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Management of Infertility in Females

Dr. Umesh N. Jindal

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History and Physical Examination

Complete history taking should includes detailed menstrual and obstetric history, past or present medical problems, surgeries, allergies etc. Duration of cohabitation, sexual problems, sexually transmitted diseases (STD) and any pregnancies from previous cohabitation may not be reported unless specifically asked for. Male partner should be asked for any history of testicular trauma, mumps, operations for mal-descent of testes, sexual problems. Complete general physical examination (GPE) to detect associated diseases such as anemia, hypertension (etc.) should be done. Pelvic examination, quite often is absolutely normal except when some gross pathology such as fibroids, tubo-ovarian masses, active infection etc. may be detected. In males local examination may reveal evidence of local infection or varicocele. Markedly small testes have a clear association with germ cell hypoplasia.

General Investigations

General investigations are done to assess general health status of couples. An infection screen for sexually transmitted diseases (STD) e.g. syphilis, gonorrhoea, chlamydia, Human Immuno deficiency Virus infection (HIV) etc. should be done. Chest X-ray is an integral part of female work up in areas where tuberculosis (TB) is endemic. However in a high percentage of cases of pelvic TB there is no evidence of primary focus on Chest X-ray examination.

Work up of the Male Partner

A detail discussion is not within the scope of this article. Briefly, a routine semen examination after 48 hours of abstinence suffices to screen male partner. In case of abnormal semen parameters, further tests are done to arrive at an etiological diagnosis which include hormone estimation, semen and urine culture, transrectal and scrotal ultrasound and doppler study, aspiration cytology and testicular biopsy.

Work up of the female partner

Endometrial Biopsy (EB): A timed EB in mid or late luteal phase, assessed according to standard criteria has been a gold standard for luteal preparation of endometrium. Proliferative or out of phase endometrium suggests ovulatory dysfunction. TB endometritis can be picked up by histology, acid fast bacilli (AFB) smear and culture for AFB, or polymerase chain reaction (PCR) done on endometrial tissues. In long standing anovulation EB is important to rule out endometrial hyperplasia or carcinoma.

Hormone assay: A routine Thyroid Stimulating Hormone (TSH) and prolactin assay quite frequently pick up sub-clinical hypothyroidism and hyperprolactinaemia respectively. Basal FSH (follicle stimulating hormone) done on day 2 or 3 of the menstrual cycle is an accepted predictor of ovarian sensitivity. Detailed hormonal assessment of LH, FSH, Testosterone, DHEA-S etc. are not usually required for routine infertility patients. Even in cases of oligomenorrhoea/amenorrhoea, who get spontaneous or progesterone induced withdrawal do not need detailed hormonal studies.

Hysterosalpingography (HSG): HSG has stood the test of time as the simple, relatively cost-effective and reliable method of tubal evaluation. Although both positive and negative predictive values are near 70% – 80%, still it is very good screening method.

Ultrasonography (USG): USG has revolutionized and become an indispensable tool in the management of infertility. The advent of high resolution transvaginal scans (TVS) and ease of examination due to close proximity of uterus and ovaries to vagina have made it possible to almost see through these structures. Tumours , inflammatory masses, malformations, endometrial lesions can be diagnosed with much greater accuracy. The convenience, safety and reliability of USG has made it possible to do repeated examinations for a serial study to follow the evolution of developing follicle.

Endoscopic Studies: Without a diagnostic hysteroscopy and laparoscopy, infertility work up remains incomplete especially in long standing cases. A direct visualization of endometrial problem such as polyps, fibroids, septae and adhesions, which otherwise would be missed, is of utmost importance. Similarly, laparoscopy is the only reliable method to diagnose endometriosis, pelvic adhesions, TB and fimbrial phimosis. Advances in endoscopic techniques such as salpingoscopy and mini-laparoscopy will allow us to see ‘more’ with greater safety and reliability.

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