essentially an all or none phenomenon, distal tubal occlusive disease exhibits a spectrum ranging from mild (fimbrial agglutination) moderate (varying degrees of fimbrial phimosis) severe (complete obstruction).

13. The etiology of tubal damage can be intrinsic : ascending salpingitis, salpingitis isthmica nodosa),mucus pluck, polyp. extrinsic :peritonitis, endometriosis and pelvic surgery).

14. Tubal factor evaluation The methods available for evaluating the fallopian tubes include traditional HSG, laparoscopic “chromotubation,” Sonohysterosalpingography and the chlamydia antibody test (CAT).

15. hysterosalpingogram Assessment of tubal patency is one of the first steps in fertility investigations. Hysterosalpingography (HSG) is the most common first-line diagnostic test used for this purpose. In addition to assessing tubal patency, HSG also provides an image of the outline of the uterine cavity. It has also been suggested that HSG has a therapeutic role in enhancing subfertility

16. water-soluble or oil-soluble contrast media Over the years, controversy has raged over the relative advantages and disadvantages of water-soluble and oil-soluble contrast media. both water-soluble and oil-soluble contrasts are appropriate, depending on preference.

17. test of tubal patency, HSG is approximately 60% sensitive and 95% specific, meaning that when it suggests obstruction, the tubes are often truly patent, but when it demonstrates patency, the tubes are almost always truly open. 16 16

18. Normal HSG

19. The relatively poor sensitivity of HSG as a test of tubal patency results from the difference in test accuracy for diagnosis of proximal and distal tubal occlusion. The diagnosis of distal tubal obstruction generally is accurate, but apparent proximal tubal occlusions are often not real, representing artifacts of transient uterine contractions, so-called “tubal spasm,” or catheter placement (with the tip lying near one tubal orifice).

20. The HSG diagnosis of proximal tubal obstruction must, therefore, be confirmed, either by repeating the study, or by performing either fluoroscopic or hysteroscopic selective tubal catheterization.

21. Both false-negative (obstructions that are not real) and false-positive results (patency that is not real) occur, the former being much more common than the latter.

22. HSG is best scheduled during the 2–5 day interval immediately following the end of men-ses, to minimize risk for infection, avoid interference from intrauterine blood and clot, and to prevent any possibility that the procedure might be performed after conception.

23. Bilateral tubal abstraction

24. Hydrosalpinx

25. Uterine cavity abnormalities can be a contributing cause of subfertility in 10 % of women. Abnormal uterine findings are reported in as many as 50 % of women with recurrent implantation failure. These findings include endometrial polyps or fibroids, intrauterine adhesions and congenital abnormalities.

26. Bicorn uterus

27. Uterus with Septume

28. Unicorn uterus

29. Uterine myoma

30. Severe Asherman

31. TB

32. Sonohysterography:

33. The Thickened endometrium may be a Submucosal leiomyomas

34. Septate uterus

35. Sonohysterosalpingography hysterosalpingo-contrast sonography

36. Laparoscopic “Chromotubation Although generally more accurate than HSG, the diagnosis of proximal tubal occlusion has the same pitfalls as HSG and, ideally, should be confirmed by selective tubal catheterization.

42. Chlamydia antibody test The most common causes of pelvic inflammatory disease (PID) are Chlamydia trachomatis, Neisseria gonorrhoeae. Studies have demonstrated that the severity of tubal damage found in infertile women is directly related to their serum chlamydia antibody IgG titer (CAT)

43. Chlamydia antibody test Most asymptomatic tubal pathology is mainly attributed to the history of pelvic inflammatory disease (PID). past Chlamydia infection using serology is readily available and the test is simple and quick to perform.

44. Chlamydia antibody test Several European studies have suggested that the sensitivity of CAT for detection of tubal pathology approaches that of HSG and laparoscopic chromotubation. At least in theory, the CAT should help to identify women with tubal pathology who might benefit most from more specific tests, such as HSG or laparoscopic chromotubation. However, at present, the diagnostic accuracy of the CAT has not been established and the test is not used widely in the United States.

45. Chlamydia antibody test So while a negative CAT can be reassuring, a positive test would warrant more invasive diagnostic procedures, such as laparoscopy, to assess the severity of the disease even if there is no history of chlamydial PID.

46. Chlamydia antibody test The Dutch Society for Obstetrics and Gynaecology (NVOG) recommends the use of CAT as a first-line test in the basic work-up of subfertile couples, with a fixed cut-off level (immunoglobulin G MIF 1:32 or ELISA 1.1) above which post-infectious pelvic disease should be ruled out with laparoscopy and chromotubation.

47. Human Reproduction, Vol.26, No.5 pp. 967–971, 2011 Should a hysterosalpingogram be a first-line investigation to diagnose female tubal subfertility in the modern subfertility workup?

48. Conclusion CAT is comparatively inexpensive, less invasive and can be performed at any time during the menstrual cycle and can identify patients who need further evaluation. Laparoscopy remains the gold standard in diagnosing tubal pathology. We also suggest a flow chart of investigations for determining tubal pathology in women with subfertility as a compromise between invasiveness and diagnostic accuracy (Fig. 1), rather than a blanket policy of using HSG.

49. For CAT-positive patients, laparoscopy may be warranted, whereas CAT-negative patients should have a HyCoSy that carries a similar cost and has at least the same accuracy as HSG while avoiding radiation. We feel that HSG is out of date and has no place in modern evidence-based fertility investigations.

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