This document discusses infertility investigations and treatments. It recommends referring couples for investigations after 1 year of unprotected sex if the woman is under 36, or earlier if she is over 36 or there is a known cause of infertility. Common causes of infertility include male factors, female tubal issues, ovulatory disorders, and unexplained causes. Recommended initial investigations include a semen analysis, HSG, and progesterone test. Treatments discussed include IVF for moderate to severe tubal disease or other complicating factors, and laparoscopic surgery for mild tubal disease. The document provides guidance on investigating and treating various conditions that may cause infertility such as PCOS, hyperprolactinemia, and ovarian failure.

1. Benha University Hospital, Egypt
Aboubakr Elnashar

2. When to refer a couple for
investigations?
Not conceived with unprotected sexual
intercourse
Age <36 y
Absence of any known cause of infertility
After one year
Age >36 y
known clinical cause of infertility
history of predisposing factors for infertility
Earlier
Aboubakr Elnashar

3. Incidence
1 in 7 couples
Main causes
Male factors: 30%
Female: 45%
• Tubal: 20%
• Ovulatory disorders: 25%
• Uterine: 10%
• Endometriosis: 5%
Unexplained: 25%
Combined male and female: 40%
Aboubakr Elnashar

4. Investigations
(ESHRE, 2000)
I. Tests that have an established association
with pregnancy:
Conventional semen analysis
HSG
Midluteal progesterone
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5. II. Tests that are not consistently associated
with pregnancy:
Post-coital test
Antisperm antibody tests
Zona-free hamster egg penetration test
III. Tests that have no association with
pregnancy:
Endometrial biopsy
Varicocele assessment
Chlamydia testing
Aboubakr Elnashar

6. Aboubakr Elnashar

7. Investigations
1. HSG
No co morbidities:
PID
Previous ectopic pregnancy or
Endometriosis
{reliable test for ruling out tubal occlusion
less invasive
makes more efficient use of resources than
laparoscopy}
Aboubakr Elnashar

8. Aboubakr Elnashar

9. HS-contrast-US
experience
effective alternative to HSG
Prophylactic antibiotics
before uterine instrumentation if screening for CT
has not been carried out.
Aboubakr Elnashar

10. HS-contrast-US
Free fluid collection in the cul-de-sac following
successful demonstration of oviductal patency.
Oviductal fimbria are clearly observed in the collected
fluid.
Aboubakr Elnashar

11. 2. Laparoscopy and dye test
Co morbidities
{tubal and other pelvic pathology can be assessed
at the same time}.
Aboubakr Elnashar

12. 3. Hysteroscopy
Not an initial investigation unless clinically indicated
{effectiveness of surgical treatment of uterine
abnormalities on improving pregnancy rates has not
been established}.
Aboubakr Elnashar

13. Classification of Tubal disease
British Fertility Society
Minor
Proximal occlusion
without tubal fibrosis
Distal occlusion without
tubal distension
Healthy mucosal
appearance at HSG,
salpingoscopy
Flimsy peritubal/ovarian
adhesions.
Intermediate
Unilateral
severe tubal
damage
Limited dense
adhesions of
tubes & ovaries
Severe
Bilateral severe tubal
damage
Extensive tubal fibrosis
Tubal distension >1.5 cm
Abnormal mucosal
appearance
Bipolar occlusion
Extensive dense adhesion
Aboubakr Elnashar

14. Hydrosalpinx
well-constrained fluid
accumulation in the adnexae.
In some cases, adhesions
between the oviduct and ovary
may be visualized.
Aboubakr Elnashar

15. Treatment
I. IVF:
1. Moderate to severe tubal disease
2. Other factors e.g
A. Sperm dysfunction
B. Age >36 yr
Aboubakr Elnashar

16. Hydrosalpinges
salpingectomy, preferably by laparoscopy, before
IVF treatment
{improves the chance of a live birth}.
Aboubakr Elnashar

17. II. Laparoscopic surgery:
mild tubal disease
appropriate expertise
Aboubakr Elnashar

18. III. Selective salpingography plus tubal
catheterisation, or hysteroscopic tubal
cannulation
Proximal tubal disease
If pregnancy has not occurred within 12 mo
of surgery: IVF
Aboubakr Elnashar

19. Aboubakr Elnashar

20. Investigations
1. Midluteal progesterone
in regular and irregular cycles
{confirm ovulation}
In irregular prolonged cycles
Depending upon the timing of menstrual periods, conducted later in
the cycle (for example day 28 of a 35-day cycle) and repeated
weekly thereafter until the next menstrual cycle starts
2. Basal FSH and LH
• Only in
irregular prolonged cycles
Aboubakr Elnashar

21. 3. Prolactin
Only in
ovulatory disorder
galactorrhoea or
pituitary tumour
4. TSH:
only if
symptoms of thyroid disease
Endometrial biopsy
To evaluate the luteal phase: No
{no evidence that medical tt of luteal phase defect
improves pregnancy rates]
Aboubakr Elnashar

22. 5. Ovarian reserve testing
 Woman’s age:
An initial predictor of overall chance of success
through natural conception or with IVF
 Predictors of ovarian response to Gnt stimulation
in IVF:
High responseLow response
16 or more4 or lessTotal AFC
3.5 or more
25
0.8 or less
5.5
AMH
ng/ml
pmol/l
Conversion ratio:7
4 or less8.9 or moreFSH IU/L
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23. • Do not use
1. ovarian volume
2. ovarian blood flow
3. inhibin B
4. E2
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24. WHO: I. Hypothalamic pituitary failure
II. Hypothalamic pituitary dysfunction
III. Ovarian failure
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25. Amenorrhea or severe oligomenorrhea
FSH & LH: low
Prolactin: normal
Aboubakr Elnashar

26. 1. Reverse the life style factors:
Increase wt if BMI <19
Moderating exercise if high levels of
exercise.
Treat stress
2. Gonadotrphins with LH activity or
Pulsatile GnRH (pump)
 CC:
not effective
Aboubakr Elnashar

27. PCOS
2 of 3 (Noterdam definition,2003):
•U/S PCO
•Hyperandrogenism (Clinical or Laboratory)
•Irregular or absent ovulation
Aboubakr Elnashar

28. PCO
Multiple peripheral
subcentimetric follicles (arrow).
Aboubakr Elnashar

29. OVULATION INDUCTION IN PCOS
NICE, 2013
1. Weigh loss:
If BMI >30 K/m2
 alone may restore ovulation
 improve response to ovulation induction agents,
 positive impact on pregnancy outcomes
Aboubakr Elnashar

30. 2. One of the following taking into account
•potential adverse effects
•ease and mode of use
•BMI
•monitoring needed:
CC: (not more than 6 m) or
Metformin or
CC + Metformin
Aboubakr Elnashar

31. 3. CC resistance:
one of the following 2nd line tt, depending on
•clinical circumstances
•woman's preference:
CC and met if not already offered as1st line tt or
LOD or
Gnt
US monitoring
{measure follicular size and number {reduce the risk
of multiple pregnancy and OHSS}
Aboubakr Elnashar

32. Aboubakr Elnashar

33. Hyperprolactinaemia
I. Idiopathic
.Dopamine agonist (anxiety, pregnancy ).
Stop during pregnancy
II. Microadenoma
. Dopamine agonist (anxiety, pregnancy).
Stop after 2-3 yr.
. Surgery (rapid growth).
III. Macroadenoma
. Dopamine agonist: long term
. Surgery
(No response, suprasellar extension, pregnancy).Aboubakr Elnashar

34. < 40 yr, 2ndry amenorrhea
Repeated FSH > 20 IU/L
Causes
1. Idiopathic.
2. Genetic.
3. Autoimmune
3. Viral/bacterial infection
4. Pelvic surgery, chemotherapy
5. Galactosemia
Aboubakr Elnashar

35. POF.
Only the stroma of the ovary is identified.
A very few follicles of less than 1 mm on the inferior aspect of
the ovary.
Aboubakr Elnashar

36. 1. Oral contraceptive suppression of gonadotrpins
followed by discontinuation to allow a rebound in
gonadotropins & ovarian function.
2. GnRH agonist suppression of gonadotropins
secretion followed by high dose gonadotropin
injection
3. Glucocorticoids suppression of immune system.
Non of these tts has demonstrated efficacy in RCT
(van Kastren et al, 1995)
Aboubakr Elnashar

37. Aboubakr Elnashar

38. Aboubakr Elnashar

39. Aboubakr Elnashar

40. Infertility workup
1. Ovarian reserve 2. Semen
analysis
3. F tubes
Compromised:
IVF
Not compromised: surgery
Allow 6-18 month
No pregnancy: IVF
No surgery before IVF
except:
Large endometrioma ,
hydrosalpinx,
pelvic pain
de Ziegler et al, 2010Aboubakr Elnashar

41. I. Minimal and mild
(Aboulghar,2003):
• Medical treatment does not enhance
fertility & should not be offered
• Expectant treatment.
• ±COH/IUI.
• Surgical ablation*
• IVF.
*Minimal or mild endometriosis who undergo
laparoscopy should be offered surgical
ablation or resection of endometriosis
plus laparoscopic adhesiolysis
• {improves the chance of pregnancy}.
Aboubakr Elnashar

42. II. Moderate & severe
• IVF:
Treatment of choice (Aboulghar, 2003).
• Postoperative medical treatment
does not improve pregnancy rate & not
recommended
Moderate or severe:
surgical treatment {improves the chance of
pregnancy}.
Aboubakr Elnashar

43. • Endometrioma:
Laparoscopic cystectomy
{improves the chance of pregnancy}
Aboubakr Elnashar

44. Aboubakr Elnashar

45. 1. Uterine myoma
Aboubakr Elnashar

46. Myomectomy:
-Indications:
1. Distorting the uterine cavity
 Submucous:
interfere with fertility and should be removed in infertile
patients, regardless of the size or presence of symptoms
(Gambadauro,2012).
 Intramural:
distorting: reduce the chances of conception
not distorting: controversial results.
 Subserosal:
No evidence supports removal in asymptomatic, infertile
3. >5-7cm
4. Multiple >3 (3-5 cm)
(Bajekal & Li, 2000)
Aboubakr Elnashar

47. Aboubakr Elnashar

48. Intramural fibroid
Examples of fibroids which
compromise the contours of the
endometrial cavity.
Refraction artifacts {tissue
density interfaces and the
texture of the fibroids} often aid
in their identification.
Aboubakr Elnashar

49. Fibroid
1. Cavity
Distorted Not distorted
2. Size
>7 cm <7 cm
3. Number (3-5 cm)
>3 <3Aboubakr Elnashar

50. A. Open myomectomy
(Bajekal & Li, 2000)
The route of choice:
Large SS or IM(>7 cm)
Multiple fibroids (>5)
When entry into uterine cavity is to be
expected
Aboubakr Elnashar

51. B. Hysteroscopic myomectomy:
The route of choice:
SM fibroids.
Compared to laparotomy, it is associated with a
lower risk of scar rupture & no pelvic
adhesion (Bajekal & Li, 2000)
Large (>5 cm) type II SM fibroids may be
unsuitable for hysteroscopic surgery.
A significant benefit of removing SM fibroid
>2cm (Varasteh et al, 1999)Aboubakr Elnashar

52. Aboubakr Elnashar

53. C. Laparoscopic myomectomy:
 Pedunculated or SS: not candidate for removal {not
the cause of infertility or recurrent miscarriage}
(Bajekal & Li, 2000).
IM:
 Very experienced laparoscopic surgeon
 Uterine rupture: 2 reports both at 34 w
{inability to effectively close the myometrium
laparoscopically}
Uterine indentation
Uterine fistula Aboubakr Elnashar

54. Aboubakr Elnashar

55. 2. Septate uterus
Not increased among women with infertility
compared with other women (2–3%).
More common: RM or PTL.
Hysteroscopic metroplasty:
No increase pregnancy rates in women with
infertility [Evidence level 2b–3]
Aboubakr Elnashar

56. Aboubakr Elnashar

57. 3. Intrauterine adhesions
with amenorrhoea
hysteroscopic adhesiolysis
{restore menstruation and improve the chance
of pregnancy}. (C)
Aboubakr Elnashar

58. IU adhesions
Bright (hyperechoic) uterine lining - scar tissue in uterine
cavity
Aboubakr Elnashar

59. Aboubakr Elnashar

60. Inability to conceive after one year with
routine (standard, basic) investigations of
infertility showing no abnormality.
(RCOG guidelines,1998; Randolph,2000)
Dependent on:
Availability of resources ,
Patients’ age
Duration of infertility.
IUI:
ESHRE (2004)
indicated as empiric treatment
Aboubakr Elnashar

61.  Protocol for Management
(Ray et al, 2012)

62.  Cochrane (2012)
• IUI with OH increases the live birth rate compared
to IUI alone.
• The likelihood of pregnancy was also increased
for treatment with IUI compared to TI in stimulated
cycles
Aboubakr Elnashar

63. • NICE, 2013
 Do not offer oral ovarian stimulation agents
(such as clomifene citrate, or letrozole).
{no increase the chances of a pregnancy or a live
birth}.
 Offer IVF after 2 years
 IUI:
 when social, cultural or religious objections to
IVF
without stimulation: no better than
expectant management.
with stimulation: better than expectant
management Aboubakr Elnashar

64. Benha University Hospital, Egypt
E-mail: elnashar53@hotmail.com
Aboubakr Elnashar
Aboubakr Elnashar