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Female infertility investigations  

Ovulation predictors:

1. Normal menstruation history suggests ovulation. Other predictors being basal body temperature (BBT) around the time of ovulation which is biphasic. It is a rough estimation of ovulation if not the perfect time of ovulation.

2. Serum progesterone concentration of 3ng/ml suggestive of ovulation which is reliable.

3. LH kits are available to predict the LH surge and to assess the fertility period

Ovulation reserve should be assessed in women who are anovulatory in nature and also who have high risk of premature menopause.

How to check for ovulation reserve?

1. Day 3 FSH Measurement

2. Serum Estradiol

3. Antimullerian hormone (AMH)

4. Clomiphene challenge test

5. Antral follicle count (AFC)

Endometrial dating is not a valid method anymore to assess luteal phase dysfunction. According to ASRM, it has a role only in detecting endometrial pathology and  also Post coital test should no longer be included in the list of female infertility evaluation anymore.

IMAGING IN THE EVALUATION OF FEMALE INFERTILITY

It gives a complete evaluation of female reproductive system. Several congenital and aquired causes can be diagnosed.

The main tests are:

Hysterosalpingogram (HSG)

Ultrasound / Ultrasonogram (USG)

SonoSalineHysterogram (SSG)

Hysteroscopy

Laparoscopy

HYSTEROSALPINGOGRAM( HSG ) :

It is a simple office procedure which doesn’t need anesthesia where liquid media is introduced into the uterus and series of x-rays are taken .It helps in delineating the abnormalities of uterine cavity and the tubes. Historically, it’s the main stay of evaluation.

ULTRASOUND (USG)

It’s the more simple and non invasive imaging  with no radiation exposure ,helps in identifying  uterine fibroids, polyps, adnexal pathology,and features of ovulation .

Sonosalinehysterogram(SSG)

It’s a combination of ultrasound and HSG where liquid media is introduced into the uterine cavity to delineate uterine wall abnormalities and tubal patency.

It is also a simple minimally invasive procedure which doesn’t need anesthesia.

HYSTEROSCOPY

It is an endoscopic office procedure where sterile saline solution is introduced into the uterine cavity to diagnose the intrauterine pathology like polyp,submucous fibroids ,intrauterine adhesions , septal abnormalities . It can be done under regional or general anesthesia .The advantage of hysteroscopy is the simultaneously intrauterine pathology can be corrected .It can also be combined with laparoscopy.

Patients with repeated history of abortions should be subjected for hysteroscopy.

LAPAROSCOPY

It is an minimally invasive endoscopic procedure to visualize the abdominal and pelvic organs to diagnose uterine abnormalities, adnexal pathology like tubal adhesions,tubo –ovarian mass,ovarian cyst,endometriosis. When laparoscopy is done chromopertubation is done simultaneously to know the tubal patency.

Advantages of laparoscopy: it is minimally invasive, diagnostic and operative at the same time. In cases of PCOD drilling can be done to enhance the pregnancy rates. In cases of endometriosis as much as possible endometriotic patches can be removed ovarian cyst can be excised.

According to ASRM (American Society of Reproductive medicine) laparoscopy is indicated clearly in patients with abnormal HSG and ultrasound, unexplained infertility and in cases of endometriosis. In special cases, there may be a place for laparoscopy in young women with a period of infertility of more than 3years with no recognised abnormalities.

Anovulatory patients not responding to medical line of treatment for more than 3-6 cycles should also be considered for additional investigations along with laparoscopy.

Combined Hysteroscopy and Laparoscopy:

Both are complimenatary to each other in diagnosing the intrauterine and exrauterine abormalities and treating the cause simultaneously.