01 ff00 09 08 009 89 98 97 79 78 34908067uu 23 09 tt
Investigations




    MALE
  1. Semen analysis
  2. Hormone tests
  3. Ultrasound scanning of the scrotum
  4. Testicular biopsy
  5. Vasogram
    BOTH
  1. Genetic Screening
    FEMALE
  1. Ultrasound scan
  2. Hormone tests
  3. Ovulation tests
  4. Laparoscopy and dye test
  5. Hysterosalpingo-Contrast Sonography (hy co sy)
  6. Hysterosalpingogram (HSG)

Semen analysis

The semen analysis test is the most important infertility test. Semen analysis is the first step in the medical evaluation of male infertility. The semen analysis test is usually performed after 3-5 days of sexual abstinence. The sample is usually collected after masturbation into a sterile pot. The volume of the ejaculate is measured, and liquefaction of the ejaculate is estimated. Then a drop of semen is examined under the microscope where the number of sperm is counted, how they move around is assessed, and the proportion of normal sperm can be estimated. Semen assessment should be performed in accordance with World Health Organization (WHO) methodology. The WHO semen values are based on populations of fertile men and are described as 'reference' values rather than 'normal' values.

You may be asked to produce a “split-ejaculate” collecting the first one or two spurts of the ejaculate into the “first pot” and the remainder into the “second pot”. The reason for the split ejaculate is to assess each pot separately. Pot one usually contains the best sperm.

Providing a semen sample by masturbation can be very stressful for some men. Men who have this problem should ask for help, their wives can help them to provide the sample, other methods such as mechanical vibrators, viagra tablet can help some men to get an erection. If all this fail it is possible to collect semen sample using a special condom during sexual intercourse.  

Normal values of semen variables (WHO 1992):

WHO NORMAL RANGES FOR SEMEN ANALYSIS
Semen Characteristics WHO-1987 WHO-1992
Volume (ml) > or = 2 > or = 2
pH 7.2-8.0 7.2-8.0
Sperm concentration (M/ml) > or = 20 > or = 20
Total sperm count (M/ejaculate) > or = 40 > or = 40
Morphology (% normal) > or = 50 > or = 30
Vitality (% live) > or = 75 > or = 75
WBC (M/ml) <1.0 <1.0
Immunobead test (%sperm with beads) < or = 10 <20
MAR test (%sperm with RBCs) <10 <10
Motility Within 1h of ejaculation
class a (%) > or = 25 > or = 25
classes a and b (%) > or = 50 > or = 50
Neutral alpha-glucosidase (mU/ejaculate) > or = 20
Total zinc (µmol/ejaculate) > or = 2.4
Total citric acid (µmol/ejaculate) > or = 52
Total acid phosphatase (U/ejaculate) > or = 200
Total Fructose (µmol/ejaculate) > or = 13


NORMAL AND PATHOLOGICAL RANGES IN SEMEN ANALYSIS
Semen Characteristics Normal Borderline Pathological
Volume (ml) 2.0-6.0 1.5-2.0 <1.5
Sperm concentration (M/ml) 20-250 10-20 <10
Total sperm count (M/ejaculate) >50 20-50 <20
Motility (0.5-2 h after ejaculate) >50 35-49 <35
Progression at 37oC (0-4) 3 or 4 2 <2
Vitality (% live) > or = 75 50-74 <50
Morphology (/100sperm)
Head defects <35 35-59 >60
Midpiece defects < or = 20 21-25 >25
Tail defects < or = 20 21-25 >25

A normal sperm test is reassuring. If the test is abnormal the test will need to be repeated two to three times over two to three months to confirm whether the abnormality is persistent or not.

Remember that fertile men may have from time to time an abnormal test, so a single semen analysis test is of little significance. Because of the natural variation in sperm quantity and quality, many doctors request that two or three samples be examined over an interval of one to three weeks. It is just not possible to say with certainty that a man with a low sperm count is infertile, as many men with low or moderately low sperm counts are fertile. Similarly, it is not possible to say with certainty that a man with a normal count is fertile as his sperm may be lacking fertilizing capacity.

Top

Testicular biopsy

A testicular biopsy can be used to help determine the cause of infertility.

The testicular biopsy is a minor surgical procedure that is usually performed under a local anesthetic. A small incision is made in the scrotum (the bag that carries the testicles), then a tiny piece of testicular tissue is removed and examined under the microscope to see if there are sperm present. Bruising and discomfort may occur after the operation, but wearing tight under wear for about two days helps to prevent this.

When surgery is carried out outside a treatment cycle, any sperm found may be stored for future use in an ICSI treatment cycle.

Top

Genetic Screening 

This includes genetic screening for chromosome count and structure, Y chromosome microdeletion and cystic fibrosis gene mutations. These screening tests are recommended for men with no sperm (excluding those who have no sperm because of vasectomy) or have a severely low sperm count (count of less than 5 million per ml).

Approximately 40-70% of these infertile men are carriers of cystic fibrosis and about 10-15% have Y-chromosome microdeletion, the gene responsible for sperm production is stored in the long arm of the Y chromosome. The overall frequency of chromosomal abnormalities among infertile men is about 7% compared to less than 1% among fertile men. Klienfelter's syndrome accounts for about two thirds of chromosomal abnormalities. Men with balanced translocations have an increased risk of having chromosomally unbalanced offspring.

If both partners carry the gene for cystic fibrosis, there is one in four chance that their child will have the full-blown disease. This is an unpleasant disease, affecting lungs and digestive system, and there is currently no cure for it. There are many hundreds of mutations of the cystic fibrosis gene, and laboratories can currently only screen the most common of these. So, a negative screening test indicates a very low, but not zero, risk of pregnancy being affected by cystic fibrosis. If a man has a Y chromosome microdeletion, there is a risk of passing on the abnormality to his son, and thus also passing on the potential risk of infertility.

Failure to detect cystic fibrosis gene mutations does not rule out the presence of a mutation currently unidentified by routine testing methods. Similarly, a negative Y chromosome microdeletion test does not necessarily rule out a genetic abnormalities because there may be other unknown genes that might also be necessary for sperm production.

Top

Hormone tests

Hormone tests are important in male investigation.

Measuring the blood levels of FSH, LH, testosterone and prolactin are essential in selected cases. Normal sperm production and sexual function are dependent on normal hormonal environments. The measurement of FSH and LH levels can be valuable in distinguishing patients with azoospermia. Those patients who have azoospermia due to an obstruction have normal FSH levels, meanwhile those patients whose testes are not making sperm have raised FSH levels. Low levels of FSH and LH may indicate that the pituitary gland is not producing enough hormones and there is therefore the possibility of effective hormone treatment.

Top

Ultrasound scan

The use of high frequency ultrasound waves to examine the cervix, uterus, ovaries and Fallopian tubes. The reflection of these waves can be used to produce an image on a screen similar to an X-ray, but with the added advantage that the ultrasound scan is quite harmless. Ultrasound examination is routinely performed as an outpatient procedure and takes about 10 minutes.

It is used as a diagnostic procedure to assess pelvic organs and detect abnormalities in the womb e.g. a forgotten coil (used for contraception), polyp, malformation, abnormalities in the Fallopian tubes e.g. hydrosalpinx (water in the tubes) and abnormalities in the ovaries e.g. polycystic ovaries etc.

Ultrasound scan showing ovarian cyst.

It is also used to monitor treatments such as insemination and IVF by assessing the development of the follicles and measuring the thickness of the endometrium.

Ultrasound scan of the endometrium.

Ultrasound scan is the method of choice to diagnose pregnancy and multiple pregnancies. The pelvic organs can be examined either by passing the probe over the abdomen (abdominal scan) or by gently inserting the probe into the vagina (vaginal scan). For best results, the abdominal scan requires a full bladder, which pushes the bowel away from the ovaries, and at the same time acts as a good transmitter for the ultrasound waves. A vaginal scan gives a more accurate picture of the pelvic organs than an abdominal scan because of the shorter distance for the sound waves to travel (between the probe and the pelvic organs). A full bladder is not required for a vaginal scan, hence making the patient more comfortable.

Top

Ovulation tests

Women with normal (regular) menstrual cycles are likely to be ovulating. It is important to remember that every woman may fail to ovulate from time to time, so a single negative ovulation test is meaningless. The main methods for detecting ovulation are detailed below.

Blood prolactin

This is a simple blood test to measure the blood level of prolactin; the idea is that too much of prolactin (milk hormone) may prevent ovulation. If the prolactin level is elevated, the test needs to be repeated to confirm that it is a persistent problem. Prolactin levels could be raised due to stress.

FSH and LH blood levels

Measurements of these hormones needs to be carried out at a particular time during the woman's menstrual cycle (usually between day 2-4 of menstruation) for the results to be valid. High FSH levels generally indicates diminished ovarian reserve while low FSH levels may indicate disorders of the pituitary or hypothalamus glands.

Ultrasound scans

Serial ultrasound scanning can detect the development of the follicle (a thin-walled structure containing fluid with an attached egg to its wall) and its collapse after ovulation. Vaginal ultrasound scan is not only much more comfortable to the patient but it also gives a much clearer picture than the abdominal ultrasound scan. The follicle is usually ready for ovulation when it measures 1.8 - 2.5 cm in diameter. 

Follicle as seen by ultrasound scan.

Endometrial biopsy

This is not a very reliable method of detecting ovulation. The ovulation test involves taking a small strip from the lining of the womb (endometrium). The strip is then stained and examined under a microscope. The procedure is performed about a week before the expected period i.e. about 7 days after ovulation. The idea is that after ovulation, the hormone progesterone will induce secretary changes in the endometrium glands. It should be noted that the procedure may cause uterine cramps and discomfort and there is a very small risk that an early pregnancy could be disrupted.

Top

Laparoscopy and dye test

The laparoscopy and dye test is is the golden standard method to check the Fallopian tubes, particularly in high-risk patients (women with a past history of pelvic infection or abdominal surgery). Laparoscopy allows the internal organs of the abdomen and pelvis to be inspected visually and excludes other problems such as endometriosis, fibroids, ovarian cysts and adhesions. Most infertile couples require a diagnostic laparoscopy for complete evaluation of their infertility. Among women whose tubes were found to be unobstructed using HSG, 18% were found to have tubal obstruction or peritubal adhesions using laparoscopy and a further 34% were found to have endometriosis or fibroids.

The laparoscopy procedure is usually done as a day case surgery under general anesthetic. It takes about 15-30 minutes.

When performing the laparoscopy procedure, a fine needle is inserted into the abdomen and gas (carbon dioxide) is pumped into the abdomen to push the intestine away. The laparoscope is placed safely into the abdomen thus decreasing the risk of injury to internal organs and blood vessels. A fibre-optic telescope (laparoscope) is then inserted through a small incision under the belly button; (this leaves a minute scar which is almost invisible). A powerful light is then shone down through the laparoscope. The doctor then inspects the inside of the abdomen and pelvis including the outside of the womb, the tubes and ovaries. A second incision might also be made so that a probe can be inserted in order to move pelvic organs such as the ovaries into clear view.

A colored dye (methylene blue) is then injected through the cervix. If the tubes are not blocked the dye should pass along them and spill into the abdomen.

Normal pelvic organs as seen by laparascopy.

Dye seen spilling from the Fallopian tube.

If an abnormality is  found during laparoscopy, this may be dealt with at the same time thus avoiding another operation. When performing operative laparoscopy such as opening of blocked tubes, cutting of adhesions and freeing of the tubes etc. Additional instrument such as micro-scissors and forceps are placed in the abdomen through an additional cuts.

When the surgery is completed, the gas is removed and a stitch may be inserted to close the incision. After the laparoscopy procedure the patient may experience some discomfort and shoulder tip pain, this is due to the gas that was injected into the abdomen. She may also feel bloated. The discomfort usually lasts about 24-48 hours.

Top

Hysterosalpingo-Contrast Sonography
(hy co sy)

This is a relatively new technique to detect a blockage of the Fallopian tubes using ultrasound.  Hysterosalpingo-Contrast Sonography (hy co sy) is performed as an outpatient procedure and takes about 20 minutes. No anesthetic is required but the patient may experience some discomfort.

A speculum is inserted into the vagina to visualize the cervix, clean it, and then a fine tube with a balloon at its end is inserted through the cervix. The balloon is then inflated to hold it in position. The speculum is then removed and a vaginal ultrasound probe is inserted into the vagina. A special dye is then injected through the uterus into the tubes.

The dye should be observed filling the cavity of the womb, passing through the tubes and spilling out at the end.

Hycosy

The main advantages of HyCoSy is that it can be performed at the time of ultrasound examination and it avoids the use of X-rays.

Top

Hysterosalpingogram (HSG)

The term hysterosalpingogram, also known as HSG, refers to an x-ray of the womb and tubes. The uterus and Fallopian tubes are invisible on the X-ray. To make them visible in the hysterosalpingogram a special X-ray fluid (contrast medium) is injected via the neck of the womb. The contrast medium shows up on the X-ray and outlines the shape and contours of the uterine cavity and may also work its way along the tubes. HSG is usually recommended in low-risk patients to demonstrate a blockage in the tubes, it may also demonstrate an abnormality within the womb.

The hysterosalpingogram procedure is performed in the X-ray department and usually takes about 15-20 minutes.

How is the HSG procedure carried out? The patient lays on a table under the X-ray imager. The doctor inserts a speculum (an instrument inserted into the vagina to visualize the cervix), cleans the cervix from any discharge, then a fine tube is inserted through the cervix and a special contrast medium is injected. The flow of the dye from the uterus to the tubes is observed through an X-ray image intensifier (which looks like a TV screen). Films of the HSG are usually taken for the record.

Hysterosalpingogram (HSG)

No anesthetic is required in most cases when performing the HSG, but some mild discomfort similar to period pain may be experienced. This can be greatly reduced by taking pain killer tablets. The test has to be performed in the first half of the cycle after menstruation has stopped and before ovulation, to avoid x-ray exposure to a fertilized egg. A course of antibiotics might be given after the procedure to prevent the possibility of infection.

Tubal spasm may occasionally obstruct the proximal end of the tube (near the uterus) during the HSG, and gives a false impression of tubal blockage on the screen. Furthermore, the HSG provides little or no information about peritubal adhesions that could impair the tubal function.

Top

Vasogram

The vasogram is an X-ray of the vas deferens and is performed in theatre under a general anesthetic. The procedure consists of a special dye being injected into the vas deferens (the tube connecting the testis with the seminal vesicles) and then x-ray films are taken. The aim is to pinpoint the exact site of any blockage in the vas.

Top

Ultrasound scanning of the scrotum

The use of ultrasound waves to examine the scrotum and check for abnormalities. For example, varicocele and cysts.

Top