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Age, duration of marriage, history of previous marriage with proven fertility if any, are to be noted. Any treatment and investigations of infertility carried out in the past. The surgical history should be directed specially towards abdominal or pelvic surgery. General, systemic and gynecological examinations are made to detect any abnormality which may hinder fertility. Special Investigations
Ovarian Factors
Ovarian dysfunctions (dysovulatory) commonly associated with infertility are: Diagnosis of Ovulation
The various methods used in practice to detect ovulation are grouped as follows:
Indirect Menstrual History:
The following should be noted: Evaluation of Peripheral or Endorgan Changes
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 .
Endometrial Biopsy
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.
Vaginal Cytology
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.
Hormone Estimation
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: Insufflation Test
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.
Hysterosalpingography (HSG)
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.