Integrated Approach to

Infertility Work-Up

EMAD DARWISH MDPROFESSOR OF OBSTETRICS AND GYNECOLOGY

INTEGRATED FERTILITY CENTERALEXANDRIA

Etiology of infertility:

Male factor 30%Female factor 40%

Combined factors

10-20 %

Unexplained 10-20%Infertility

Male factor Female factor Combined fac-tors Unexplained

Meet the coupleHistory: 1- Married for how long? 2- For how long together?L.M.P. 1- Date 2- RegularityPast History: Pelvic Surgery eg myomectomy, ovarian cystectomy ( H.P. ) to exclude endometriosis. Medical disorders thyroid, Diabetes Male partner mumps, orchitis, surgeryHusband Job eg driversPrevious investigations: HSG, Endoscopy, IUI, ICSI Details about sexual intercourse.

Four Points to be Covered

1- Male Partner2- Ovarian function3- Tubal function4- Utereus

Male Partener

History Examination: General and Local Semen Analysis: Conventional or CASA DNA fragmentation If azospermia Serum FSH : Obstructive or

Testicular or Hypo-Hypo TESE Where to do ?

Volume Normal: 2-6 ml

> 6 ml may be due to chronic prostatitis or seminal vesiculitis.

<2 ml may be due to obstruction or retrograde ejaculation (hypospermia)

Sperm count: > 20 million/ml (new WHO strict criteria: < 15 million/ml)

Reaction (pH): 7.2-8 (alkaline)

Liquefaction: Completed within 30 minutes.

Motility: > 50 % motile

morphology: > 30 % is considered normal according to the WHO criteria.

Agglutination: not exceed 10 %.

Cellular elements:

< 5 x106/ml rounded cells of which < 1x106/ml are WBCs.

Semen Analysis

Important items in Semen report Count more than 15 million/ml Motility A ( fast forward) 25% B (slow forward) 25% C ( shaking) D ( immotile) Normal Forms more than 4%

Ovarian Function

Regular Cycles TVS for follicular scanning Mid luteal phase serum Progesterone PCOS: Trunkal obesity, Hirsutism,

Oligomenorrhoea, TVS , family H. of Diabetes Lab: LH:FSH ratio, AMH, Prolactin, Testosteron Insulin resistance FBS and Fasting serum insulin

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Ovarian Reserve1- Age2- AFC day 3 of cycle3- FSH day 3 of cycle4- History of previous COH

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Choclate CystDiagnosis: TVS Laparoscopy limited rule now for diagnosis, treatment mainly for pain, before ICSI ??

Tubal Function

HSG Laparoscopy Hysteroscopy

Uterine Factor

HSG 2D and 3D TVS, SIS Hysteroscopy Endometrial biopsy for diagnosis of chronic endometritis

HSG: To diagnose uterine congenital anomalies, intrauterine adhesions,

submucous fibromyomata..

Hysteroscopy:For direct visualization of the interior of the

uterus, diagnosis and surgical correction of intrauterine adhesions, uterine anomalies & submucous fibromyomata.

Lab Investigations Serum Progesterone FSH AMH FBS and Fasting serum insulin E2 Prolactine TSH