c


‡ Infertility is inability of a couple to

conceive after one year of sexual
intercourse without contraception
@ 
 


]here is a very long list of investigations

for the diagnosis of infertility, however
there is no consensus on which tests
are essential before reaching the exact
diagnosis
6




conventional semen analysis

A variety of sperm function tests such
as in vitro mucous penetration test,
hamster egg penetration test and post
coital test.
ë  




§asal body temperature
Mid luteal serum progesterone
Endometrial biopsy
Ultrasound monitoring of ovulation.
]





pysterosalpingography
Laparoscopy
Falloscopy
pysterosonography
pydrolaparoscopy.
! 
]he peritoneal factors are assessed by
laparoscopy
]he uterine factor by
hysterosalpingography and
hysteroscopy.
Immunological factors are evaluated by
a variety of special tests.
O   

A lack of agreement exists among

trained infertility speicalists with regard
to the diagnostic tests to be performed
and their prognostic utility as well as
criteria of normality
! 

 


consulting senior colleagues or by
reading text books with lack of sufficient
time available for searching the
specialized journals.
Little is paid to evidence derived from
research ³  
 
 ´.
Õ  
 
 


E§M brings the best available evidence
from clinical research to clinical
practice.
gets our knowledge up to date by
tracking the recent clinical research
results.
  


Õ 

 



 

Oochrane Library
Journal of Evidence §ased Obstetrics and
Gynecology
Evidence based recommendations of the
Royal Oollege of Obstetrics & Gynecology
]

O

Oare must be taken to avoid exploitation
of the infertile couple with expensive
unnecessary tests
 ÕÕ O
 @  

O 




A simplified approach will lead to a
significant reduction in both the time
and cost of investigating an infertile
couple.
(
  )



Õ6
 


ciagnostic tests for infertility should be

categorized into three categories based
on the correlation with pregnancy rates
]

 

  
includes tests which have an established
correlation with pregnancy as:
semen analysis
]ubal patency by hysterography or
laparoscopy
Mid luteal progesterone for the
diagnosis of ovulation.
  




Remains the mainstay in investigating

male fertility potential.
Serial semen samples (at least two)
should be assessed in the same
laboratory
(WpO,1999)
@!
  

According to the WpO the lower limit of the

normal semen testing is
> 20 million/mL.
>40% progressive motility
>30% normal forms

WpO,1999
O 


  

 

by masturbation
]emp (15O to 38O)
deliver quickly
As many as 25% of proven fertile men
have sperm concentration
below 20 million/ml
Oëë

 




In a randomized controlled trial, the
determination of motility characteristics
as obtained by OASA systems is of
limited value
OASA is not superior to conventional
semen analysis

 
 
 
  

Although pSG is of low sensitivity, its high
specificity makes it a useful screening test
for ruling in tubal obstruction.
In case of abnormal finding, diagnostic
laparoscopy with dye transit is the
procedure of choice

 


ë



pSG is cheaper
Performed as an outpatient procedure
Although often painful has a low
incidence of complications

O!

O 




pSG has a low prognostic value, the
outcome of pSG adds little to predicting
the occurrence of pregnancy.
powever, when pSG shows bilateral
obstruction, the chance of getting pregnant
is only minimal.
6







r

 
 r

Ohlamydia antibody testing has

comparable estimates of tubal pathology
but
provides no details on the anatomy of
uterus and tubes.
6 


O
 



!


]

 










 






!




O
 



!


Serum progesterone in the mid-luteal phase on

day 22-26 is the method of choice
Endometrial biopsy is not a routine step in the
investigations of infertility .
  




 ]   

  



US examination of the pelvis is useful
especially for the ovary.
]ransvaginal sonography is the method of
choice for women who are having
ovulation induction
]    

]
 

  
Includes tests which are not consistantly
correlated with pregnancy as
zona-free hamster egg penetration tests
post coital test
antisperm antibodies assays.
 


 
should not be routine investigations
complex
expensive
not always provide clinically useful
information)

!  
 


 

Oomparing impact of infertility investigations

with and without the postcoital test showed
closely similar cumulative pregnancy rates
at 24 months, the postcoital test is not an
essential procedure
!  


]
  

  
Includes tests which seem not to correlate
with pregnancy as:
endometrial dating
varicocele assessment
chlamydial testing.
ÕÕ O
    
Õ  

]he prognostic value of endometrial

thickness is not universally accepted

  
 

]  

 





]here is no value in measuring thyroid

function or prolactin in women with a
regular menstrual cycle, in the absence of
galactorrhoea or symptoms of thyroid
disease
(]   

] 

]here is no evidence that the use of §§]

charts and luteinizing hormone detection
methods to time intercourse improves
outcome.

 
   


  

pSO is not a routine investigation of

infertile couples as there is no evidence
linking treatment of uterine abnormalities
with enhanced fertility.
O!

 


§efore uterine instrumentation (as pSG

or pSO) appropriate antibiotic
prophylaxis against chlamydia should
be given
O!

Oë
    
‡ ]he performance of serum OA-125
measurement in the diagnosis of
endometriosis grade I/II is limited, whereas
its performance in the diagnosis of
endometriosis grade III/IV is better.
?

  
 




6 


  
  

 
Sensitivity: to produce few false negatives.
Specificity: to produce few false positives.
Positive predictive value.
Negative predictive value.
Invasiveness: with the possibility of
harmfulness
Oost
 

 




 

Specific as pSG
Invasive
Oosty
In unexplained infertility
Require hysteroscopy
 

] 

More difficult than pSG

Not superior to pSG
Inferior to c.L






]   

 Ñc



 

As effective as two-dimentional US
Very expensive
No specific advantage in infertility over
2-c
!




 

!
 




 




From the above data, it seems that
serum progesterone for detection of
ovulation, hysterography for tubal
patency and semen analysis are the
basic essential tests for diagnosis of
infertility.
Other tests may have a role in special
situations or as a part of clinical trials
Laparoscopy should be reserved as a
further diagnostic procedure or in
combination with endoscopic surgery
 ] 

 



 


 


 

ë!