- Age: Fertility is at its peak between the age of 20–25 years. It declines rapidly after the age of 40 years of age.
- Duration of marriage: Problem regarding coitus and contraception.
- A general medical history should be taken with reference to tuberculosis, sexually transmitted disease or any pelvis inflammatory diseases.
- Menstrual history should be taken in details.
- Previous obstetric history–including number of pregnancies, the interval between the two pregnancies is to be enquired.
- Sexual problems such as painful sexual intercourse and loss of libido are to be enquired. There may be some psychosomatic reason.
- General examination must be thorough–Any recent changes in weight like obesity or marked reduction in weight are to be noted. Abnormal distribution of hairs or underdevelopment of secondary sex characters are also to be noted.
- Systemic examination may accidentally detect abnormalities like hypertension, organic heart disease, chronic renal lesion, endocrinopathies and alike.
- Gynecological examination includes –adequacy of hymeneal opening, any vaginal infections, cervical tear or chronic infection. Undue elongation of the cervix, uterine size, position and mobility, presence of unilateral or bilateral adjoining abnormal masses. Examination may reveal abnormal cervical discharge. The discharge is to be collected for Gram stain and culture.
Ovarian dysfunctions (dysovulatory) commonly associated with infertility are:
- Anovulation or Oligo–ovulation (infrequent ovulation).
- Corpus Luteal Insufficiency (CLI).
The various methods used in practice to detect ovulation are grouped as follows:
- Menstrual History.
- Evaluation of peripheral or endorgan changes due to estrogen and progesterone.
- Any gonadotrophins or steroid hormones preceding, coinciding or succeeding the ovulatory process.
The following should be noted:
- Regular normal menstrual loss between the age of 20–35.
- Mid–menstrual bleeding (spotting) or pain or excessive mucoid vaginal discharge.
- Premenstrual syndrome or primary dysmenorrhoea (Painful menses).
Basal Body Temperature (BBT)
There is “Biphasic pattern” of temperature variation in ovulatory cycle. In the 2nd half of the menstrual cycle there is rise in the body temperature by approximately 5degree C. The temperature falls 24–48 hours before the onset of menstrual flow and remains at a lower level during the first half of the cycle. But in anovulatory cycle, there is rise of temperature throughout the cycle. If pregnancy occurs, the rise of temperature sustains along with absence of the period .
Endometrium showing secretary changes in the second half of the cycle gives the diagnosis of ovulation. Tuberculosis is a common reason for blockage of the fallopian tube. Curettage is to be done on 21–23rd day of the cycle. Barrier contraceptive should be prescribed during the cycle to prevent accidental conception. However, if the cycle is irregular, it is done within 24 hours of the period.
Cervical Mucus Test
Alteration in the properties of the cervical mucus occurs due to the effect of estrogen and progesterone. Disappearance of fern pattern beyond 22nd day of the cycle which was present in the mid cycle is suggestive of ovulation. Persistence of fern pattern even beyond 22nd day also suggests anovulation. Progesterone causes dissolution of the sodium chloride crystals. Following ovuation there is loss of this fern pattern which was present in the mid cycle.
Maturation index shifts to the left from the mid cycle to the mid second half of cycle due to the effect of progesterone. However, a single smear on day 25 or 26 of the cycle reveals features of progesterone effect if ovulation occurs.
Serum progesterone: Estimation of serum progesterone is done on day 8th and 21st of a cycle. An increase in value from less than 1 ng/ml to greater than 5 ng/ml suggests ovulation. Serum Leutinizing Hormone– Daily estimation of Serum Leutinizing Hormone at mid cycle can detect the Leutinizing Hormone surge and the ovulation is expected within 24 hours. Serum estradiol (a hormone) attains the peak rise approximately 24 hours prior to LH surge and 48 hours prior to ovulation. The serum LH and oestradiol estimation is used for in vitro fertilization.
Sonography during midcycle can accurately measure the Graafian follicle just before ovulation (15–20 mm). It is particularly helpful in the initiation and verification of ovulation, artificial insemination and in vitro fertilization.
Laparoscopic visualization of recent corpus luteum or detection of the ovum from the aspirated peritoneal fluid from the pouch of Douglas (pouch between rectum and uterus) is the only direct evidence of ovulation.
It is done in cases of:
- Abnormal HSG findings.
- Failure to conceive after reasonable period even with normal HSG.
- Unexplained infertility.
In this Air or Carbon Dioxide gas is injected into the uterine cavity under pressure. If both the tubes are blocked, there is no leakage of the gas and its pressure in the manometer is maintained.
This test is carried out in the second half of the cycle.
Limitation–Not to be done in the presence of pelvic inflammatory disease.
This is a test for patency of the Fallopian tubes. In this test a radio–opaque dye is injected into the uterine cavity and radiographs are taken. It is the same as insufflation test. Instead of air or C02, dye is instilled transcervically.
It is done when insufflation test is negative. It can precisely detect the side and site of block in the tube. It can reveal any abnormality in the uterus (congenital or acquired like fibroid). But it cannot be done in presence of any bacterial infection of the pelvic organ.
This includes hormonal treatment of anovulation, corpus luteum insufficiency, hyperprolactinaemia and thyroid dysfunction. Endometriosis is to be treated. Genital tuberculosis should be treated adequately.
Tubal surgery: Tubal plasty is done which is a finer surgery on the fallopian tubes. Uterine surgery: Operation on the uterus. Cervical operation: Cauterization of the cervix is done in cases of excessive leucorrhoea or in presence of erosion or chronic infection of cervix. (cervicitis) Also Vaginal operations.