Work Up of Female Infertility
In the last few years, the importance of fertility workup has risen. A fertility workup is like an infertility evaluation of a female or a male that includes certain tests that tell us about their health.
The need for infertility workup comes in when the couple has been trying to have a child for a long time but isn’t getting successful at it. It is said that a couple may have some fertility issues if there is a continuous failure in conceiving after trying for over one year with unprotected intercourse.
If the female is over 35 years, they preferably immediately require this evaluation or maximum after waiting for 6 months This will tell us about the exact infertility problem that is affecting the couple and causing problems.
Steps of Infertility workup for a female:
The essential elements of an initial infertility workup include three major steps like medical history, physical examination, and other investigations.
Steps 1: Medical History
* Duration of infertility
* Menstrual history regarding regularity and flow.
* Information about any previous pregnancy, delivery, or miscarriages is important. Poor
outcomes in previous pregnancies are important.
* Previous surgeries or illnesses as endometriosis, cyst surgery, pelvic infections,
tuberculosis, etc. are significant details.
* If suffering from any medical disorders like thyroid, diabetes, hypertension need evaluation.
* Any genetic illnesses in the family as cystic fibrosis, thalassaemia etc. Are important to
know.
* Frequency of intercourse and any difficulty in it.
* Use of alcohol, smoking, or any drugs.
Steps 2: Physical Examination
Physical examination is done to see some physical indications in order to rule out any fertility issue. For physical examination, your doctor will examine various things like:
Pelvic Examination: Your doctor will perform a vaginal or pelvic examination to inspect the cervix and look out for any sores, discharge or infections.
Hair growth on face and body: Unusual growth of hair on the face and the body may indicate the excess male hormones in the body that result in infertility problems.
Breast Examination:Your doctor may also examine the shape and size of the breast. He may do other examinations that may rule out certain things.
Other examinations: A targeted physical examination is done with special attention to weight (BMI) pulse, blood pressure, thyroid, signs of androgen excess as hirsutism, acne, pap smear, etc.
Steps 3: Investigation
Investigations in infertility workup include laboratory and imaging tests which form the cornerstone for establishing the cause of infertility. These investigations for the female partner will focus on evaluating ovarian reserve, ovulatory function, and structural abnormalities. These tests will give different results and indicate different things like:
1. Ovarian Reserve : Ovarian Reserve tells us the number of useful eggs in the ovaries that have the potential to fertilize. This test is done with a blood investigation called the Anti-Mullerian Hormone. Also, a transvaginal scan is also done for Antral follicular count. Now, after the result, Ovarian reserve is said to be poor if:
* The AMH level is less than 1 ng/ml
* The antral follicle is low and counts less than 5–7 (follicles 2-10 mm) in both the ovaries.
* The follicle-stimulating hormone (FSH) is greater than 10 IU/L.
* A history of poor response to IVF stimulation, which is getting fewer than four oocytes at the time of egg
retrieval.
2. Ovulatory Dysfunction: Ovulatory dysfunction estimates for a significant proportion of female infertility in which the woman has disturbed ovulation or no ovulation. To examine this issue, various tests are done:
* Midluteal (Day 21) measurement of serum progesterone.
* Follicular monitoring and Ovulation studies: Sequential Ultrasounds are performed to detect
the development of follicles and their release.
* Thyroid disease and hyperprolactinemia can cause ovulatory dysfunction, hence a measurement of
Thyroid-stimulating hormone and serum prolactin levels is also done.
3. Tubal Factor: Tubal factor examination is done to assess whether the fallopian tubes are open or blocked. This is done by:
* Hysterosalpingography (HSG): A procedure used to view the uterus and fallopian tubes by
injecting radiopaque dye contrast through the cervix. We can see whether tubes are open or
blocked with this procedure.
* Sonosalpingography: It is the ultra-sonographically visualization of the uterus and adnexa
with the infusion of fluid through a transcervical canal.
4. Uterine Factor: Uterine factors that may cause infertility issues include endometrial polyps, uterine adhesions, uterine anomalies, and fibroids. These uterine problems cause difficulties in conceiving. These issues are detected by:r
Transvaginal ultrasonography: It aids in the detection of the fibroids, their size, number, and location. Using three-dimensional ultrasonography improves detection of müllerian anomalies (abnormalities in the shape of the uterus) and cavity distorting fibroids.
Sonohysterography: The uterine cavity usually is easily defined, and abnormalities like endometrial polyps, submucosal fibroids, and intrauterine adhesions can be easily seen with the help of Sonohysterography.
Hysteroscopy: It is direct visualization of the uterine cavity and provides the most definitive method for diagnosis of endometrial polyps, uterine synechiae, and submucosal fibroids. Hysteroscopy is a procedure that is not commonly used for the initial evaluation of infertile women because of its cost and access considerations. Hysteroscopy indicates to confirm and treat intracavitary lesions detected by the other imaging modalities.
Three-dimensional ultrasonography and Magnetic resonance imaging and provide a more accurate definition of müllerian anomalies.
