The HSG is the most frequently used diagnostic tool to evaluate the endometrial cavity. Furthermore, the HSG provides indirect evidence of pelvic adhesions and uterine, ovarian, or adnexal masses. The HSG should be performed during the early follicular phase. At this time, the endometrium is thin and the HSG provides better delineation of minor defects. In addition, the possibility of accidental irradiation to the fetus in an undiagnosed pregnancy is eliminated. The cervix is cleansed with a povidone-iodine solution Betadine to avoid the transfer of bacteria to the endometrial cavity during the procedure.
A breakaway vaginal speculum is used so it can be removed before injection of the radiopaque medium. A single-tooth tenaculum is used to apply traction of the uterus and to correct any anteroflexion or retroflexion that yields suboptimal images. A Jarcho-type metal cannula with a plastic adjustable acorn or a balloon HSG catheter is used for the injection of radiocontrast media. The use of water-based contrast media is preferable to oil-based media to avoid the risks of oil embolism and granuloma formation. The images below provide further information. In the s, pelvic ultrasonography became an important tool in the evaluation and monitoring of infertile patients, especially during ovulation induction.
Pelvic ultrasonography should be part of the routine gynecologic evaluation because it allows a more precise evaluation of the position of the uterus within the pelvis and provides more information about its size and irregularities. Pelvic sonograms also help in the early detection of uterine fibroids, endometrial polyps, ovarian cysts, adnexal masses, and endometriomas.
Ultrasonography can also assist in the diagnosis of anovulation, polycystic ovaries, and persistent corpus luteum cysts. Some common ultrasonographic findings are depicted in the images below.
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Saline infusion sonography SIS provides a simple and inexpensive means by which to evaluate the uterine cavity and assess tubal patency. It is well-tolerated by patients and can be done in the office. Additionally, it eliminates the risks associated with the use of dye and radiation required by the HSG.
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SIS has been shown to reveal a substantial percentage of infertile patients with intracavitary abnormalities and uterine anomalies. The SIS should be performed during cycle days so that the endometrium is thin, allowing better detection of intrauterine lesions.
In addition, this ensures that an undiagnosed pregnancy is not disrupted. A breakaway speculum is placed and the cervix is cleansed with Betadine solution. A transcervical catheter with acorn or balloon is placed. The speculum is removed and saline is injected under ultrasonographic visualization. Longitudinal and transverse views of the cavity are evaluated for filling defects.
Finally, a small amount of air bubbles are injected to assess tubal patency. If the patient has a history of genital tract infection or pelvic inflammatory disease, antibiotics may be given before the procedure. If hydrosalpinges are noted, antibiotics are given after the procedure. While the SIS can confirm tubal patency, it does not provide information about the contour of the tubes. Thus, if a patient has a history of endometriosis or other tubal disease, an HSG would be preferred.
The use of MRI has increased in recent years, although it should be limited to those patients in whom a definitive diagnosis cannot be ascertained by conventional HSG, ultrasonography, and hysteroscopy findings. MRI is useful for delineating complex pelvic masses and for assisting in the diagnosis of such conditions as congenital malformations related to cryptomenorrhea and absence of the cervix. Hysteroscopy is a method of direct visualization of the endometrial cavity. The instrument used has evolved from the historical cystoscope and is based on the same principles.
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The use of glycine and sorbitol solutions, different from the classic Hyskon, administered under constant pressure using an automatic pump, improves imaging resolution and is less risky to the patient. The diameter of the device has become smaller, making it more user friendly; thus, the procedure can be performed in the physician's office using local anesthesia ie, paracervical block.
Carbon dioxide hysteroscopy is for diagnostic purposes only and requires a constant flow of carbon dioxide. It does not require cervical dilation and allows a rather easy evaluation of the endometrial cavity. The operative hysteroscope has been designed based on the resectoscope principle.
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The design of refined instruments eg, scissors, cautery loops, lasers facilitated the treatment of pathologies such as uterine synechiae, endometrial polyps, submucous myomas, and the removal of foreign bodies eg, intrauterine devices. In combination with specially designed catheters, it can be used to perform tubal cannulation.
The endometrial lining constantly responds to the different hormonal secretions that occur during the menstrual cycle or to the exogenous administration of estrogen and progesterone. In the s, Novack and Noyes published their findings on the microscopic changes of the endometrium throughout the menstrual cycle and established the criteria for endometrial dating.
Jones first described the luteal phase dysfunction and its association with recurrent pregnancy loss. A luteal phase dysfunction diagnosis is based on the lack of correlation between 1 endometrial development, diagnosed using premenstrual endometrial biopsy, and 2 the onset of the immediate menstrual cycle. A large, multicenter prospective study showed that out-of-phase biopsy results poorly discriminated between women from fertile and infertile couples in either the midluteal or late luteal phase. Therefore, histological dating of the endometrium does not discriminate between women of fertile and infertile couples and should not be used in the routine evaluation of infertility.
The 2 most frequent tests used for diagnosis of tubal pathology are laparoscopy and hysterosalpingogram. The laparoscope is one of the greatest developments in gynecologic instrumentation. Its origin dates to the pioneering work of Jacobaeus in The procedure was abandoned in the s because of fatal complications.
In the s, a new generation of laparoscope was developed using a fiberoptic technique; later, safer electrocautery techniques resurrected the application and use of operative laparoscopy, especially for sterilization purposes and for diagnosis of ectopic pregnancy. Laparoscopy is not part of the routine infertility evaluation. It is used when abnormalities are found on ultrasonography, HSG, or suspected by symptomology. Because of the added risks of surgery, need for anesthesia, and operative cost, it is only used when clearly indicated. Laparoscopy is contraindicated in patients with probable bowel obstruction ileus and bowel distention, cardiopulmonary disease, or shock due to internal bleeding.
Because of the risk of bowel perforation, uterine and pelvic vessel injury, and bladder trauma, a skilled and experienced surgeon must perform the procedure. Relative contraindications include massive obesity, large abdominal mass or advanced pregnancy, severe pelvic adhesions, and peritonitis. Ovulation is usually inferred when a woman reports regular cycles. Sonographic confirmation of follicle rupture with serial ultrasonography can also be performed. Basal body temperature charts can be used to predict ovulation.
A basal body thermometer measures the slight rise in temperature that occurs immediately after ovulation. However, most patients and physicians prefer to use urinary ovulation predictor kits as they are more accurate and easier to administer. The level of ovarian reserve and the age of the female partner are the most important prognostic factors in the fertility workup. Ovarian reserve is most commonly evaluated by checking a cycle day 3 FSH and estradiol level. In cases where the patient is 35 years or older, dynamic ovarian reserve testing may be indicated.
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The most common test used is the clomiphene citrate challenge test CCCT. A serum FSH and estradiol level is drawn on cycle day 3. Clomiphene citrate mg by mouth is administered on cycle days and a serum FSH level is drawn again on day An FSH level greater than 10 is associated with decreased fertility and lower pregnancy rates. One large prospective observational trial suggests that age, AMH, inhibin B, and FSH combined have significant predictor of poor oocyte yield. However, most of these have not been found to be of adequate sensitivity, specificity, or positive predictive value when applying cutoffs across all age groups for pregnancy.
They are predictive of response to ovulation induction medications. Thus, any result must be interpreted within the clinical context of the patient. A serum AMH assay could be used to identify patients with decreasing ovarian reserves and polycystic ovarian insufficiency. Because thyroid disease and hyperprolactinemia can cause menstrual abnormalities and infertility, a serum TSH and prolactin should always be checked and corrected prior to instituting therapy.
The male partner must submit a semen sample for a comprehensive semen analysis. Previous paternity does not guarantee current fertility status. The comprehensive semen analysis must be performed in a certified andrology laboratory. The semen sample should be collected at the same andrology laboratory that will conduct the test.
However, if the sample must be collected at home, it must be collected in a sterile plastic container and delivered to the andrology laboratory at body temperature no later than 30 minutes after ejaculation. Some patients cannot produce a semen sample through masturbation. In these cases, the sample can be collected through intercourse, using a special nonspermicidal condom provided by the andrology laboratory.
To optimize results, the semen sample should be collected after a period of 3 days but no more than 5 days of sexual abstinence. The basic semen analysis assesses sperm concentration, motility, morphology, and viability. The World Health Organization's semen analysis parameters with the variable and the corresponding reference range are as follows [ 98 ] :. Morphology has become an important parameter to evaluate the quality of sperm and fertilization capability. Kruger reported a new classification based on strict sperm morphology after fixing and staining the sperm.
Specific biochemical analyses relevant to accessory sex gland function can be performed using the semen sample.
follow Sperm agglutination is an indirect indicator of the presence of sperm antibodies. The immunobead test can be performed either directly on the sperm or indirectly on sperm and blood. The antibodies can be specific for the head or for the tail of the sperm.
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Sperm antibodies are associated with infection ie, orchitis , testicular trauma, and a history of vasectomy. Spermatogenesis takes approximately 72 days. Abnormal semen analysis results can be attributed to various unknown reasons eg, short period of sexual abstinence, incomplete collection, poor sexual stimulus ; therefore, repeating the semen analysis at least 1 month later is important before a diagnosis is made.
The patient should be informed of the normal fluctuation that can occur between semen samples.