INTERNAL CHECK UP
Initially, a simple internal examination of the cervix and uterus is a must for every lady before proceeding to any other investigation. This should necessarily be followed by ultrasound evaluation of the uterus and ovaries. On examination of the cervix, any discharge found, should be promptly treated and any erosion should be biopsied and treated by `cryo' or cautery. The position of the uterus (whether it is Anteverted, retroverted or Midposition) Should be ascertained.
Ultrasound examination helps to assess some important features such as:
1. Size of the uterus, presence of uterine tumours like fibroids etc., as well as the endometrial reaction;
2. Size of the ovaries, Number of ovarian follicles, and the presence of pathological and physiological cysts in the ovaries;
3. Hydrosalphinx (dilatation of the tubes);
4. Presence of pelvic inflammatory disease;
5. Ultrasound also helps to pinpoint the exact day of ovulation.
The patient is evaluated for the presence of chlamydia, mycoplasma, trichomonas and monilial infections by serological assays, cervical discharge smear study and culture and sensitivity. They are the treated appropriately. This should necessarily be followed by blood test for VDRL, AIDS, Hepatitis and so on.
Antisperm Antibodies have to be ruled out by doing the relevant blood tests on the patient.
Hysterosalpingogrphy (HSG) is a very important and invaluable investigation which involves the injection of 8-10cc of radio opaque dye into the uterine cavity through the cervix via a tube testing cannula followed by an X-Ray picture, which directly reveals the uterine cavity and contour, internal structure of the tube, its patency and peritubal adhesion. The presence of pelvic infection should be totally ruled out before a patient is subjected to HSG and the test should necessarily be followed by a course of antibiotics to prevent the flaring up of infection. The test should be performed only during the follicular phase and 3 days after the menstrual flow stops, i.e. preferably during the 8-12th day of the menstrual cycle. It is important that the patient's menstrual flow should be good and not scanty since, the patient may already be pregnant, In cases of doubt an ultrasound evaluation and pregnancy urine test is invaluable. This investigation is recommended for couples married for a short duration and also as a compliment following Diagnostic Laparoscopy.
An Interesting Case History
A patient underwent as HSG examination without mentioning that she had scanty periods as she obviously did not give much importance to it. She was married for 5 years. The |HSG picture showed an enlarge uterus and bilateral (both sides) tubal block. However, ultrasound done the very next month revealed pregnancy of 11 weeks. The pregnancy had to be terminated in view of the hazardous consequences of radiation of the foetus.
This has by far, has proved to be the most invaluable and near to perfection investigation, in my many years of practice in infertility. This test is primarily advised for couples married for more than 3 years.
In this investigation, the uterus, ovaries, tubes and the pelvis can be directly visualised and evaluated at the same time, It is a fairly simple procedure done under a short general anesthesia and is more or less like an outpatient procedure which does not require hospitalization.
It involves a small nick at the umbilicus through which carbondioxide gas is introduced through this nick to visualise the pelvic organs. At the same time, non toxic methylene blue dye is intrroduced through the cervical canal to assess the patency of the tubes, the same spill through fimbrial ostia being visualised through the laparoscope. Any pelvic pathology like endometriosis, chocolate cyst of ovaries, fibroids, pelvic infections, post operative adhesion and congenital malformations can be evaluated.
At the end of the procedure, the uterine cavity is assessed for its length and direction by a gentle curettage. The histopathology report helps to evaluate the endocrinological aspect of the menstrual cycle and also establishes the presence or absence of pelvic tuberculosis.
Some women do not menstruate regularly. Instead, they have irregular cycles, once in 2-3 months with stray ovulation and profuse bleeding. This is diagnosed by analysis of Leutinizing Hormone (LH), Follicular Stimulating Hormone (FSH) and Prolactin. After ultrasonogram, the menstrual cycle is regularised by giving the patient hormones and inducing ovulation with clomiphene citrate and/or other gonadotrophins.
All patients treated for infertility undergo natural or induced cycles with drugs and follicular study is done to assess the ovarian response which is made out by the number of follicles present. When the follicles reach the mature size/stage, injection HCG in the dose of 2000-10,000 I.U. is given based on the individual response, to time the Intrauterine insemination and follicular repture. The luteal phase is supported by progesterone tablets or injections.
Male infertility: Seminal analysis is a very important criteria in the assessment of male infertility. There are some basic requirements in the semen parameter when Intrauterine Insemination or Assisted Reproductive techniques are done.
Normal seminal analysis:
Volume - 2.5 ml
Count - Between 60-120 Millions
Motility - More than 70%
Sperm Abnormalities - Less than 40%
White cells - 1-3/ HPF
Pus cells - 1-2/ HPF
The Minimum requirement for successful fertilization
Volume - 1.0 - 3 ml
Count - More than 20 Millions
Motility - More than 40%
Sperm Abnormalities - Less than 50%
White cells - Minimum
Pus cells - 1-2/ HPF
Basically there are three important abnormalities which contribute to male infertility:
1. Azoospermia (Absence of Sperms)
2. Oligospermia (Low Sperm count)
3. Asthenospermia (Decreased motility,/ Decreased movement of the sperms)
For Patients with azoospermia, the sample should be analysed atleast 3 times at 3 different laboratories. Patients with Azoospermia should necessarily undergo hormonal analysis of LH, FSH, Prolactin and Free Testosterone. Based on the results, further investigations can be done. Patients with normal level of FSH may undergo testicular biopsy for further assessment and to rule out any obstruction.
Local examination of the testes: The volume, presence or absence of testes (undescended testes) hernia, varicocele, hydrocele and filariasis will form an important criteria while evaluating male infertility.