Female Infertility 3

Question 1

What are the key components of today’s evaluation of infertility?

Answer 1

• Semen analysis
• Documentation of ovulation
• Assessment of ovarian reserve
• Assessment of uterine cavity
• Documentation of tubal patency

Question 2

What are the components of the male factor evaluation?

Answer 2

• Reproductive history
• Semen analysis twice at least 4 weeks apart
• Standard values from men whose partners had a time-to-pregnancy of less than 12 months
  
  • Seminal volume, pH (not as important)
    
    • > 1.5 mL
  • Sperm concentration
    
    • > 20 million/mL
  • Motility
    
    • > 50%
  • Morphology
    
    • >4% using strict criteria
• Low threshold for urologic referral

Question 3

What are some methods of assessment of ovulation?

Answer 3

• Various methods acceptable
  
  • history consistent with ovulation
    
    • regular cycles
    • moliminal symptoms before menses
  • basal body temperature charting
  • determination of serum progesterone on day 21 of a 28 day cycle
  • home ovulation predictor kits

Question 4

What are the most common test for ovarian reserve?

Answer 4

• Day 3 FSH
  
  • FSH > 10-15 IU/L on day 2 or 3 considered abnormal
• Anti-mullerian hormone (AMH)​
  
  • produced by granulosa cells of preantral and small antral follicles
  • number of small antral follicles correlates with the size of the residual follicular pool
  • AMH levels decline as a woman approaches menopause
• Antral follicle count (AFC)
  
  • transvaginal ultrasound measurement of follicles, 2-10 mm in both ovaries
  • indirect measure of ovarian reserve
  • histological studies have revealed that the number of small antral follicles in ovaries is proportional to the number of primordial follicles remaining

Question 5

How is tubal patency assessed?

Answer 5

• Hysterosalpinogram (HSG)
  
  • oil or water based dye injected through the cervix
  • pictures of the uterus and fallopian tubes are taken under fluroscopy
• Saline infused sonohistogram (SIS)
  
  • simple, safe, inexpensive
  • ability to demonstrate tubal patency as high as 80%
    
    • BUT inferior to HSG when evaluating for tubal factor infertility
• Historical gold standard - Laparoscopy with chromopertubation
  
  • risks of operation
  • exensive
  • time intensive

Question 6

How is the uterine cavity assesed?

Answer 6

• Hysteroscopy - gold standard
• Transvaginal ultrasound
• SIS
• HSG