Basic Infertility Workup - Here’s what you need to know!

 

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So how do we do basic workup of infertility? We all know that the prevalence of infertility in India is not ranging between 3.9 to 12.6. It is much more than this. It is much more. And after COVID, it has really increased.

So how to go about? Look, so many times we can do only a good examination and seeing the patient once she enters, we know how to go about. For example, these are two types of patients. And I know as soon as I get a patient like this, who's an oldie, that even if she doesn't want to go for IVF, if she's around 40, we have no time to lose. Probably she should go for IVF, whatever eggs she's got, we have to utilise them. We all know that the fertility declines after the age of 35 years. The Indian women have menopause 5 to 6 years earlier than the Western world.

In fact, the Asian women. So, we have to learn to take action as soon as possible. We've already talked about the carrying angle, the web neck. So, we have to keep our eyes open once the patient is entering. This boy is typically looking like hypoandrogenism, PCOS we know. So, we have to see these features because so many times a patient enters my OPD clinic and the first question which I ask her is, what is your menstrual cycle? How often do you have it?

So menstrual history is important. Any history of overdue periods, how is the period like? I have already talked about the importance of temperature in a clinic who is doing infertility practise. ESR again is very important.

Even if you people are not doing your scans by yourself, the first step of practising infertility is start putting a TVS probe. It is very easy. But the more you do, the more you learn. Thyroid and prolactin, I have always, I've already talked that it is really important to get thyroid and prolactin done.

Now, as an infertility specialist, any TSH more than 2.5 should be treated. Right? Number two, if the TSH is anywhere between 2.5 to 6.7, I would just treat her by 12.5 L-Troxin. The medicine for thyroid should be taken empty stomach. It is like hit and try as well. Usually, my policy is if somebody's TSH is 50, I know it will click somewhere around 50, the dose of L-Troxin, but it is obviously hit and try. Once you start giving L-Troxin, you can call her after one and a half months and see that if she is in your range or not, and you can titrate. Increase and a little bit decrease is absolutely on to you. Number two, as far as prolactin is concerned, we have to understand that prolactin is an emotional hormone. Right? Why do people secrete prolactin when the baby feeds? So, the prolactin is secreted by the pituitary.

Yes, by the pituitary and this will help in milk release. So, if we do one sample of prolactin, the results might not come normal. I have seen prolactin as high as 180, but the next day when I did, the prolactin was absolutely normal.

So, one recommendation as an infertility specialist is that do a polled sample. Patient does not have to pay for the three samples. You have to take three samples or your lab person is instructed to take three samples at an interval of one hour so that if there is an emotional element in one sample, by the time second and third sample comes, you know, it's mixed and we get the average result.

Semen analysis again, it's very important as a basic workup, but I told you yesterday also that it is not just the semen analysis we do, we also do the culture simultaneously in the first visit itself. In fact, to tell you, our centre has got a machine to test the semen which is a very interesting machine. We put a drop of the semen sample on it and the result comes on the screen.

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It's an AI, the AI is put into it and the results come within a minute. The best part about it is, it's so easy to explain it to patients that what her semen report is like because otherwise, they are just getting pages and pages and pages of so many reports and they don't know. And usually, we as infertility consultants also see just the reports, we don't see the sample ourselves.

The WHO recommends that at least 4% of the sperms should be normal morphology. That is, out of every 100 sperms, at least 4 should be normal. So, this report also tells about the morphology. So, now coming to the next slide, we have already talked about the male infertility, what every gynaecologist must know. We get three type of scenarios. Number one, a very good count in motility. Number two, not so good count, but something is there and they are not very active as well.

And the third scenario is azoospermia. I want to say that a very good count and motility excludes out a male only in 90% cases. It is not that a good count and motility is a sure shot indication that the male is fertile because there are so many times acrosomal defects which is affecting the egg penetration.

So, this sure shot confirmation that the male is fertile is number one, if the wife is pregnant. Number two, if we see fertilisation in IVF. So, we can't guarantee every male that he is not responsible for infertility.

Lots of cases of unexplained infertility where we have worked up and we are seeing that the girl is normal, that the male is normal, but still they are not getting pregnant. So, so many times the male is responsible. Number two, situation where the count and motility is not so good. The constituents in it really have wonderful effect on male fertility.

Number two, in such a case I will always see at the culture because I already told you that the subtle infection of the semen is responsible for DNA fragmentation, spoiling the sperms and making it effective. So, this is number two.

No, we have to take care, we have to follow rules because maybe no problem comes today, but 20 years after, suppose that there is some problem between husband and wife and they sue against each other, you will unnecessarily come into their trap. So, if the FSH is less than 15, it means that there is normal spermatogenesis. Ideally yes, you should refer this patient to IVF centre so that we can see that it is some blockage because in such cases IVF is required.

What do we do in ICSI? We'll be sharing a short video or we'll be posting in the group that how do we do ICSI. In ICSI, what is the difference between IVF and ICSI? I'll take just a moment to discuss that. In IVF, we collect the eggs and we put sperms in it for natural fertilisation.

This is called in vitro fertilisation. It is happening inside the lab, inside the incubators. Now in ICSI, one egg is picked up and one sperm is inserted in it.

So, I'll be sharing a real video today only in the group and whatever I'm saying, if I'm forgetting something, please do message so that our team can take care. So, this is called ICSI. Now what is PISA? In PISA, there is percutaneous needle.

I mean the needle goes from the groyne area to the epididymis and we aspirate the fluid in it. Where is it required? It is required in the cases where there is a blockage, the epididymal blockage. It could be congenital or it could be secondary, so some infection of the male.

So, in PISA, we are going to take out the sperms, see them under microscope and we do it at the time of pickup. So, here we are collecting the eggs. Once the pickup is done, the embryologist or the urologist or the surgeon will aspirate the sperm sample from the male and then these sperms are going to be used to inseminate, to do ICSI.

So, this is called PISA. What is TISA? In TISA, we put a needle directly into the scrotum, into the testes and aspirate the sperms. But what is the difference between PISA and TISA? In PISA, we will get the motile sperms, the mature sperms which have left the testes. But in TISA, so many times we will not get mature sperms. So, we prefer PISA rather than TISA. Low count and motility.

So, oxidative stress is very important which is leading to high sperm DNA fragmentation and this is responsible for 30% of unexplained infertility and also cases of recurrent abortions. When I will be taking the class of recurrent abortion, I will be telling you that 50% times the male is responsible. So, once we are treating a patient of recurrent abortions, we are just not allowed only to take care of the lady or think about the factors which are affecting only the female.

Yes, oral antioxidants do have a role in bringing the live birth and pregnancy. Okay, so this is again, although I did touch about this topic yesterday, but the male genital tract infections, subclinical. What do I mean by the word subclinical? Clinical is when the male comes to you or to a surgeon with a problem.

He comes with a complaint of prostatitis or some pain while passing urine or recurrent UTI. So, this is clinical male genital tract infection. But a subclinical male genital tract infection is when the male doesn't know absolutely that there is any problem or not, but it is you who are going to pick up. There could be temperature rise in as well. So, always keep in mind that semen culture plus semen PCR. So, whenever we are treating any subclinical infection, it's not just the antibiotics we should give, we should also give antioxidant and again males require antibiotics for a longer time.

Usually, it is the residual corpus luteum. At times, I would call the patient after 2-3 days and check if it has gone or not. If it has not gone, then I would try to take a break cycle and give her any OCP or something so that by next cycle, this is not seen.

So, on day 2, we want to see silent ovaries. Number 2, you also have to count the antral follicles. We call them antral follicles, these small bubble like things because this is going to help you to plan your action and at the level of the endometrium, we want to see thin endometrium.

Day 2, day 3, we expect that the endometrium has already shed. So, it's like a new beginning. Suppose if the endometrium is still thickened, what does it mean? It means that there hasn't been adequate progesteronization which we see very commonly in PCOS patients.