The document provides an overview of the evaluation process for a case of female infertility. It begins with definitions of infertility terms and discusses causes of infertility. The evaluation involves taking a medical history, physical exam, transvaginal ultrasound, screening tests, and further tests based on initial findings. These include testing for ovulation, ovarian reserve, uterine and tubal factors, and male factor evaluation. Methods to evaluate tubal patency such as HSG, HyCoSy, laparoscopy and falloposcopy are described. The summary evaluates the tubal assessment algorithm and discusses tubal surgery and treatment of hydrosalpinges before IVF.

1. APPROACH TO A CASE OF
FEMALE INFERTILITY
Candidate: Dr Monikha
Consultant Guide: Prof Neena Malhotra
Sr Guide: Dr Swati Tomar

2. Introduction
• Infertility: Disease of the reproductive system defined by failure to
achieve a clinical pregnancy after 12 months or more of regular
unprotected sexual intercourse
• Fecundability: Probability that a cycle will result in pregnancy
• Fecundity: Probability that a cycle will result in live birth
• Chance of conception in individual cycle -20%
• Evaluation indicated-15% of couples
• Lifetime risk of infertility- 6.6% to 32.6 %
Hamilton et al The epidemiology of Infertility Human reproduction ,2009
85% of couples achieve conception by 1 year
92% of couples by 2 years
NICE 2013

3. Causes of Infertility
Speroff’s Clinical gynaecologic endocrinology and infertility 8th ed

4. Causes of female infertility
ASRM 2017

5. When To Investigate?
NICE 2013
1year:
Unprotected sexual intercourse without any known cause of infertility
6 months:
-Woman >35yrs
-H/o Oligomenorrhea/ Amenorrhea,
-Known Uterine/ Tubal/ Peritoneal disease/ Endometriosis
-Known male subfertility

6. General Considerations
3 simple questions need to be addressed:
1. Is there evidence of normal sperm production and
ejaculatory competence?
2. Is the woman ovulating?
3. Is the female pelvic anatomy normal and coital function
adequate?

7. BASIC INFERTILITY EVALUATION PROTOCOL - AIIMS
• History
• Exam
• TVS
• Screening
• FBC, ESR
• MTx, X-ray chest
• Rubella
• Hep B, C, HIV
EA
Ovulation status Conventional molecular
-ve for FGTB +ve molecular
-ve vonventional
+ve convention
ATT
Findings
HSG
Laparoscopy

8. Evaluation
HISTORY
•Duration of Infertility/ Contraceptive use
•Fertility in previous/current relationships
•Previous fertility investigations/ treatment
MEDICAL HISTORY
Menstrual History:
•Menarche
•Cycle length & duration of flow
•Dysmenorrhea
•Amenorrhea episodes
•HMB/IMB
Obstetric History:
•No of previous pregnancies
(MTP/miscarriage/ectopic preg)
•Time to initiate previous pregnancies
Drug History:
•Agents causing ↑PRL/ CT/RT
Surgical History
•Previous abdominal/pelvic
/gynaecological surgeries
Occupational History:
•Work patterns including separation from
partner
Sexual History:
•Coital frequency, timing, knowledge of
fertile period
•Dyspareunia
•Postcoital bleeding

9. Physical Examination
General :
• Height
• Weight
• BMI
• Fat & Hair distribution
• Acne
• Galactorrhea
• Acanthosis nigricans
• Thyroid examination
Abdominal :
• Abdominal mass & tenderness
Pelvis :
• Assess state of hymen, clitoris and labia
• Look for vaginal infection, septum,
endometriotic deposits
• Check for cervical polyps
• Accessibility of cervix for insemination
• Uterine size, position, mobility and
tenderness
• Cervical smear if needed

10. Investigations in Infertility
Couple with infertility
Female
Investigations of
suspected ovarian
disorders
Regularity of
menstrual cycles
Ovarian reserve
testing
Investigations of
suspected uterine
and tubal disorders
Investigations of
peritoneal factors
male
Semen analysis
NICE 2013

11. Transvaginal Ultrasound
• UTERUS
– Size
– morphology-fibroid, cong.
abnormality, polyp
• OVARY
– Size
– AFC
– Morphology-PCOS, cysts
– Outline
– accessibility
• FALLOPIAN TUBES
• ENDOMETRIUM
– ET, Pattern
– Doppler

12. TVUS
Dominant follicle Triple line endometrium
Dermoid cyst
Polycystic ovaryB/L hydrosalpinx

13. TVUS
Adenomyosis Endometrioma
Endocavitary leiomyoma Asherman syndrome

14. Infertility work up-Baseline TVS
Patient Name …………………………. LMP.………… Date………….. Day…………...
Uterus: size ……….. x ……….. x ……….. cm
Myometrium: Normal / adenomyotic / calcification / fibroid
Fibroids: Number- Size – Site –
Endometrium: regular / irregular/calcification
ET-……….. mm / TL / Diffuse
Doppler: (Sub-endometrial)
Right ovary: Size ……..x …….. x……..cm, vol-
AFC ……………
Outline: Hazy/well defined
Proximity to uterus: Yes / No
Accessibility : Yes/ No
Endometrioma / Cyst / Others
Left ovary: Size ……..x …….. x……..cm, vol-
AFC ……………..
Outline: Hazy/well defined
Proximity to uterus: Yes / No
Accessibility : Yes/ No
Endometrioma / Cyst / Others
Others: Hydrosalpinx: Rt- ……x …….. cm
Left ……x…….. cm
TO Mass: Rt- ……x …….. cm
Left ……x …….. cm

15. Pre Conceptional Testing
Rubella
Chlamydia serology
Cervical screening
Vaccinate if not immune and avoid conception for one month
HIV If compliant with HAART
& if viral load <50 copies/ml for
more than 6 months
Timed unprotected intercourse
Sperm washing and IUI
HBSAg
HCV
+
-
Vaccinate if partner positive
Treatment before conception
IgG Antibodies testing
Prophylactic treatment of both partners before any
instrumentation if unable to investigate
According to screening guidelines
NICE 2013
TB screening, though not
recommended by NICE, is
necessary in India

16. Lifestyle Modifications
Alcohol :
• Women: 1-2U per week
• Men: 3-4U per day
Smoking:
• Active & passive smoking decreases
chances of conception
Caffeinated beverages: no association
Obesity :
• BMI > 30 ↓ fertility
• Weight loss ↑ conception chances
Folic acid supplementation:
• 0.4mg/day
• 5mg /day if h/o NTD/antiepileptic drug
intake/DM
Frequency/timing of sexual intercourse:
• Every 2-3 days ↑ chances of preg
NICE 2013

17. Male Factor
WHO LOWER REFERENCE LIMITS FOR SEMEN CHARACTERISTICS
2010
Criteria Lower reference values
Vol (in ml) 1.5
Total sperm number(206 per ejaculate) 39 million
Sperm concentration (106 per ml) 15 million
Total motility (PR+NP,%) 40
Progressive motility(PR,%) 32
Vitality (live forms,%) 58
Morphology (normal forms,%) 4
NICE 2013

18. Tubal Patency Test
AETIOLOGY:
• Previous tubal infection
C trachomatis infection- 50-70%
Genital TB- 19% (India)
• Previous surgery
Post op adhesions after gynae
surgeries: 50-70%
• Endometriosis
Distortion & blockage of FTs
• Congenital abnormalities
-Aplasia /Hypoplasia
-Accessory ostia
TESTS FOR TUBAL PATENCY:
• Imaging
-Hysterosalpingography (HSG)
-Hysterosalpingo-contrast sonography
(HyCoSy)
-Saline infusion sonography (SIS)
• Surgery
-Laparoscopy + Dye test
-Falloposcopy
-Salpingoscopy
• Indirect testing
-Chlamydia serology

19. Historical techniques
Diagnostic techniques
Non surgical
Ascending
Tubal insufflation
Pneumosalpingogram
Phenolsulfonphthalein test
Methylene blue test
Tubal scan
Descending
China ink
Starch
Radioactive
transportation
Surgicall
Partial evaluators
Colpotomy
Culdoscopy
Complete evaluators
Laparoscopy
Laparotomy
Amir et al,Fertility Sterility 1979

20. Tubal Patency Test: HSG
PROCEDURE
2-5 days immediately following menses
(follicular phase)
3 basic films
 1st - Scout- preliminary film
 2nd - To document uterine contours &
tubal patency
 3rd - Post-evaluation film to detect any
areas of contrast loculation
INDICATIONS:
• Tubal patency- infertility/ post tubal Sx
• Uterine factor in RPL
• Staging & grading of uterine synaechiae
• Preoperatively before myomectomy
GENERAL CONSIDERATIONS:
• Perform in proliferative phase
• Irregular periods- rule out pregnancy
• Exclude acute pelvic infection
• Routine antibiotics in high risk cases
PROCEDURE
• Fluoroscopy table in lithotomy position
• Parts painted and draped
• P/s P/V examination
• Karmans Cannula placed intracervically
• Under fluoroscopic guidance inject 5-
10ml contrast agent over 1 min
• Radiographs obtained
• Procedure halted after adequate spill
into peritoneal cavity
Steinkeler et al.,Radigraphics,2009

21. Tubal Patency Test: HSG
a)Early filling stage-small filling defects best seen
b)Uterus fully distended-filling defects and uterine contour best seen
c)Tubal filling phase-for tubal abnormalities
d)Peritoneal spillage Steinkeler et al.,Radigraphics,2009

22. Beaded Tubes Convoluted tube, loculated spill
Tobacco pouch appearance
Stem pipe with beaded tube and IUA
Normal HSG findings
Tubal Patency Test: HSG

23. Tubal Patency Test: HSG
COMPLICATIONS
• Pain
• Infection
• Bleeding
• Vascular /lymphatic intravasation
• Vasovagal attack
• Radiation exposure
• Allergy to contrast
• Uterine perforation
CONTRAINDICATIONS
• Suspected pregnancy
• Acute pelvic infection
• Active vaginal bleeding
• Contrast sensitivity
• Immediate pre and post menstrual
phase
• Tubal /uterine surgery within last 6
weeks
THERAPEUTIC EFFECTS OF HSG
• Expulsion of mucus plugs
• Dilatation of fimbrial phimosis
• Stimulation of tubal contractility
• Enhanced fertility with oil based contrast

24. Oil vs Water Soluble Contrast?
Oil soluble contrast significantly increased the likelihood of pregnancy
compared to no intervention
Jon Bosteel et al,Human Reproduction Update

25. Saline Infusion Sonography
• Usually scheduled between day 5 – 10 of the
menstrual cycle
• No routine anesthesia or analgesia needed
• Bimanual exam
• Place speculum
• Aseptic prep of the cervix
• SIS
– Flush catheter
– Insert catheter
• Fill balloon and snug catheter against the internal
os
• Remove speculum
• Attach 10ml syringe of sterile saline
• Insert TV U/S probe

26. Hysterosalpingo-Contrast-Sonography
(HyCoSy)
• Uses Sonoreflective echo
contrast fluid
(Echovist,SonoVue)
• Good consistency with
laparoscopic
chromopertubation as the
reference standard

27. Which one to choose: HSG/HyCoSy?
HSG
Pros:
-Films available for review
Cons:
-X-ray exposure
-Needs radiology set up
-Radio-opaque contrast contains iodine
(Risk of sensitivity)
HyCoSy
Pros:
-USG at same time
-Foam used is inert
-100% sensitive
-75% specific
Cons:
-No films,report only or video
-Steep learning curve
-Operator dependent
-Not widely available

28. Hyfosy
Hysterosalpingo-foam sonography:
• Foam containing hydroxyethylcellulose
& glycerol instilled
• More accurate diagnosis of tubal
patency compared with HyCoSy
Newer modifications of sonography:
• Pulse Doppler
• Color Doppler
• Combined air and saline
• 3D saline SSG
Hystsero-salpingo-lidocaine foam
sonography-pulse doppler (HyLiFoSy-PD)
• Contrast :Foam + 3-4 ml of 2%
lidocaine gel+ saline + air
• Flaming tube sign : This sign is result of
the orange color of PD surrounding the
contrast flowing into the patent tubes
Emanuel et al.,USG Obs Gyn,2011
Arthur et al.,HiLiFoSy-PD,2016

29. Laparoscopy
• Gold standard
• Pelvic pathology concomitantly treated
Hull and Rutherford Laparoscopic Classification of tubal disease
GRADE 1-MINOR:
•Tubal fibrosis absent even if tube occluded
(proximally)
•Tubal distension absent even if tube
occluded (distally)
•Mucosal appearances favourable
•Adhesions flimsy
GRADE 2-MODERATE:
•U/L severe tubal disease ± C/L minor damage
•“Limited” dense adhesions of tubes/ovaries
GRADE 3-SEVERE:
•B/L tubal damage
•Extensive tubal fibrosis
•Tubal distension > 1.5cm
•Abnormal mucosal appearance
•Bipolar occlusion
•‘Extensive’ dense adhesions
Significance : to predict the
favourable ,fair and poor prognosis
of live birth following tubal surgery
Rutherford et al., BJOG,2004

30. Laparoscopy
Beaded appearance in GTB
Large hydrosalpinx in GTB
Endometrioma Adhesions
Fibroid uterus

31. Other Methods for Tubal Evaluation
FALLOPOSCOPY:
• To evaluate tubal mucosa
• Endoscope introduced trans-cervically
Techniques of Falloposcopy:
1. Coaxial technique
2. Linear everting catheter system(LEC)
technique
Success rate of cannulation by
falloposcopy in ‘abnormal’ tubes of
patients is >90%
Wong et al HKMJ 1999

32. Salpingoscopy
• Endoscope introduced via fimbrial end of FT during
laparoscopy
• Visualises internal tubal mucosa
Brosens and Puttemans classification of
salpingoscopic mucosal appearance:
Grade I: Normal mucosal folds
Grade II: Major folds separated & flattened, but otherwise normal/dye staining
of mucosa/minimal flattening
Grade III: Focal adhesions b/w mucosal folds & variable flattening
Grade IV: Extensive adhesions b/w mucosal folds & disseminated flat areas
Grade V: Complete loss of mucosal fold pattern
Upto grade III-Compatible with fertility
Higher grades-Counselled for IVF

33. Transvaginal Hydrolaparoscopy
Transvaginal hydrolaparoscopy:
• Endoscope introduced through posterior fornix after
insufflation of pelvis with 0.4-0.6L of fluid
• Outpatient procedure
• 0.61% of rectosigmoid injury
FERTILOSCOPY :
• Hysteroscopy+transvaginal hydrolaparoscopy+ salpingoscopy
• High concordance b/w Laparoscopy and Fertiloscopy
Dutch healthcare authority,2009

34. Chlamydia Antibody Tests
• As a pretest to select women who warrant earlier or more
detailed evaluation
• Micro immunofluorescence CAT preferred
• Negative CAT: <15% likelihood of tubal pathology
• Disadvantage : cross reactivity with C. pneumoniae may give
false positive results
• Does not differentiate b/w remote & persistent infection
ASRM 2015

35. Tubal Assessment algorithm(NICE)
Co-morbidities
Previous surgeries,PID,Endometriosis
Laparoscopy HSG/HyCoSy
OVI
+ve
Non patent
Patent
-ve
NICE 2013

36. Tubal surgery-
Option for women with mild distal tubal disease
Women with previous tubal sterilization
Women with hydrosalpinges planning for IVF-laparoscopic salpingectomy or
proximal tubal occlusion increases IVF success rate by 2-fold
Fertility sterility 2015

37. Excision/Occlusion of Hydrosalpinges
before IVF
Both laparoscopic salpingectomy and tubal occlusion before IVF increases the
odds of pregnancy
Johnson et al. Cochrane review 2010
Laparoscopic salpingectomy before IVF increases the chances of live birth
NICE 2013

38. Tests of Ovulation
Menstrual history
BBT:
• 0.4-0.8 deg rise
• Ideal BBT recording biphasic
• Reveals a cycle b/w 25-35 days in
length with menses beginning 12
days or more after temp rise
• Not recommended
Serum Progesterone levels:
• <3ng/mL- anovulation
• D21 S. progesterone is not always the
best time
• Best time: 1 week before expected
menses
TVUS:
• Serial TVUS for size and number of
preovulatory follicles
• Most accurate estimate of ovulation
Urinary LH secretion:
• To predict midcycle LH surge in urine
• LH kits/Ovulation predictor kits available
• Sensitive to fluid intake and time of the
day (4 to 10pm)
• Interval of greatest fertility –day of surge
and following 2 days
Endometrial biopsy:
• Secretory endometrium -ovulation
• R/o hyperplasia in chronic anovulation
Speroffs Clinical Gynaecologic Endocrinology 8th ed

39. Endometrial Biopsy/Aspiration
• Routine work-up
• Not to diagnose ovulation/LPD
• Exclude FGTB
– 40-80 % of FGTB presents with infertility (Bazaz-Malik,1983, Bhide A
1987, Tripathy S 2002, Jindal UN 2006)
– 15-19% of infertile women in India have GTB (Deshmukh KK 1985,
Parikh F 1997)
• EB/EA
– Conventional tests
• AFB, HPE, solid culture
– Molecular
• DNA-PCR, RT-PCR, BACTEC

40. STATIC TESTS
Basic hormone tests
•Basal FSH levels
•Anti Mullerian
Hormone
•Inhibin B
•Estradiol levels
Biophysical tests
•Antral follicle count
•Ovarian Volume and
dimensions
•Stromal blood flow
DYNAMIC TESTS
•Clomiphene citrate
challenge test
•GnRH agonist
stimulation
test(GAST)
•Exogeneous FSH
ovarian reserve test
( EFORT)
OVARIAN RESERVE TESTS

41. Ovarian Reserve Test
Ovarian reserve testing can best be justified for women with any of the
following characteristics
• Age over 35.
• Unexplained infertility.
• Family history of early menopause.
• Previous ovarian surgery (ovarian cystectomy or drilling, unilateral
oophorectomy),chemotherapy, or radiation.
• Smoking
• Demonstrated poor response to exogenous gonadotropin stimulation
An ideal ovarian reserve test should yield consistent results and highly specific,
to minimize the risk for incorrectly categorizing normal women as having a
diminished ovarian reserve

42. Fertility with aging
• Progressive follicular depletion
• High abnormalities in aging oocyte
• High prevalence of miscarriage
• High prevalence of benign uterine pathology
Speroffs Clinical Gynaecologic Endocrinology 8th ed

43. Ovarian Reserve Tests: Hormones
Predicts response to ovarian stimulation with exogenous Gonadotropin
Basal FSH concentration:
• Day 2-4
• High levels 10-20IU/L- high
specificity(80-100%) for predicting
poor response to stimulation
• Sensitivity is low (10-30%)
Basal E2 level:
• Little value as an ORT
• Helps interpreting FSH levels
• ↑E2/normal FSH or ↑E2/↑FSH-poor
response to stimulation
Inhibin B:
• Little value as an ORT
• Secreted during follicular phase and
vary between cycles
• 64-90% specificity
• 40-80% sensitivity for poor response
AMH
• Granulosa cells- pre & small antral follicles
• GnRH independent
• Little variation within & b/w cycles
• 40-97% sensitivity;78-92% specificity
• Neither sensitive nor specific to predict PR
• Very promising screening test for DOR
Speroffs Clinical Gynaecologic Endocrinology 8th ed

46. •Increased risk of false positives when tests are used in low
risk populations
•Insufficient evidence to recommend that any ovarian reserve
test to be used as a sole criterion for the use of ART.
ASRM 2015

47. Hormonal evaluation
PRL measurement:
• Incidence of ↑PRL in infertile but
ovulatory women-3.8% - 11.5%
• Estimation of PRL levels should be
reserved for women with ovulatory
disorder/galactorrhea/pituitary
tumour
Thyroid function tests:
• Abnormal TFT -1.3-5.1% of
infertile women
• 0.8-11.3% of women with
ovulatory disorders have
subclinical hypothyroidism
NICE 2004

48. Biophysical Tests
Antral follicle count:
• AFC correlates to number of remaining
follicles
• Total no of antral follicles measuring 2–
10 mm in both ovaries
• Performed on cycle days 2-5
• A low AFC has high specificity for
predicting poor response to ovarian
stimulation and treatment failure
• Low sensitivity limits clinical utility
Ovarian volume:
• length × width × depth ×
0.52=volume
• A low ovarian volume(< 3mL) has
high specificity (80–90%) but widely
ranging sensitivity (11–80%) for
predicting poor response to ovarian
stimulation
Speroffs Clinical Gynaecologic Endocrinology 8th ed

49. NICE Recommendations
• Use one of the following measures to predict the likely ovarian response
to gonadotrophin stimulation in IVF:
1. Total AFC
2. AMH
3. FSH
Ovarian volume/ovarian blood flow/InhibinB/E2 are not used to predict
fertility outcome

50. Dynamic tests of Ovarian Reserve
Clomiphene citrate challenge test(CCCT)
• 100mg Clomiphene citrate given from days 5-9
• Day 3 and day 10 FSH levels measured
• Elevated day 10 FSH indicates DOR
Mechanism : less negative feedback on clomiphene induced pituitary
release d/t less inhibin B and E2 release by the smaller follicular cohort of
aging women
Speroffs Clinical Gynaecologic Endocrinology 8th ed

51. 1. Clomiphene citrate challenge test (CCCT)
2. GnRH agonist stimulation test (GAST)
3. Exogenous FSH ovarian reserve test (EFORT)
• A positive test (abnormal CCCT) did not provide
convincing evidence of non-pregnancy
• Diagnostic accuracy of GAST and EFORT could not be
calculated
CONCLUSIONS-Inaccuracies in defining normality,
dynamic ORT should be abandoned
Maheshwari A et al,RBM 2009

52. Uterine factors
Uterine factors in
infertility
10-15%
Congenital uterine
anomalies:
Defect in the
development or fusion of
paired mullerian ducts
Acquired uterine
abnormalities:
Endometrial polyps
Fibroids
Adenomyosis
Intrauterine adhesions

53. Evaluation of Uterine Factors
HSG:
• Identifies uterine anomalies/submucous
polyps/intrauterine adhesions
TVUS/SIS:
• Identifies important uterine pathology
but no useful measure about
endometrial function/receptivity
HYSTEROSCOPY :
• GOLD STANDARD
• Direct visualisation of uterine
cavity
MRI:
• Non-invasive with 100% sensitivity
• Added advantage of identifying
urological abnormalities

54. UTERINE EVALUATION
HSG
Intrauterine
filling defect
Hysterographic
USG
Submucosal
fibroid
Adhesions
Endometrial
polyp
Uterine contour
abnormality
Pelvic USG Pelvic MRI
Fibroid
Adenomyosis
Mullerian duct
anomaly

55. Hysteroscopy
IU adhesions Uterine polyp
Uterine septum

57. Congenital uterine anomalies
• Associated with pregnancy loss and obstetrics complications
• Not infertile
• Prevalence 2-4% in fertile and infertile women
• Septate(35%)> bicornuate(26%)> arcuate(18%) > didelphys(8%)> agenesis(3%)
LBRs before hysteroscopic septal resection-10% & after resection 75-80%
Joesph et al,Reproductive outcomes after septal resection,Journal of Obstetrics and Gynaecology,2014

58. Uterine Myomas
• 5-10 % infertile women
• Interferes with implantation
• Submucous myomas reduce success rates in IVF by 70%,
intramural myomas by 30% and subserosal myomas no effect
Pritts et al.,Fertil-Steril 91:1215-23,2009

59. Submucosal Fibroids
The European Society of Hysteroscopic classification of submucosal
fibroids:
Type 0: Complete protrusion of a pedunculated fibroid into cavity
Type 1: sessile myomas with <50% of mass in the myometrium
Type 2: >50% of fibroid within the myometrium
Hysteroscopic myomectomy is the Gold standard treatment for
submucosal fibroids
Pritts et al.,Fertil-Steril 91:1215-23,2009

60. HSG-large intrauterine filling defect due to a large submucosal leiomyoma
MRI demonstrates a region of heterogeneous increased signal intensity that represents a fundal
intramural fibroid (arrow) with a submucosal component (arrowhead).

61. Endometrial Polyp
• Prevalence- 6 to 32% in infertile women
• Effect on embryo implantation &infertility is uncertain
• Diagnostic modalities:
TVUS:Appears hyperechoic
Colour doppler shows feeder vessel
Hysteroscopy: Gold standard
SIS and Hysteroscopy are equally sensitive in terms
of their diagnostic accuracy
Lieng et al.,Trestment of endometrial polyps,Acta Obstet Gynecol Scand,2010

62. Endometrial Polyp
(a) HSG- well-circumscribed ovoid IU
filling defect
(b) USG posterior fundal polyp
(c) Color Doppler central feeding vessel

63. Adenomyosis
• Poor reproductive outcomes due to disordered uterine peristalsis
and disruption of endo-myometrial junction zone (JZ)
EVALUATION
 TVUS:
• Specific feature: presence of myometrial cysts
• Most sensitive feature:heterogenous myometrium
 MRI:
• Thickened JZ in adenomyosis

64. Adenomyosis
HSG saccular contrast material protruding beyond normal
contour of the endometrial cavity
USG globular uterine enlargement with asymmetric thickening and
poor definition of endomyometrial
junction

65. Intrauterine Adhesions
(a) HSG linear intrauterine filling defects
(b) SIS- multiple uterine synechiae

67. Intrauterine Adhesions
• Hysteroscopic adhesiolysis is the treatment of choice
• Unmedicated IUDs and balloon catheters used in immediate
post op period to maintain seperation
• Best results with balloon catheter
• Post op exogenous estrogen-efficacy not been established

68. Evaluation of Peritoneal factors
ENDOMETRIOSIS :
• 25-40% in infertile women
• Distorted pelvic anatomy
• Altered endometrial receptivity/ implantation
• Altered peritoneal function
Evaluation :
• USG
• MRI

69. Imaging Modalities
TVS
Adnexal masses :
• Sensitivity: 64-89%
• Specificity:89-100%
• Can elicit probe tenderness and
ovarian mobility - advantage over
MRI
Rectal endometriosis
• sensitivity: 91%
• specificity: 98%
• Useful for identifying and ruling
out rectal endometriosis
Usefulness of 3D sonography
not well established
MRI
• Sensitivity – 83%
• Specificity- 98%
• Usefulness of MRI not well
established for diagnosis
• Useful for detection of
deep endometriosis;
rectosigmoid, bladder
endometriosis
Hudelist et al., Ultrasound Obstet Gynecol 2011. 37:257-263
Benacerraf et al., J Ultrasound Med 2012. 31:651–653

70. Usg features of endometrioma
• Ground glass echogenecity
• 1-4 compartments
• No papillary projections with
detectable blood flow
ESHRE Endometriosis Guideline Development Group,2013

71. Cervical Factor
• Rarely the sole or principal cause of infertility
Post coital test for the diagnosis of cervical factor is no longer
recommended - NICE 2013

72. Unexplained infertility
Includes :
• Normal semen quality
• Ovulatory function
• Normal uterine cavity
• Bilateral tubal patency
More common in women >35 yrs
Causes :
Abnormalities in zona pellucida
Genetic defects in centrosome
Age of the female and duration of infertility affect pregnancy rates
NO VALID DIAGNOSTIC TEST
Speroffs clinical gynaecologic endocrinology 8th ed

73. Take home message
• Evaluation of an infertile female depends on the resource settings
of the country
• Institution based standardized guidelines
• Avoid aggressive treatment or inappropriate recommendations in
women with normal ovarian reserve
• History and physical examination –vital role
• Baseline screening for general health and ANC
• Tests of ovulation and tubal patency correlate with pregnancy
outcome
• Hormone assays are not recommended routinely
• Tests for ovarian reserve not recommended
• Endometrial biopsy/aspirate is done not to document ovulation but
to rule out tuberculosis

74. THANK YOU!