GUILDE TO INFERTILITY INVESTIGATIONS

The philosophy of care in any infertility clinic should be a success oriented approach (getting infertile couples pregnant) rather than the usual problem oriented approach (doing endless, useless and unnecessary investigations) as is the norm in our environments these days.
In a problem oriented approach, a lot of time, money and effort would be wasted by the doctors concentrating on a long list of useless and fanciful tests and investigations. Many of these investigations do not affect the treatment or the outcome of the treatment options.
It is bad enough being infertile, but for the infertile couples to go through endless tests and investigations that add no value to the outcome of any treatment option DRAINS them emotionally and financially.
Keeping the investigations complex however helps some clinics to justify the abnormally high fees they charge to reach a diagnosis.
Couples that come to doctors for infertility want to have babies, not unnecessary extended investigations and having to wait too long in achieving their objectives.
Every infertility investigations protocol should ideally be easy, simple, safe and less stressful with a proper diagnosis and successful treatment (having babies) achieved.

Criteria for Getting Pregnant Naturally.

There are basically 5 criteria for achieving pregnancy naturally.

• The sperm of the man must be of adequate quantity and quality.

• Sex should occur around the ovulation period (fertile period) of the woman.

• The inside of the woman’s womb should be able to keep and maintain a pregnancy. Nothing inside should be able to disrupt a pregnancy.

• The fallopian tubes should be open on both sides, so that the eggs produced on the ovary can meet with the sperm.

• The ovaries must be producing quality eggs regularly (monthly)

From the above criterion, it would be easy to see that the essence of any infertility investigation is to check out these 5 requirements and confirm they are all working well.
About 95% of infertile couples would first see their general practitioners before seeing an infertility expert. It is therefore important that there is a guide on what the GP should do at this level as frontline doctors.
About 45% of infertile couples will get pregnant by themselves, by changes in their lifestyles and by the standard gynaecological treatment. However, 60% will require some form of assisted conception such as Intrauterine Insemination (IUI), Invitro fertilisation (IVF) etc at a specialised infertility centre. It is important for the GP to know when to refer to an infertility specialist so that time, money and effort are not wasted.

GP Guideline in Infertility Management

The frontline general practitioner should try as much as possible to see the couples together. Both should be involved in the management of their infertility.
A detailed history including drug and examination of the couple is mandatory.
The GP should advise every woman presenting with infertility to take folic acid as a supplement whilst they are trying to conceive and at least during the first 12 weeks of a pregnancy in order to prevent neural tube defects. The dose should be increased in women who have previously had an infant with neural tube defect or who have epilepsy and are on medications.
Environmental factors can affect infertility and therefore an occupational history should be taken as part of infertility investigations.

General Advice GP Should Give to Infertile Couples.

Women complaining of infertility should be advised to give up smoking if they do smoke.
Men who smoke should be advised to stop in order to remove one variable that may affect their infertility.Women should be advised not to drink more than one or two units of alcohol once or twice a week when trying to become pregnant.
In men there is evidence that excessive drinking can adversely affect reproductive function and general health, therefore men who drink excessively should be advised to limit their drinking.Any woman with a body mass index > 30 should be advised to loose weight whether ovulating or not.
Although weight loss in overweight men will improve their general health, there is little evidence to suggest that this will improve fertility.
Men with poor quality sperm should be advised to wear loose fitting underwears and trousers and avoid occupational or social situations that might cause testicular overheating.There is no evidence that the use of temperature charts and ovulation kits to time intercourse improves infertility outcome. There use should be discouraged. Couples should be advised instead to have REGULAR intercourse 2-3 times a week throughout their cycle.

Initial Investigation at GP Clinic

The male partner should have 2 semen analysis performed during the initial investigation. The laboratory that performs the semen analysis should undertake the analysis according to recognised WHO methodology. The laboratory should also practice internal quality control. The GP should try and send the sample to the same laboratory used by specialist infertility clinics.
Whilst regular menstruation is strongly suggestive of ovulation, this should be confirmed by the measurement of serum progesterone in the mid luteal phase (Day 21 progesterone)
There is no VALUE in measuring thyroid function or prolactin in women with a regular menstrual cycle, in the absence of galactorrhea (milk from the breast)
or symptoms of thyroid diseases.

When Should a GP Refer to Infertility Specialist?

For the sake of the infertile couples a general practitioner should consider an early referral to infertility specialist if the woman is aged 35 years and above. An early referral to an infertility specialist is required when the woman is not seeing her periods, or when her period is scanty and irregular (amenorrhea & oligomenorrhea). The GP should refer if the woman has a previous history of abdominal or pelvis surgery (e.g. fibroid opx), if there is a history of sexually transmitted diseases and if there is an abnormal pelvic examination.
The GP should consider early referral when the man has a previous genital disease, a previous urinary or genital surgery. A previous sexually transmitted disease, a varicocele or any significant systemic illness and if there is an abnormal genital examination.
Further Investigation in a Specialised Infertility Clinic
Further management of infertile couple should be in a specialised infertility clinic staffed by an appropriately trained multi professional team with facilities for investigating and managing problems in both partners.
GPs should endeavour to refer patients to such clinics and patients should request that they be referred to such clinics. GPs should continue to offer ongoing support to the couples after the referral.
The female should normally have a test of tubal patency. A Hysterosalpingogram (HSG) or a salime Sono Hysterogram may be used as a screening test for tubal patency. A diagnostic laparoscopy and dye test is however the procedure of choice to properly evaluate the pelvis.
Before any uterine instrumentation at the GPs or infertility centres, a screening for sexually transmitted diseases especially Chlamydia should be performed and any infection should be appropriately treated.
An Ultrasound scan (Abdominal and Vaginal) to properly evaluate the uterus and the ovaries is very essential.

Non Essential Investigation in Routine Infertility Management

An endometrial biopsy (D&C) to evaluate luteal phase should not be performed as part of routine investigation of the infertile couple.
The so called “Tubal flushing” or Hydrotubation has no place in the modern investigation or treatment of infertile couple. Apart from the fact that it is rarely successful, it causes discomfort and could actually disseminate genital infection into full blown PID
The post coital test is not recommended in the routine investigation of infertile couples.
Sperm function test are specialised tests and should not be used in routine investigations of infertile couple (Routine semen analysis is sufficient)
Routine testing for antisperm antibodies in semen is not recommended.
Hysteroscopy should not be considered in routine investigation.

Guide to Semen Collection and Normal Values

Before the man goes for his semen collection, he should have abstained for 2 to 3 days. The sample is preferably produced by masturbation, rather than by coitus interruptus. The sample should not be collected in condoms. A wide mouthed sterile plastic specimen pot should be used in the collection. The plastic container should be marked with the name, date and time of production. Delivery of the specimen to the laboratory as soon as possible within one hour is essential. The sample should be protected from the extreme of temperatures e.g less than 15oc or above 38oc during the transportation.

WHO values for ‘normal’ semen analysis
The WHO values should be the basis of any referrals from GP to the infertility specialist.
The volume should be between 2 to 5 mils.
The liquefaction time should be within 30mins.
The sperm concentration (or count) should be above 20 million per ml.
The sperm motility should be over 50% having progressive motility.
The shape (morphology) of the sperm should at least be over 30% with normal forms.
The white blood cells suggestive infections should be less than 1 million per mil.
In conclusion, with these basic investigations a diagnosis of the cause of infertility should easily be reached and an appropriate management options outlined for the couples. There is no need for endless repetitive investigations that wear out the couples and sometimes the medical team.
The philosophy of care must always remain success oriented rather than problem oriented.