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The female partner is specifically assessed for ovarian reserve, tubal patency , one basic transvaginal ultrasound The various tests are described below:
Each woman is born with fixed number of eggs. Ovarian reserve tells us the number of eggs a woman has or in other words, its the quantitative measure of eggs. It is related to the reproductive potential. More the number of eggs, better the chances of conception.
(a) Age: Age is a very good indicator of ovarian reserve. The oocyte number and quality declines with age. The fertility peaks at 20-25 years of age and number of eggs declines sharply after 37 years of age.
(b) Biochemical Tests:
Serum Anti mullerian Hormone (S.AMH): She is evaluated for ovarian reserve by S.AMH. AMH is secreted by the developing follicles of 2-9 mm. It is quite a good indicator of ovarian reserve. In fact, S.AMH is more sensitive and specific than the antral follicular count (AFC) on ultrasound as it also reflects pre antral and small antral follicles (<2 mm), which are hardly seen in ultrasound. It has many advantages over other markers of ovarian reserve, like it can be done during any day of the cycle unlike AFC and S. FSH which can only be measured during the first five days of cycle and its values are stable from one cycle to another.
Follicle Stimulating Hormone (S.FSH ): It is also commonly used for measuring ovarian reserve. S.FSH >12 IU/L indicates poor ovarian reserve. S. FSH is measured on day 2 /3/4 of cycle.
Inhibin B: Its a hormone secreted by the preantral follicles .With advancing age, the number of follicles decreases hence there is a decrease in Inhibin – B levels . Its an ovarian hormone that inhibits FSH release.
Estradiol: Day 3 E2 levels < 50pg/ml combined with normal FSH indicates good ovarian reserve , good response to stimulation and better pregnancy rates. High E2 levels on day 2/3 of cycle suggest premature selection of follicles. This may occur as the ovary ages, or when ovarian follicular cysts remains from a prior menstrual cycle. This follicular cysts may interfere with egg selection in current cycle and might lead to poor response to fertility treatment.
(c) Ultrasound Imaging
Antral Follicular Count (AFC ): The antral follicular count describes the total number of follicles measuring 2-10 mm in both the ovaries. AFC is assessed preferably during early days of the cycle .Total AFC count of < 5, indicates poor ovarian reserve.
Ovarian Volume: Ovarian volume of < 3 ml, predicts poor response to ovarian stimulation. Ovarian volume has a limited value for predicting ovarian reserve.
(d) Proactive Tests:
Clomiphene Citrate Challenge Test (CCCT): In contrast to the static measurements of ovarian reserve mentioned previously, the clomiphene citrate challenge test (CCCT) is a dynamic approach.
When undergoing CCCT, the first step is to measure day 3 FSH and E2. Then 100 mg of clomiphene is administered on cycle days 5 through 9, and FSH and E2 measurements are repeated on cycle day 10. In general, a high day 10 FSH suggests poor ovarian reserve. Clomiphene stimulates follicles to grow which causes E2 secretion. This E2 via a negative feedback mechanism causes suppression of FSH secretion from pituitary. In patients with poor ovarian reserve, there is poor follicle growth hence low E2 which in turn causes more production of FSH.
Infertility evaluation is incomplete without a transvaginal sonography. It is usually done to evaluate the uterus and the ovaries. Uterus is evaluated for size, shape and position and specially looked for any mass like fibroid, polyp, adenomyosis or any adhesions in the endometrial cavity. Simultaneously the ovaries are assessed for antral follicular count and ovarian volume and to rule out any ovarian mass like endometriosis. Tubes are generally not seen on ultrasonography unless they are diseased and dilated as in hydrosalpinx.
Hysterosalpingography: It is the most common procedure to evaluate patency of fallopian tubes. This procedure visualizes the uterine cavity and the fallopian tubes under fluoroscopic guidance in an X Ray Room. Read More..
Sonosalpingography: It is another method for evaluating tubal patency. It is reliable, simple and well tolerated method to assess tubal patency in an outpatient setting. Read More..
Laparoscopy: It is the best technique for diagnosing tubal and peritubal disease. It is a patient friendly , day care surgery, the patient is admitted in the morning and is discharged the same day. Laparoscopy combined with hysteroscopy usually completes the pelvic evaluation. Read More..
a. Hysterosalpingography (HSG)
This procedure visualizes the uterine cavity and the fallopian tubes under fluoroscopic guidance in an X Ray Room.
A radio opaque dye is instilled into the uterine cavity via cervix. Filling of the uterine cavity and the bilateral filling of the fallopian tubes and spill into the abdominal cavity is seen on the screen. In case one or both tubes ae blocked, it shows the site of blockage.
It can also show abnormalities of the size and shape of the uterus which may be there by birth like bicornuate, septate or arcuate uterus, or if any polyp or submucous fibroid is present.
When and How is it done?
It is usually performed between day 6 – 11 (usually after cessation of menstrual flow and before ovulation) of a menstrual cycle. Its done in an X Ray room. An antibiotic prophylaxis and a pain killer are usually given for three days, starting one day before. The patient is called after a light breakfast at 11 a.m. Anesthesia is not routinely needed, but may be used in selected patients (in that case patient comes fasting). After a detailed written informed consent, the patient is taken to a X ray room where she is asked to lie down on her back in a dorsal position with knees folded up.
Under all aseptic conditions, 2 – 3 ml of a radio opaque, water soluble dye injected through the canula into the uterine cavity is sufficient to delineate uterine cavity. Further 3 – 4 ml is sufficient to demonstrate bilateral tubal patency or tubal obstruction. Usually 3 – 4 X ray images are taken during the entire process for permanent record of the result.
The patient is kept under observation and allowed to go 3 – 4 hours after the procedure.
What are risks and hazards of the procedure?
It is a very short and safe procedure with minimal risk of complications like:
Pain which is usually avoided by giving Injection Buscopan , half an hour before the procedure
Allergic reaction to the dye
Endometrial infection (Endometritis)
Fallopian tube infection (Salpingitis)
Perforation of the uterine cavity
What are the contraindications of the procedure?
The procedure should not be performed:
In the presence of genital infection
If the patient is sensitive to Iodine
b. Sonosalpingography (SSG)
It is another method for evaluating tubal paten cy. It is reliable, simple and well tolerated method to assess tubal patency in an outpatient setting.
Like HSG it is also performed from day 7 to day 11 of a regular 28 days menstrual cycle under antibiotic and pain killer.
It’s a non invasive procedure done under ultrasound guidance. After obtaining informed consent, patient is made to lie down in an ultrasound room, the vagina is cleaned with antiseptic solution. A sterile speculum is introduced into the vagina and a pediatric Foley’s catheter is introduced into the uterus through the speculum which is retained in situ by inflating 2 ml of saline. Normal saline is then installed into the uterine cavity, if the tubes are patent, the flow of saline is observed as shower at fimbrial end. Apart from tubal patency, this is an excellent test to diagnose sub mucous polyp or intrauterine adhesion. It is as accurate as HSG in in evaluating tubal patency but if the tube is blocked, it doesn’t give the site of blockage.
Advantages of Sonosalpingography
It is a very short and safe procedure with minimal risk of complications
It’s an outpatient, noninvasive procedure
There is no radiation hazard
It also helps in diagnosing uterine anomalies like sub mucous polyp and intrauterine adhesions
There is no allergic reaction as no dye is used
Site of blockage cannot be detected
It requires an expertise in ultrasonography
The findings are subjective
c. Laparoscopy
It is the best technique for diagnosing tubal and peritubal disease . In todays era of excellent ultrasonography combined with very high sensitivity and specificty of HSG , Laproscopy is prefered when there is associated pelvic pathology like endometriosis , fibroid or blocked tubes on HSG or Sonoslpinography where corrective surgery can be performed in the same sitting . Thus it is used more as a therapeutic modality for corrcting pelvic pathologies rather than just a diagnostic tool .
