The World Health Organization defines infertility as a failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse. It is estimated to affect between 8-12% of reproductive-aged couples worldwide. Because fertility in women is known to decline steadily with age, women aged 35 years or above who fail to conceive after 6 months of unprotected sex should seek professional opinion. Some health problems also increase the risk of infertility. Therefore, couples with the following symptoms or medical history should not delay seeing a doctor when they are trying for a pregnancy:
Very painful periods;
Pelvic inflammatory disease;
Previous abdominal surgeries or surgeries to pelvic organs (ovaries, uterus, fallopian tubes), chemotherapy or radiotherapy to the pelvis;
More than one miscarriage;
Suspected male factor (i.e., history of testicular trauma, hernia surgery).
The doctor will begin by collecting a medical and sexual history from the couple. The initial evaluation usually includes:
2) tubal assessment
3) ovarian reserve tests
Tubal assessment is an essential investigation for infertility. Around 1/4 of infertile couples experience tubal problems. Tubal assessment should be considered in couples who failed to conceive after 1 year of trying for a pregnancy or if the woman has risk factors for tubal blockage. These risk factors include history of pelvic infection, ectopic pregnancy, abdominal or pelvic surgery, and endometriosis.
1) Ultrasound scan of the pelvis (USG)
2) Laparoscopy (Keyhole surgery) and chromotubation
3) Hysterosalpingogram (HSG)
4) Hysterosalpingo-Foam Sonogram (HyFoSy)
Ultrasound scan of the pelvis (USG)
Regular USG can only detect hydrosalpinx. Hydrosalpinx is a collection of fluid in the fallopian tube as a result of distal tubal blockage. However, proximal tubal blockage or subtle blockage will not be picked up by pelvic USG.
Laparoscopy (Keyhole surgery) and chromotubation
During laparoscopy, a detailed inspection of the whole pelvis including the fallopian tubes, the womb and the ovaries will be performed. Blue dye will then be injected into uterine cavity through the cervix using a fine catheter. Tubal patency is confirmed if blue dye is observed to come out from the ends of the fallopian tubes. It may be possible to carry out corrective procedure at the same operation if abnormalities are found such as blocked tubes or adhesions in the pelvis. Therefore, laparoscopy allows direct visualization of the pelvic organs and their condition other than tubal patency alone, and it is both diagnostic and therapeutic.
The surgery involves general anaesthetic and surgical risks, including infection, pain, bleeding and risks of injuries to other internal organs. Due to its invasive nature, laparoscopy is generally not the recommended first-line test for tubal patency, unless the woman requires surgery for other diseases such as ovarian cysts or uterine fibroids.
HSG is the traditional first-line test for tubal patency. It is done in X-ray centers. It involves injection of contrast medium into the womb via the cervix through a fine catheter followed by taking multiple X-rays as the contrast fills the uterus and fallopian tubes. Tubal patency is confirmed if the contrast spills out freely from the far end of the tubes into the abdominal cavity. Side effects include pain, allergic reaction to the contrast, pelvic infection and a small dose of radiation exposure.
Hysterosalpingo-Foam Sonography (HyFoSy)
Hysterosalpingo-Foam Sonography (HyFoSy) is a newer technique for testing tubal patency that is done in the clinic. It involves injecting ultrasound-visible foam into the womb cavity via a tiny catheter inserted through the cervix, then using ultrasound scan to determine tubal patency by tracking whether the foam flows along the fallopian tubes into the abdominal cavity. The whole procedure lasts for around 15-20 minutes, which is potentially shorter than HSG. Since HyFoSy can be performed in the gynaecologist’s clinic, it can be done as a one-stop procedure, together with USG for assessment of ovarian reserve and any uterine abnormalities rather than attending a separate appointment as in HSG. The result is also available for interpretation immediately.
Side-effects include pain and pelvic infection. There are no reported major complications and it does not involve radiation. Majority of women described HyFoSy as either non-painful or only mildly painful; and was half as painful than HSG. This newer sonographic technique has a similar accuracy and a high concordance rate with other tubal patency tests like HSG and laparoscopy.
Ovarian reserve or ovarian function plays a crucial role in achieving pregnancy following any treatment in infertile women. The estimation of ovarian reserve is routinely performed through various ovarian reserve tests (ORT) in an effort to predict the ovarian response to stimulation during assisted reproductive technology treatments namely IVF.
The most commonly used markers of ovarian function include:
Blood test for Follicle Stimulating Hormone (FSH) value on Day 2 to 3 of the menstrual cycle
Blood test for Anti-Müllerian Hormone (AMH) value
Antral Follicle Count (AFC) using a transvaginal ultrasound scan