1. Fertility Testing Sana Javed Amnah Mahroo Sidrah Naseem
Fatima Darakhshan
Tehreem Tanveer
Misha Mazhar

2. Fertility Testing
Required when infertility is suspected: the biological inability of a person to contribute to conception
The state of a woman who is unable to carry a pregnancy to full term
Infertility
Female
Male

3. Female Infertility: Pathophysiology
Age
Weight
Genetic causes: Gonadal dysgenesis (Turner syndrome)
Hypothalamic-Pituitary disorders
Anatomical disorders
 Sometimes it can be a combination of factors, and sometimes a clear cause is never established.

4. Female Infertility: Pathophysiology
Acquired/ Environmental problems
Age
Weight
Anatomical disorders
Ovulatory
Tubular
Cervical
Uterine

5. Pathophysiology: Ovulatory problems
Hormonal
FSH & LH
Prolactin
Ovarian Factors
Anovulation
PCOS
Diminished Ovarian Reserve
Ovulation disorders account for infertility in 25 percent of infertile couples. These can be caused by flaws in the regulation of reproductive hormones by the hypothalamus or the pituitary gland, or by problems in the ovary itself
Premature menopause
Luteal dysfunction
Ovarian cancer

6. Tubular Infertility
When fallopian tubes become damaged or blocked, they keep sperm from getting to the egg or close off the passage of the fertilized egg into the uterus.
Infection      
Abdominal Diseases       
Previous Surgeries      
Ectopic Pregnancy       
Congenital Defects
When fallopian tubes become damaged or blocked, they keep sperm from getting to the egg or close off the passage of the fertilized egg into the uterus. Causes of fallopian tube damage or blockage can include:
1. Inflammation of the fallopian tubes (salpingitis) due to chlamydia or gonorrhea
2. Previous ectopic pregnancy, in which a fertilized egg becomes implanted and starts to develop in a fallopian tube instead of in the uterus
3. Previous surgery in the abdomen or pelvis
Infection       Caused by both bacteria and viruses and usually transmitted sexually, these infections commonly cause inflammation       resulting in scarring and damage.  A specific example is Hydrosalpnix, a condition in which the fallopian tube is occluded at       both ends and fluid collects in the tube.
(2) Abdominal Diseases        The most common of these are appendicitis and colitis, causing inflammation of the abdominal cavity which can affect the        fallopian tubes and lead to scarring and blockage.
(3) Previous Surgeries       This is an important cause of tubal disease and damage.  Pelvic or abdominal surgery can result in adhesions that alter the       tubes in such a way that eggs cannot travel through them.
(4) Ectopic Pregnancy        This is a pregnancy that occurs in the tube itself and, even if carefully and successfully overcome, may cause tubal damage        and is a potentially life-threatening condition.
(5) Congenital Defects

7. Pelvic causes
Pelvic causes include any disruption of the normal pelvic anatomy:
Scar tissue or "adhesions"
Endometriosis
Blocked, scarred, or distorted fallopian tubes
Benign tumors (fibroids) of the uterus
Endometriosis occurs when tissue that normally grows in the uterus implants and grows in other locations. This extra tissue growth — and the surgical removal of it — can cause scarring, which impairs fertility. Researchers think that the excess tissue may also produce substances that interfere with conception.
Approximately 10% of infertile couples are affected by endometriosis.  Endometriosis affects five million US women, 6-7% of all females.  In fact, 30-40% of patients with endometriosis are infertile.  This is two to three times the rate of infertility in the general population.  For women with endometriosis, the monthly fecundity (chance of getting pregnant) diminishes by 12 to 36%.  This condition is characterized by excessive growth of the lining of the uterus, called the endometrium.  Growth occurs not only in the uterus but also elsewhere in the abdomen, such as in the fallopian tubes, ovaries and the pelvic peritoneum.  A positive diagnosis can only be made by diagnostic laparoscopy, a test that allows the physician to view the uterus, fallopian tubes, and pelvic cavity directly.  The symptoms often associated with endometriosis include heavy, painful and long menstrual periods, urinary urgency, rectal bleeding and premenstrual spotting.  Sometimes, however, there are no symptoms at all, owing to the fact that there is no correlation between the extent of the disease and the severity of the symptoms.  The long term cumulative pregnancy rates are normal in patients with minimal endometriosis and normal anatomy.  Current studies demonstrate that pregnancy rates are not improved by treating minimal endometriosis.

8. Cervical infertility
involves inability of the sperm to pass through the
mouth of the uterus due to damage of the cervix.
Causes:
Inadequate or inhospitable cervical mucous
Cervical narrowing or "stenosis"
Infections of the cervix with common sexually transmitted diseases \
Immune attack of sperm or "sperm allergy“
Cervical narrowing or blockage Also called cervical stenosis, this can be caused by an inherited malformation or damage to the cervix. The result is that the cervix can't produce the best type of mucus for sperm mobility and fertilization. In addition, the cervical opening may be closed, preventing any sperm from reaching the egg.
Infections of the cervix with common sexually transmitted diseases (chlamydia, gonorrhea, or trichomonas, as well as mycoplasma hominis and ureaplasma urealyticum)

9. Uterine causes Uterine causes include: Thin or abnormal uterine lining
Anatomic problems
(polyps, uterine fibroids, abnormal shape of the uterus, septum or "dividing wall" within the uterus)
Uterine:
Benign polyps or tumors (fibroids or myomas) in the uterus, common in women in their 30s, can impair fertility by blocking the fallopian tubes or by disrupting implantation. However, many women who have fibroids can become pregnant. Scarring within the uterus also can disrupt implantation, and some women born with uterine abnormalities, such as an abnormally shaped (bicornuate) uterus, can have problems becoming or remaining pregnant.

10. Unexplained Infertility
Difficulty in picking up the egg by fallopian tube
Failure of implantation of the embryo into the uterus
Failure of the sperm to fertilize the egg when in contact with each other
Behavioral Factors: 
Diet and Exercise
Smoking
Alcohol
Drugs
Environmental and Occupational Factors: 
Lead
Medical Treatments and Materials
Ethylene Oxide
Dibromochloropropane (DBCP)
Unexplained causes:
Approximately 10% of infertile women suffer from unexplained infertility. This simply means that the commonly performed tests to diagnose the cause of infertilty are all normal and do not define the reason for infertility. However, we perform a more thorough search for a cause, since many subtle abnormalities may be discovered to explain the infertility. Usually such problems are due to:
Difficulty in picking up the egg by fallopian tube
Failure of implantation of the embryo into the uterus
Failure of the sperm to fertilize the egg when in contact with each other
In some instances, a cause for infertility is never found. It's possible that combinations of minor factors in both partners underlie these unexplained fertility problems. The good news is that couples with unexplained infertility have the highest rates of spontaneous pregnancy of all infertile couples.
  At least 10% of all cases of female infertility are caused by an abnormal uterus.  Conditions such as fibroid, polyps,
Other variables that may cause infertility in women:
  and adenomyosis may lead to obstruction of the uterus and Fallopian tubes.     Congenital abnormalities, such as septate uterus, may lead to recurrent miscarriages or the inability to conceive.
   Approximately 3% of couples face infertility due to problems with the femaleís cervical mucus.  The mucus needs to
  be of a certain consistency and available in adequate amounts for sperm to swim easily within it.  The most common    reason for abnormal cervical mucus is a hormone imbalance, namely too little estrogen or too much progesterone.
(2)  Behavioral Factors:         It is well-known that certain personal habits and lifestyle factors impact health; many of these same factors may limit a         couple's ability to conceive.  Fortunately, however, many of these variables can be regulated to increase not only the         chances of conceiving but also one's overall health.Diet and Exercise
Optimal reproductive functioning requires both proper diet and appropriate levels of exercise.  Women who are significantly overweight or underweight may have difficulty becoming pregnant.   Smoking
Cigarette smoking has been shown to lower sperm counts in men and increases the risk of miscarriage, premature birth, and low-birth-weight babies for women.  Smoking by either partner reduces the chance of conceiving with each cycle, either naturally or by IVF, by one-third.   Alcohol
Alcohol intake greatly increases the risk of birth defects for women and, if in high enough levels in the motherís blood, may cause Fetal Alcohol Syndrome.  Alcohol also affects sperm counts in men.   Drugs
Drugs, such as marijuana and anabolic steroids, may impact sperm counts in men.  Cocaine use in pregnant women may cause severe retardations and kidney problems in the baby and is perhaps the worst possible drug to abuse while pregnant. Recreational drug use should be avoided, both when trying to conceive and when pregnant.
(3)  Environmental and Occupational Factors:         The ability to conceive may be affected by exposure to various toxins or chemicals in the workplace or the surrounding         environment.  Substances that can cause mutations, birth defects, abortions, infertility or sterility are called reproductive         toxins.  Disorders of infertility, reproduction, spontaneous abortion, and teratogenesis are among the top ten work-related         diseases and injuries in the U.S. today.  Despite the fact that considerable controversy exists regarding the impacts of         toxins on fertility, four chemicals are now being regulated based on their documented infringements on conception.Lead
Exposure to lead sources has been proven to negatively impact fertility in humans.  Lead can produce teratospermias (abnormal sperm) and is thought to be an abortifacient, or substance that causes artificial abortion.  Medical Treatments and Materials
Repeated exposure to radiation, ranging from simple x-rays to chemotherapy, has been shown to alter sperm production, as well as contribute to a wide array of ovarian problems.   Ethylene Oxide
A chemical used both in the sterilization of surgical instruments and in the manufacturing of certain pesticides, ethylene oxide may cause birth defects in early pregnancy and has the potential to provoke early miscarriage.   Dibromochloropropane (DBCP)
Handling the chemicals found in pesticides, such as DBCP, can cause ovarian problems, leading to a variety of health conditions, like early menopause, that may directly impact fertility.

11. Fertility Test For Women
Cervical Mucus Test
Cervical mucus becomes clear and stretchy
Allow sperm to survive in and travel through it.
The consistency of fertile mucous is akin to egg white.
Ovarian function tests
To check functioning and working of hormnes during your ovulation cycle.
Tests include
Day 3 FSH
Day 3 Estradiol
blood tests to determine the levels of inhibin B.
Cervical mucus becomes clear and stretchy during the fertile window, to allow sperm to survive in and travel through it. The consistency of fertile mucous is akin to egg white. Tests include
Day 3 FSH (measuring follicle stimulating hormone) -Day 3 Estradiol (measuring estrogen), -ultrasound (to confirm ovulationoccurred) -blood tests to determine the levels of inhibin B.
Cervical mucus becomes clear and stretchy during the fertile window, to allow sperm to survive in and travel through it. The consistency of fertile mucous is akin to egg white.

12. Post Coital test(PCT) To determine: receptivity of cervical mucus
ability of sperm to penetrate the cervical mucus and to maintain activity
volume of mucus is measured
amount of mucus is determined
( scant, moderate, profuse )
Color and clarity is noted
involves a bacterial screening.

13. Ultrasound tests
assess the thickness of the lining of the uterus (endometrium)
monitor follicle development
to check the condition of the uterus and ovaries.
maybe conducted two to three days later to confirm that an egg has been released.

14. Hormone Tests Hormone tests include the following: Luteinizing Hormone
Follicle Stimulating Hormone
Estradiol
Progesterone
Prolactin
Free T3
Total Testosterone
Free Testosterone
DHEAS
Androstenedione

15. Endometrial biopsy
Endometrial biopsy is a procedure in which a tissue sample is taken from the lining of the uterus and is checked under a microscope for any abnormal cells or signs of cancer
NORMAL RESULTS:
The biopsy is normal if the cells in the sample have no abnormalities.
ABNORMAL RESULTS:
Endometrial cancer or precancer (hyperplasia)
Uterine fibroids
Uterine polyps
Infection
Hormone imbalance
If the lining is being tested for infertility, the sample may determine if hormones are properly stimulating the lining so that the fertilized egg can implant.

16. Laparoscopy
This is a procedure done under general anesthesia, that involves the use of a narrow fiber optic telescope
The laparoscope is inserted into a woman’s abdomen to provide a view of the uterus, fallopian tubes, and ovaries
If any abnormalities such as endometriosis, scar tissue or other adhesions are found, they can be removed by a laser

17. Hysteroscopy
A narrow instrument called hysteroscope is inserted into the uterus enabling the doctor to examine it.
There are two types of hysteroscopy. Diagnostic hysteroscopy is used to detect any problems inside a woman's uterus. Operative hysteroscopy is used to help perform surgical procedures
What Can Hysteroscopy Detect? Diagnostic hysteroscopy can be used to detect a number of uterine abnormalities that may be contributing to infertility. These abnormalities include: 
uterine fibroids
uterine adhesions
uterine cysts
septate uterus

18. Hysterosalpingogram
A hysterosalpingogram (HSG) is an X-ray test that looks at the inside of the uterus and fallopian tubes and the area around them.
PROCEDURE:
A dye is put through a thin tube into the uterus.
The dye will flow into the fallopian tubes because the uterus and the fallopian tubes are hooked together.
Pictures are taken using a steady beam of X-ray (fluoroscopy) as the dye passes through the uterus and fallopian tubes.
The pictures can show problems such as an injury or abnormal structure of the uterus or fallopian tubes, or a blockage in the fallopian tube.

19. Male Infertility: Pathophysiology
Complete absence of sperm (azoospermia)
Low sperm count (oligospermia)
Abnormal sperm shape (teratozoospermia)
Problems with sperm movement (asthenozoospermia)
Sperm that is completely immobile (necrozoospermia); the sperm may be alive and not moving, or they may be dead
Problems with sperm delivery, due to sexual dysfunction, an obstruction, previous vasectomy, or retrograde ejaculation
Problems with erections or other sexual problems

20. Male Infertility Tests
Diagnosing male infertility problems usually involves:
General physical examination and medical history
Examination
Questioning about any inherited conditions
chronic health problems illnesses
injuries or surgeries that could affect fertility.
Semen analysis
Semen is generally obtained
sent to a laboratory to analyse
signs of problems such as infections

21. Additional tests
1. Scrotal ultrasound 2. Transrectal ultrasound. 3. Hormone testing

22. Post-ejaculation urinalysis
Genetic tests
Testicular biopsy
Anti-sperm antibody tests