Male and Female Infertility Including ART

Ideally, the couple need to be investigated together. Since it is known that in African settings, in 30 – 40% of infertile couples, both husband and wife have discernible problems. Proper counselling on the need for these investigations should be offered.

Efforts should be made not to over or under prognosticate the chances of the couple. Where it may not be possible to start with the couple together, the woman can start her own investigations pending the time the husband could be invited and investigated.

Investigation of the infertile couple should start with general investigations such as haemogrammes (including ESR), urethral, cervical or high vaginal swab, urinalysis, urine culture and sensitivity.

• Semen analysis
• Hormonal evaluation
• Special sperm function tests
• Tests of ovulation
• Tests of tubal patency

Semen Analysis

Semen analysis is the specific investigation for male infertility and should be done early. It should be stressed that 2-3 tests should be done at least 1 month interval before a conclusion could be reached as to the normality of the test especially if a subnormal result was obtained.

The semen sample is normally obtained after 3-5 days of abstention. The sample obtained by masturbation is better for analysis than that obtained by withdrawal method or with the aid of condoms as these contain spermicides.

The sample is collected in a sterile wide mouthed container and should be sent to the laboratory within 2 hours. Parameters such as volume, colour, pH value, consistency, spermatozoal count per ml, motility and morphology of spermatozoa and fructose contents are examined.

The sperm sample could also be cultured for microorganisms when indicated and the sensitivity pattern to antimicrobials shown.

The computer-assisted semen analysis (CASA) systems couple video technology and sophisticated microcomputers for automatic image digitalization and processing. This technology was developed for more objective assessment of seminal parameters over the subjective measurements of standard semen analysis. CASA permits the measurements of additional motility parameters such as curvilinear velocity, straight line velocity, linear and flagellar beat frequency.

Semen with volumes <1ml or >6mls per ejaculate, density <15 million/ml or >250 million/ml, poor motility and morphology may be incompatible with normal fertility.

Hormonal Evaluation

• Routine evaluation of hormonal parameter is not necessary unless sperm density is extremely low or there is clinical suspicion of an endocrinopathy.
• The incidence of primary endocrine defects in infertile men is less than 30%. Such defects are rare in men with a sperm concentration of >5 million/ml.
• When an endocrinopathy is discovered, specific hormonal therapy is often successful. Follicle Stimulating Hormone(FSH), Luteinizing Hormone(LH), Testosterone and Prolactin levels are checked to differentiate hyper or hypogonadism, primary and secondary testicular failure as well as obstructive lesions.
• In men with a history of precocious puberty, one should consider Congenital adrenal hyperplasia (CAH), hence serum levels of 17-OH progesterone are evaluated. Other pituitary hormones like ACTH, TSH and GH could be assessed but this is rarely necessary.

Chromosomal studies

• Chromosomal studies may be specially indicated in men with small testes, azoospermia and elevated FSH levels to look for both autosomal and sex chromosomal abnormalities.

Antisperm antibodies

• Antisperm antibodies, though not an absolute cause of infertility, may reduce the likelihood of pregnancy.
• These antibodies may impair sperm function by attaching to the plasma membrane of the spermatozoa, encouraging sperm agglutination particularly in the presence of infections. Antisperm antibodies should be suspected in couples who persistently have abnormal post-coital tests. Immunological factor may be responsible for up to 20% of unexplained infertility.

Special Sperm Function Tests

1. Sperm-cervical mucus interaction (post-coital test, PCT)
• This test assesses the ability of sperm to penetrate and progress through the cervical mucus. Cervical mucus is examined 2-8 hours after intercourse at the time of expected ovulation.
• The presence of greater than 10-20 motile sperms per high power field is generally accepted as a normal PCT.
• PCT is a bioassay that provides information concerning sexual function, sperm motility and sperm-mucus interaction. A positive result implies normal semen and mucus.
• A poor result in an individual with normal semen parameters implies either cervical abnormalities or the presence of sperm antibodies.
2. Sperm Penetration Assays.
• Penetration of an oocyte requires sperm capacitation, acrosome reaction, fusion and incorporation into the oocyte. Cross-species fertilization is normally prevented by the zona pellucida.
• Hamster eggs stripped of the zona pellucida can be penetrated by human sperm. This in-vitro functional test measures the penetration ability of the sperm.
• The end point of this assay is penetration of the ovum and decondensation of sperm heads. The percentage of oocytes penetrated and the number of sperm penetrating each oocyte are measured. Sperm that are capable of multiple penetrations per oocyte appear to have greater fertilizing potential than sperm that do not penetrate.
• The result of the sperm penetration assay (SPA) have primarily been used to predict the results of assisted reproductive technique, in particular, in-vitro fertilization.
• Men with sperm of low SPA score are less likely to achieve a spontaneous pregnancy than those with a high SPA score. However, abnormal penetration does not indicate that fertilization cannot occur, nor does good penetration assure fertilization.
• Generally speaking, less than 10% penetration is evidence of sperm dysfunction and male infertility. Although the SPA is a reliable indicator of the fertilizing capacity of human spermatozoa, it does not predict the ability of sperm to bind to and penetrate zona pellucida or the sperm’s motility and progression in the female reproductive tract.

Tests Of Ovulation

The regularity of a menstrual cycle does not confirm occurrence of ovulation, though most women who have regular cycles tended to ovulate regularly.

Tests of ovulation are numerous including

• Basal Body Temperature(BBT),
• Endometrial biopsy,
• Hormonal Assay,
• Serial ultrasound folliculography,
• Cervical mucus and vaginal cytological changes.

However, the only confirmatory evidence of ovulation is pregnancy or observation of the corpus luteum during laparascopy.

1. Basal Body Temperature.
• In this environment, BBT is usually reserved for literate and well motivated patients.
• Temperatures should be taken at the same time each day and by the same route, preferably just after rising from sleep each morning taken either by axillary method or oral route.
• A BBT chart is kept on daily basis and a biphasic pattern suggests that ovulation had occurred.
• In ovulatory cycles, the elevated temperatures post-ovulatory is brought about by the thermogenic effect of progesterone as opposed to monophasic temperature pattern in anovulatory cycles.
2. Endometrial Biopsy.
• Endometrial biopsy is commonly used to determine the occurrence of ovulation.
• A histological examination of an endometrial sampling on day 21 or 23 of the menstrual cycle will show secretory endometrium in ovulatory cycles compatible with the day of endometrial sampling while simple hyperplasia or atrophic changes will be seen in anovulation.
• An added advantage of this method is that it also permits the diagnosis of tuberculous endometritis and luteal phase deficiency. Inadequate or improper endometrial sampling could lead to errors in reporting.
3. Hormone Assays.
• Serum progesterone assay using radioimmunoassay technique measures progesterone levels on day 21 or a progesterone index (mean value of days 20,21,22 samples).
• There is inter-laboratory variations but values less than 10 mmols/l are unsatisfactory. Low levels (< 5mmols/l) will suggest anovulation while values between 5-10mmols/l may suggest luteal phase defect.
4. Serial Ultrasound Folliculography
• This has now been made easier with the use of sector scanner and a vaginal probe.
• Serially, the ovaries are scanned from the beginning of the menstrual cycle when the follicles measure on an average 3-5mm to the peri-ovulatory period where diameters of up to 20-23mm could be obtained.
• Usually a dominant follicular diameter of >16mm is highly suggestive that ovulation will occur.
• Following ovulation, the follicular diameter will diminish due to the discharge of its contents and eventual transformation into a corpus luteum.
• Serial ultrasound folliculography is extremely useful in monitoring ovulation during induction of ovulation and assisted reproductive techniques.
5. Cervical mucus and vaginal cytological changes
• They are not routinely used in clinical practice in our environment.
• However, a semi-quantitative estimation of four parameters – the amount of cervical mucus, spinnbarkeit (threadability), crystallization capacity of the mucus and the degree of opening of the external os corresponds well with the hormonal interplay during the index menstrual cycle.
• Each of the parameters may receive a score of 0-3 points with the total score being 0-12 points.
• Since the amount and type of mucus produced by the endocervical mucosa are under hormonal control, the cervical score is an indirect indicator of relative levels of estrogen and progesterone.
• Estrogen stimulation results in a high score while progesterone results in a low cervical score.
• A low cervical score indicates either lack of estrogen or a high progesterone level and a high score (>8 points) indicates distinct estrogen stimulation unopposed by progesterone action.
• During a normal ovulatory cycle, the cervical score is low at the beginning, becomes positive 5-7 days before the temperature nadir, increases steadily during the pre-ovulatory period reaching a high plateau within 2-3 days of ovulation, declines 1-3 days following the temperature nadir, and becomes negative 5 days after ovulation.
• Vaginal cytology can also be used to monitor ovulation period. Local inflammation, douching and insertion of foreign bodies can alter the results obtained.
• The presence of multilayered navicular cells with interstitial oedema in the vaginal cytology smear may suggest progesterone dominance following ovulation.

Tests Of Tubal Patency

Several tubal patency tests exist involving insufflation with air, water or carbondioxide. These are simple, cheap and easy to perform but it has been shown that these methods are grossly inadequate, and the WHO recommend that they should be abandoned even as a screening procedure.

Laparascopy plus dye hydrotubation is regarded as the ‘gold standard’ for the assessment of tubal patency. Moreover, this procedure may disclose other unsuspected infertility factors such as endometriosis and pelvic adhesions. However, laparascopy requires hospital admission, anaesthesia and a fully equipped operating room.

Hysterosalpingography (HSG), conversely, remains a safe and simple procedure that outlines the lumen of the uterine cavity and the fallopian tubes. HSG and laparascopy are found to be similar in 80% of cases with a similar number of false positives and false negatives. HSG thus remains the best screening test in our environment. The ideal technique, however, requires a television fluoroscopy monitor which is not readily available in many third world countries. A simplification of the technique was found in a plain X-ray of the pelvis taken 15 minutes after the injection of contrast material and this has been shown to have a good correlation with the findings of a complete HSG.

note

Timing of Investigations

This is necessary in order to reduce time wastage in the investigation and treatment of the infertile couple. It is recommended that these tests could be completed within a single month of a menstrual cycle and the results provided to guide treatment during the next menstrual cycle.

Following the initial assessment of the couple in the day preceding the onset of menses, a semen analysis could be ordered. BBT can be started on the first day of her menses while Hysterosalpingogram (HSG) can be done between days 7-11 and a PCT on day 14.

Laparascopy dye test, endometrial biopsy and hormone assays could be performed on day 21. The results of these tests would now form the template upon which further assessment and treatment would be based.