1. INVESTIGATIONS

2. Infertility one year or
longer
Initial evaluation , history
,physical examination
Irregular Unilatera or Structural Abnormal
Normal
menses,no bilateral endometria semen
evaluation
ovulation tube block abnormality analysis
Uterine Male
Anovulation Tubal factor Unexplained
factor factor
Counselling and psychosocial support
Multiple factors – investigate and manage

3. HISTORY
• Age
• Duration of marriage
• Menstrual history
• Past obstetric history – PROM , puerperal sepsis
• Previous use of contraceptives and its type
• Medical History - tuberculosis , pelvic infection
, STD ,diabetes , thyroid dysfunction .
• Surgical history

5. CLINICAL
EXAMINATION
• Height and weight
• Blood pressure
• Features of hirsuitism
• Galactorrhoea
• Palpation of thyroid
• Breast and lymph nodes
• Abdominal examination

6. GYNAECOLOGICAL
EXAMINATION
• Examination of perineum
• Speculum examination

7. INVESTIGATIONS FOR
CERVICAL FACTORS
• POST COITAL TEST / SIMS TEST / HUHNERS
TEST
• MILLER - KURZROK TEST
• SEMEN CERVICAL MUCUS CONTACT TEST

8. POST COITAL TEST
Done on day 12 or 13 of menstrual cycle.
Report to clinic within 8 hours of intercourse
Endocervical mucus is collected and placed on a slide
Number and motility of sperms seen under microscope

11. MILLER KURZROK TEST
Cervical mucus of the wife at the time of ovulation is placed
on slide
Semen of the husband is placed alongside
Penetration of the sperms is studied under microscope

12. MILLER KURZROK TEST

13. SEMEN CERVICAL MUCUS
CONTACT TEST
• A test for anti sperm antibodies .
• The sperm and mucus are mixed and sperms
viewed under microscope for characteristic
shaky movement.

14. Wife’s mucus+ donor Abnormal Abnormal Normal
semen
Husband’s semen+ Abnormal Normal Abnormal
donor mucus
Inference Problem in Wife’s Immunologic
both mucus problem in
abnormal male

15. INVESTIGATIONS TO
DETECT TUBAL PATENCY
• HYSTEROSALPINGOGRAPHY
• LAPROSCOPIC CHROMOTUBATION
• SONOSALPINGOGRAPHY
• HYSTEROSCOPY AND FALLOSCOPY
• AMPULLARY AND FIMBRIAL
SALPINGOSCOPY

16. HYSTEROSALPINGOGRAPHY
• To visualize uterine cavity and fallopian tubes
• Done on day 10 of menstrual cycle
PROCEDURE
Atropine is
Clean the lower genital tract given 30
min before
Radiopaque dye injected procedure
through cannula
Radiographic pictures taken

19. LAPAROSCOPIC
CHROMOTUBATION
• To visualize pelvis , fallopian tubes and ovaries
and to verify HSG findings.
• Peritubal adhesions and unsuspected
endometriosis can be diagnosed.
• Indicated in patients with blocked fallopian
tubes prior to tubal microsurgery.
• Advantage – can proceed with therapeutic
procedure.

21. SONOSALPINGOGRAPHY
• Less side effects.
• Good technique to detect submucous fibroid
polyp and intrauterine lesions.
PROCEDURE
Under ultrasound scanning slow injection
of 200ml of physiological saline through
Foleys catheter.

22. HYSTEROSCOPY AND
FALLOSCOPY
• To study the interstitial end of fallopian tube.
• ADVANTAGES
- Mucus plug or inspissated material can be
flushed out.
- Polypus can be removed.
- Synechiae can be broken.

23. AMPULLARY AND FIMBRIAL
SALPINGOSCOPY
• To study the mucosa of fallopian tube.

24. DILATATION AND
INSUFFLATION
• Also known as RUBINS TEST
• Performed 2days after menstruation stops.
• PROCEDURE – air or carbondioxide is pushed
transcervically under pressure .
• Not commonly done now.

25. TESTS OF OVULATION
• BASAL BODY TEMPERATURE
• ENDOMETRIAL BIOPSY
• FERN TEST
• ULTRASOUND
• HORMONAL STUDY

26. BASAL BODY TEMPERATURE
• Falls at time of ovulation by 0.5 F.
• In progestational half temperature is raised
above preovulatory level by 0.5 – 1 F.
• Presumptive evidence of functional corpus
luteum.
• Has now become obselete .

28. ENDOMETRIAL BIOPSY
• Curetting small pieces of endometrium 1 or 2
days before onset of menstruation.
• Histological scrutiny done after fixation in
formalin saline
• Subjected to culture – rule out genital TB
• Not done routinely

29. FERN TEST
• Specimen of cervical mucus spread on slide and
viewed under low power microscope .
• Oestrogenic phase – fern formation.
• After ovulation ferning disappears.
• At ovulation – ovulation cascade and spinnbarkeit
or thread test .
• Secretory phase – spinnbarkeit disappears and
tack appears.
• Insler scoring system

32. ULTRASOUND
• Standard procedure for monitoring
maturation of graafian follicle .
• ADVANTAGES
Non invasive accurate and safe.
Pelvic pathology can be picked up .
Endometrial thickness can be measured .

35. HORMONAL STUDY
• PLASMA PROGESTERONE
• LUTEINIZING HORMONE
• HYPERPROLACTINAEMIA
• FOLLICLE STIMULATING HORMONE
• THYROID TESTS

36. Ovarian disorders
Infrequent menses Signs of
Signs of decreased High day 3 FSH hyperandrogenism
estrogenization Abnormal CCCT Oligomenorrhoea
High FSH , LH Advanced age Anovulation
Premature ovarian Decreased ovarian Polycystic ovarian
failure reserve syndrome
Assess for and Brief trials of
Ovulation
treat secondary superovulation or
induction
causes IVF
ART ART

37. INVESTIGATIONS FOR
UTERINE FACTORS

39. THANK YOU
A presentation by
- Athira P.A
(final year: JUGGERNAUTS)