female infertility and Evaluation

Various tests that can be done for diagnosis of female infertility.

Pelvic ultrasound:

Pelvic ultrasonogram both transvaginal and transabdominal is the basic test for female. It can be considered as a part of physical examination. We do a routine ultasonogram at first visit to see the condition of uterus and ovaries.  Healthy ovaries and uterus have a distinct characteristic. Abnormal situation like size of uterus and ovaries ( smaller or bigger) , development of tumour in the uterus ( Fibroid and adenomyoma) , abnormal lining of ( endometrium) uterus, cysts ( simple cysts or chocolate cysts of endometriosis) in the ovaries, adhesion of uterus and ovaries can be detected by USG. Pelvic collection and development of pseudocysts for pelvic infections also can be detected by USG. Fallopian tubes are not visualized by USG until development of any abnormality like dilatation by accumulation of fluid, blood, pus or presence of pregnancy sac (ectopic pregnancy). Presence of pregnancy sac in uterus in early weeks of gestation and presence of embryo and embryonic cardiac pulsation is better visualized by TVS.
Ovarian cysts are misunderstood and extremely common. Women who are ovulating regularly will form a follicle during her menstrual cycle. This follicle contains an egg, or oocyte. This follicle may become as large as 3 cm in diameter. This follicle and the structure that can form after ovulation known as the corpus luteum (secretes progesterone to support the uterine lining for a pregnancy). These cysts regress in course of time. But sometimes these cysts do not regress on their own and are called functional cysts. Stopping ovarian function for one or two months by giving oral contraceptive pills can regress these cysts. These are not ovarian tumour. Another type of cysts are present in the ovaries of patients of polycystic ovarian syndrome. They are very tiny cysts and multiple in number that is why called polycystic. Sometimes patients get worried by hearing the term cyst but they are also not tumour of ovaries.

Detection of Ovulation:
Ovulation means release of a mature ovum from woman’s ovary which is the principal part of female fertility. A regular menstrual cycle is an indicator of regular ovulation. There are different tests for ovulation. Serial transvaginal ultrasosnogram (TVS) during middle part of menstrual cycle can detect development and release of mature follicle from the ovary. Serum progesterone on day 21 of menstrual cycle if 10ng/ml or more indicates production of mature follicle. TVS and serum progesterone together ensure ovulation.

Tubal Patency Tests:

Saline Contrast sonography:-
This is a special ultrasound where fluid is put inside the uterine cavity to allow for better visualization of inside of the uterus. This can detect small abnormalities inside the lining of the uterus which can decrease fertility and lead to a higher rate of miscarriages. Tubes can be visualized by observing the flow of fluid. Collection of fluid in the pouch of douglus is also  an indicator of patent tube ( at least one).

Hysterosalpingogram (HSG):-
The hysterosalpingography is a procedure done with contrast dye injected through the cervix into the uterus while observing with fluoroscopy (moving x-rays). This procedure is done in a radiology suite. The HSG‘s should be scheduled for the week immediately after menstruation, ideally between cycle days 9-12. The HSG procedure is performed by a physician who also briefly review the results with the patient after the procedure. It is a bit painful and painkiller is usually given before the procedure.

Diagnostic hysteroscopy and diagnostic laparoscopy: –
These are surgical procedures that use instruments to look inside the abdomen (laparoscopy) and uterus (Hysteroscopy). These procedures are usually scheduled beforehand as both of the procedures are inasive. Hysteroscopy (H-scope) can often be performed in the office but, laparoscopy (L-scope) is usually performed under deeper sedation or general anesthesia in a hospital setting.

Hormone Evaluations:

Hormones for ovarian reserve testing:

Hormone testing is usually done to see ovarian reserve. Estimation of level of FSH, LH (secrets from pituitary) and E2 (secrets from ovary) in the early follicular phase that is on D1-D3 is a good guide for ovarian reserve. With a good reserve FSH level should be below 10 IU/mL and E2 level should be between 80-100 pg/mL. Any one if raised is an indicator of poor reserve. Anti-mularian (AMH) hormone also can be assessed for ovarian reserve.

Other hormones:

Thyroid Stimulating Hormone (TSH): Like the thyroid exam, the TSH may uncover a thyroid abnormality that may have an impact on fertility. TSH is released from the pituitary gland and stimulates the thyroid gland to make thyroid hormone. An elevated level means the gland is not making enough hormones which is the case in hypothyroidism. Low levels indicate problems with TSH production or increased thyroid hormone production (hyperthyroidism). Additional tests may be necessary to determine the exact cause of the abnormality
Prolactin is another hormone of the endocrine system that is released from the pituitary gland. Prolactin is responsible for the production of milk. Prolactin levels can be elevated without causing galactorrhea (discharge of milk in a non-pregnant woman). Prolactin can interfere with the normal function of the hormones that govern follicular development and the menstrual cycle. Prolactin tumors may also cause the pituitary to stop producing other hormones, namely FSH and LH, which will also have an impact on normal reproductive function.
Androgens are a group of hormones usually thought of as male hormones; such as testosterone. These hormones are also present in females. There are several disorders in which the androgens are abnormally elevated in a female patient. Physical findings usually include abnormal hair growth, acne, and deepening of the voice. One of the most common scenarios in which increased effects of androgens are seen is in polycystic ovarian syndrome.

Infectious testing
:

Infectious disease testing is important to prevent the transmission of infectious agents to patients and newborns. Examples of infectious agents commonly assessed include:
HIV – Human Immunodeficiency Virus which is responsible for AIDS.
Hepatitis B & C
Syphilis
Cytomegalovirus (CMV)
Rubella Immunity

Gonorrhea & Chlamydia