how to investigate infertile couples? there are endless number of tests: How evidence based diagnosis would help us in this issue? this talk try to answer such questions?

2. Definition
• Infertility is inability of a couple to
conceive after one year of sexual
intercourse without contraception

3. Which Investigations!!
There 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

4. Male Factor
conventional semen analysis
A variety of sperm function tests such
as in vitro mucous penetration test,
hamster egg penetration test and post
coital test.

5. Assessment of ovulation
Basal body temperature
Mid luteal serum progesterone
Endometrial biopsy
Ultrasound monitoring of ovulation.

6. Tubal factor
Hysterosalpingography
Laparoscopy
Falloscopy
Hysterosonography
Hydrolaparoscopy.

7. Others
The peritoneal factors are assessed by
laparoscopy
The uterine factor by
hysterosalpingography and
hysteroscopy.
Immunological factors are evaluated by
a variety of special tests.

8. Controverses
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

9. Opinion Based Practice
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 “the Scientific Factor”.

10. Evidence-based medicine (EBM)
EBM brings the best available evidence
from clinical research to clinical
practice.
gets our knowledge up to date by
tracking the recent clinical research
results.

11. Sources of Evidence Based
Infertility investigations
Cochrane Library
Journal of Evidence Based Obstetrics and
Gynecology
Evidence based recommendations of the
Royal College of Obstetrics & Gynecology

12. Take Care
Care must be taken to avoid
exploitation of the infertile couple with
expensive unnecessary tests
( ESHRE Capri Workshop 1996)

13. Concept to keep in mind
A simplified approach will lead to a
significant reduction in both the time
and cost of investigating an infertile
couple.
(Strandell 2000)

14. So what EBM tells us?!!
Diagnostic tests for infertility should be
categorized into three categories based
on the correlation with pregnancy rates

15. The first category
includes tests which have an established
correlation with pregnancy as:
semen analysis
Tubal patency by hysterography or
laparoscopy
Mid luteal progesterone for the
diagnosis of ovulation.

16. Semen analysis
Remains the mainstay in investigating
male fertility potential.
Serial semen samples (at least two)
should be assessed in the same
laboratory
(WHO,1999)

17. WHO criteria
According to the WHO the lower limit of the
normal semen testing is
> 20 million/mL.
>40% progressive motility
>30% normal forms
WHO,1999

18. Collection of semen sample
by masturbation
Temp (15C to 38C)
deliver quickly
As many as 25% of proven fertile men
have sperm concentration
below 20 million/ml

19. CASA vs. conventional analysis
In a randomized controlled trial, the
determination of motility characteristics
as obtained by CASA systems is of
limited value
CASA is not superior to conventional
semen analysis
(Krause ,1995 )

20. Hysterosalpingography
Although HSG 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
(Swart et al, 1995)

21. Advantages
HSG is cheaper
Performed as an outpatient procedure
Although often painful has a low
incidence of complications
RCOG, 1999

22. Conception after HSG
HSG has a low prognostic value, the
outcome of HSG adds little to predicting
the occurrence of pregnancy.
However, when HSG shows bilateral
obstruction, the chance of getting pregnant
is only minimal.
(Maas et al, 1997)

23. Serum chlamydial antibodies vs HSG
Chlamydia antibody testing has
comparable estimates of tubal pathology
but
provides no details on the anatomy of
uterus and tubes.
(Mol et al, 1997)

24. Laparoscopy
Is the gold standard
Invasive
Costy
Incidence of complications 1-2%

25. Confirmation of Ovulation
The only true proof of ovulation is the
recovery of an ovum
Or
pregnancy

26. Confirmation of Ovulation
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 .
(Peters et al,1992 / Templeton,2001)

27. However, Ultrasonography
US examination of the pelvis is useful
especially for the ovary.
Transvaginal sonography is the method of
choice for women who are having
ovulation induction
(Templeton 2001)

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

29. Sperm function tests
should not be routine investigations
complex
expensive
not always provide clinically useful
information)
(Oehninger et al 2000)

30. Postcoital test
Comparing 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
(Oei et al, 1998)

31. The third category
Includes tests which seem not to correlate
with pregnancy as:
endometrial dating
varicocele assessment
chlamydial testing.
(ESHRE Capri workshop 2000)

32. Endometrium
Premestrual Endometrial biopsy does
not correlate with pregnancy:-
Pathologist: interobserver variation
type of curette used
debate on timing
Karamardian & Grimes,1992

33. Endometrium
The prognostic value of endometrial
thickness by US is not universally
accepted
(Schild et al 2001)

34. Thyroid / Prolactin assay
There 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
(Templeton,2001)

35. BBT/LH
There is no evidence that the use of BBT
charts and luteinizing hormone detection
methods to time intercourse improves
outcome.
(Leader,1992 / Guermandi,2001)

36. Hysteroscopy
HSC is not a routine investigation of
infertile couples as there is no evidence
linking treatment of uterine abnormalities
with enhanced fertility.
(RCOG,1999)

37. Precaution
Before uterine instrumentation (as HSG
or HSC) appropriate antibiotic
prophylaxis against chlamydia should
be given
RCOG,1999

38. CA-125 in endometriosis
• The performance of serum CA-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.
• Better in predicting recurrence
(Mol et al, 1998)

39. How to judge a new diagnostic
test
Sensitivity: to produce few false negatives.
Specificity: to produce few false positives.
Positive predictivevalue.
Negative predictive value.
Invasiveness: with the possibility of
harmfulness
Cost

40. Hydrolaparoscopy as a model
Specific as HSG
Invasive
Costy
In unexplained infertility
Require hysteroscopy
Gordts,1999

41. Thus
More difficult than HSG
Not superior to HSG
Inferior to D.L
Its role is still unclear
Templeton,2001

42. 3-D US: another model
As effective as two-dimentional US
Very expensive
No specific advantage in infertility over
2-D
No role in infertility yet
N.B: Bicornuate ut. Vs septate ut

43. Summary
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.

44. 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

45. Testing until uncertainty
vanishes may delay treatment
AGING process