DIAGNOSTIC

METHODS IN FEMALE
INFERTILITY

Dr. Deepti Patil

Dept. Of
Dravyaguna
 DEFINITION OF INFERTILITY

Defined as
Failure to conceive within
one or more year of regular
unprotected intercourse

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 INCIDENCE
1% of women in their early 20’s are infertile

By their late 20’s, 16% [one in six] are infertile.

By their mid-30’s almost 25% [one in four] are infertile.

By age 40, 60% [three in five] are infertile.

By age 43 it would be a rare woman who is still fertile."

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 CONT…

80% of couples achieve conception

within one year of having regular
intercourse.

10% will achieve conception by the

end of second year.

10% remain infertile by the end of

second
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 RATIO
Infertility Ratio

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 TYPES

Two types :

1. Primary infertility

2. Secondary infertility

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 DEFINITIONS
Ø Primary infertility:

Those couples who have never

conceived.

Ø Secondary infertility:

Indicates previous pregnancy but

failure to conceive subsequently
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 HORMONES INFLUENCING
FERTILITY

Follicle stimulating hormone (FSH)

Secreted by the pituitary gland, FSH is

responsible for taking immature
follicles to a more mature state.

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Estrogen

Secreted by the growing follicles.

Estrogen is essential for the development

of a healthy endometrial lining (in
preparation to support a pregnancy).

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Luteinizing hormone (LH)
The growing amount of estrogen in the
bloodstream stimulates the Pituitaries to
cut back on producing FSH and release a
surge of LH.
Responsible for full maturation of graafian
follicle and oocyte and ovulation

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Progesterone
Secreted from the luteinized theca-
granulosa cells of the corpus luteum
Progesterone is used by a woman's
body to sustain pregnancy from
fertilization through delivery.

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 FACTORS INFLUENCING
FERTILITY
Lack of understanding of reproductive
biology.

Coital frequency.

Malnutrition and obesity.

Toxic factors.

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 CONT…

Smoking & alcohol.

Related underlying medical pathology.

Previous surgeries.

Radiation.

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 CAUSES

1. Hypothalamic-pituitary factors

Hypothalamic dysfunction

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 CONT…

2. Ovarian factors

Polycystic ovarian syndrome.

Anovulation.

Luteal dysfunction

Ovarian cancer

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3. Tubal (ectopic)/peritoneal
factors

Endometriosis

Pelvic adhesion

Pelvic inflammatory diseases.

Tubal occlusion
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4. Cervical factors

Ineffective sperm penetration

-Chronic cervicitis

-Immunological factor (Presence of antisperm

antibody)

• cervical stenosis
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5. Uterine Factors

• Uterine malformation
• Mullerian agenesis (absent uterus)
• Unicornate uterus (one side uterus)
• Uterus didelphys (double uterus)

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 CONT…
● Bicornate uterus (uterus with two horn)
● Septated uterus (uterine septum or
partition)
• Uterine fibroid
• Synechiae (asherman’s syndrome)

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 Unicornate
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 Bicornate

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 Didelphys
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 Complete Septate
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 Subseptate

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 Honeycomb Appearance
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6. Vaginal factors

Vaginismus

Vaginal obstruction

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7. Genetic factors

Intersex condition like androgen

insensitivity syndrome

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 GOALS OF EVALUATION OF
FEMALE INFERTILITY
To identify the reversible conditions
To identify the significant underlying medical
pathology.

Genetic or chromosomal abnormalities that

may affect either the patient or her offspring.
A large increase in the number of women
between 25-35 yrs suffering from infertility.

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 Evaluation of
infertility

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 HISTORY
Sexual history:
Ø Dyspareunia and loss of libido.

Ø Use of lubricants

Ø Frequency of intercourse

Ø Psychosomatic evaluation

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 CONT…

Personal history:
Ø Habit of smoking and alcohol

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 CONT…
Medical history:

Ø Tuberculosis.
Ø Sexually transmitted diseases.
Ø Pelvic inflammations
Ø Diabetes.
Ø Abdominal or pelvic surgery
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Menstrual history:

Ø Amenorrhoea
Ø Oligomenorrhoea

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Previous obstetric history

Ø Number of pregnancies

Ø Interval between the pregnancies

Ø History of premature rupture of the

membranes or puerperal sepsis

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Contraceptive practice
Ø Intra Uterine Contraceptive Devises[IUCD]

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 CONT…

Family history of infertility

– Can help identify a possible genetic
cause

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 EXAMINATION

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General examination
Ø Obesity or marked reduction in weight

Ø Secondary sex characters

Ø Physical features pertaining to

endocrinopathies

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Systemic examination
Ø Hypertension

Ø Organic heart disease

Ø Chronic renal lesions

Ø Endocrinopathies

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Speculum examination

Ø Abnormal cervical discharge.

Ø Pin hole cervix.

Ø Cervical polyp.

Ø Cervical erosion.

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Gynecological examination
Ø Hymenal opening

Ø Vaginal infection

Ø Cervical tear or chronic infection

Ø Undue elongation of cervix

Ø Uterine size, position, mobility.

Ø Adnexal masses

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pouchMethods
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ASSESMENT OF OVULATION
v INDIRECT METHOD

Basal body temperature

Mid luteal serum progesterone

Endometrial biopsy

Ultrasound monitoring of ovulation.

v DIRECT METHOD

Laparoscopy

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 ASSESMENT OF TUBAL
FACTORS
Hysterosalpingography (HSG)

Laparoscopy

Sonohysterosalpingography

Falloposcopy

Salpingoscopy

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 ASSESMENT OF OTHER
FACTORS
The peritoneal factors are assed by laparoscopy

Uterine factors by Hysterosalpingography and

hysteroscopy

Immunological factors.

Post coital test.

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 Post coital test (PCT)

PCT is to assess the quality of cervical

mucosa and the ability of sperm to
survive in it.

Presence of at least 10 progressive

motile sperm per high power field
signifies the test to be normal.

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BASAL BODY TEMPERATURE

BBT chart shows a sustained elevation

in the body temperature post ovulation
until just before the onset of menses,
indicating the approximate time of
ovulation.

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 MID LEUTEAL SERUM
PROGESTERONE
Done on day 8 and 21 of a cycle.

An increase in value from less then

1ng/ml to greater then 6ng/ml suggests

ovulation.

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 ENDOMETRIAL BIOPSY

Done on 21-23rd day of cycle.

Findings:

Evidence of secretory activity of the

endometrial glands in the second half of
the cycle is suggestive of ovulation.

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 SONOGRAPHY
Particularly helpful for conformation of ovulation

after ovulation induction.

Features of recent ovulation are collapsed follicle

and fluid in the pouch of Douglas.

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 LAPROSCOPY

Laparoscopic visualization of recent

corpus luteum or detection of the
ovum from the aspirated peritoneal
fluid from the pouch of Douglas.

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HYSTEROSALPINGOGRAPHY
It detects the side and site of block in

the tube.

Reveal any abnormality in the uterus.

HSG has a low prognostic value, the

outcome of HSG adds little to

predicting
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Advantages:

HSG is cheaper

Performed as an out patient

procedure.

Though it is a Painful procedure

has a low incidence of
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Hysterosalpingiographic
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HSG DEMONSTRATING
Second level A CLOSED AND
DILATED RIGHT AMPULLARY END
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 ClickNORMAL
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 LAPAROSCOPY
The Indications Of Its Use Are:

Abnormal HSG findings

Failure to conceive after reasonable

period (6 months) even with normal
HSG

Unexplained infertility

Age
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SONOHYSTEROSALPINGOGR
APHY
Normal saline is pushed within the
uterine cavity with a paediatric Foley
Catheter.

Ultrasonography of the uterus and

fallopian tubes are done.

Ultrasound can follow the fluid through

the
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the peritoneal
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ADVANTAGES:

It can detect uterine malformation.

Synechiae or Polyps.

Tubal pathology could be detected as

that of HSG

There is no radiation exposure.

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 FALLOPOSCOPY

To study the entire length of tubal

lumen with the help of a fine and
flexible fibreoptic device

It is performed through the uterine

cavity, using a hysteroscopy.

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 SALPINGOSCOPY

Tubal lumen is studied introducing a

rigid endoscope through the fimbrial
end of the tube.

It is performed through the operating

channel of a laparoscope.

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 UTERINE FACTORS

Subfertility.

Submucous fibroids.

Congenital malformation.

Intrauterine adhesions.

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 PREVENTION
Maintaining a healthy lifestyle

Excessive exercise, consumption of

caffeine and alcohol and smoking are
all associated with decreased fertility.

Treating or preventing existing

diseases

Identifying
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and controlling
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 CONCLUSION

Infertility is a disorder of couple and hence

both partners should be investigated.

A simplified approach will lead to a

significant reduction in both the time and
cost of investigating an infertile couple.

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 T
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