Definition

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

25. 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)

26. 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)�

27. 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.

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

29. 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)

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

31. Endometrium The prognostic value of endometrial thickness is not universally accepted (Schild et al 2001)�

32. 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)

33. 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)

34. 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)

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

36. 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)

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

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

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

40. 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

41. 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.

42. 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

43. Testing until uncertainty vanishes may delay treatment  AGING process