Subfertility when to invsigate

Prevalence  ofsubfertility & when to initiate investigations?

What are the usual Investigations of subfertility & investigations  at pre-Ovulation induction : What are the salient features:-

Q,1: Has prevalence has increased?  No.,It Hs not increased . The overall incidence of infertility has remained stable.

Q.2:-When to initiate the investigations??  Ans:-The infertility evaluation is typically initiated after 1 year of trying to conceive, but in couples with advanced female age (> 35 years), most practitioners initiate diagnostic evaluation after an inability to conceive for 6 months. But, Investigations of Infertile couple should ideally be initiated after only after a provisional diagnosis from history &Clinical Examination so that the investigations are streamlined.

Q.3:-What tests??  Ans:-The Practice Committee of the American Society for Reproductive Medicine (ASRM) has published guidelines for a standard infertility evaluation. It includes a 1)  semen analysis, 2) assessment of ovulation 3) a hysterosalpingogram, and, if indicated, tests for 4) ovarian reserve and laparoscopy.

Q.4:-What is the definition of unexplained subfertility??  Ans:-When the results of a standard infertility evaluation are normal, practitioners assign a diagnosis of unexplained infertility. Although estimates vary, the likelihood that all such test results for an infertile couple are normal.

Q.5.  How to assess  of Ovulatory

Dysfunction?? Ans:-Ovulatory defects are present in 40% of infertile women and in approximately 15% of couples with infertility.  Often a defect in ovulatory function manifests itself in menstrual disturbances and can be identified by history in the majority of women.

Q.6:-What tests to order  if someone complains of menstrual abnormalities?? Ans:-   A patient with menstrual abnormalities should be investigated for underlying causes such as 1) polycystic ovarian syndrome, 2) thyroid disease, 3) hyperprolactinemia, and 4)  hypothalamic causes secondary to weight changes. My dear members  please do remember that  if menstrual pattern  is  eumenorrhea ( i.e. —normal menstrual cycles by history) then in such women. A highly accurate marker of ovulation is serum progesterone  is  that  serum progesterone will be > 3 ng/ml postovulatory.  But occasionally    an anovulatory levels of serum progesterone (< 3 ng/mL) are observed in only a very small minority of eumenorrheic patients.

Q.8: What are the Lab tets for ovulation besides history of regular cycles (eumenorrhea) ?? Ans:-In addition to a thorough menstrual history, other methods used to evaluate ovulation include urinary luteinizing hormone (LH) ovulation predictor kits, mid luteal serum progesterone testing, and endometrial biopsy to assess for secretory endometrial development. Basal body temperature (BBT) recordings are no longer used in clinical practice although BBT recordings are the least costly tool in a reliable patient they are not difficult to interpret. But BBT methodology often initiates a frustrating situation for the patient.

Q. 11: Ovulation predictor kits are useful for women who do not have very long menstrual cycles and can be used by couples to appropriately time intercourse.

Q.12:-Mid luteal progesterone levels are measured but the question is when to estimate timing of progesterone level?? Ans: Around day 21 in women with regular (∼ 28 day) cycles. However, they are often poorly timed if they are drawn on cycle day 21 in women with irregular menses. In such women it is better to use an ovulation kit and measure the progesterone levels 7 to 8 days after the LH surge is detected. Serum progesterone levels higher than 3 ng/mL suggest that ovulation has occurred and levels higher than 10 ng/mL are optimum.

What about endometrial biopsy?? It is not done nowadays. Although endometrial biopsy results were previously used to diagnose luteal phase defect, they do not correlate with fertility status and hence are no longer recommended.

Q.12:- How to assess Ovarian Reserve?

Another test  which has been added in last two decades due to increased age of marriage & environmental pollution the prevalence of dwindling ovarian reserve is on the rise. So Ovarian reserve has been added to the workup of  subfertile couples . Such tets include is designed for women with advanced age, with evidence of endometriosis or history of prior ovarian surgery. Such women are  at increased risk for diminished ovarian function or reserve. Given the relatively noninvasive nature of the testing, several practitioners are including the evaluation of ovarian reserve as first-line workup for infertility. The testing includes a cycle 1)AFC 2) AMH  3) day 3 serum follicle-stimulating hormone (FSH) and estradiol level.

Very rarely clomiphene citrate challenge test is done  The caveat is  that the results of these tests are not absolute indicators of infertility but abnormal levels correlate with decreased response to ovulation induction medications and lowered live birth rates after IVF.