The evaluation of an infertile couple should always include an assessment of the pelvis. I routinely check the medical history (for risk factors), a postcoital test, and a hysterosalpingogram (HSG). I recommend a pelvic evaluation (laparoscopy and hysteroscopy) if the HSG suggests a treatable anatomic cause for the fertility problem or when the couple has “unexplained infertility” following these initial tests (including detection of ovulation, semen analysis and these initial pelvic factor tests).
(1) a detailed menstrual and medical history should be obtained, including
Any pregnancies (and outcomes) for either partner. A prior ectopic pregnancy is an important risk factor that suggests significant tubal disease.
Pain with menses (dysmenorrhea), sexual intercourse (dyspareunia), or any persistent (recurrent) pelvic pain.
History of any pelvic infection (excluding vaginitis or vaginal discharge), including treatment and clinical course. Important pelvic infections include appendicitis, PID, sexually transmitted diseases, an infected IUD, and uterine infections (endometritis).
Prior abdominal or pelvic surgery, including intraoperative findings (especially if the reproductive organs were examined), spillage (or placement) of potentially caustic material into the pelvis (including gallstones, infected material leaking from an inflamed appendix, sebaceous material from an ovarian teratoma, significant pelvic bleeding [including from an ovarian cyst], use of surgical adjuvants to establish hemostasis by promoting thrombosis), and the clinical postoperative course (including any history of postoperative fever, slow recovery, or persistent pain).
History of DES exposure in utero, radiation or chemotherapy, malignancy, or trauma.
(2) an expert examination (generally by a gynecologist for the female and an urologist for the male)
Presence of the (male) epididymis (noting any induration, irregularity or cystic changes) and vas deferens (noting any nodularity) can be determined on examination.
Visual inspection of the (female) vaginal vault is adequate to rule out an intact hymen and a vaginal septum. Cervical abnormalities may suggest prior DES exposure in utero or Mullerian anomalies. Careful bimanual examination may suggest pelvic adhesions, endometriosis (especially if deep lesions result in nodularity) or enlarged ovarian cysts.
(3) the postcoital test (PCT)
The importance of the cervical mucus for nourishment and the survival of sperm has been recognized for a long time, yet there is still no ideal test to assess mucus quality or the ability of sperm to survive in the mucus.
The postcoital test is the most popular sperm mucus interaction test. It involves the couple having relations (intercourse) at least 2 hours prior to returning to the office (to allow for complement mediated inactivation of sperm) and in the office the infertility specialist will check the cervical mucus for the presence and number of motile sperm. The test should be completed within 24 hours of intercourse. Note: the World Health Organization has recommended that one consider performing the test 6-10 hours following intercourse to further assess longevity and survival of the sperm.
Despite wide acceptance of the postcoital test, the method of performing and interpreting the test have been highly controversial. The PCT was initially proposed by Dr. Simms in the late 1880s but was not immediately accepted. Dr. Huhner supported the postcoital test in the early 1910s. Thus, the postcoital test is frequently referred to as the Simms-Huhner test. Over the years, the test has undergone considerable modification and tremendous efforts have focused on cervical mucus research. Yet even today the medical community does not have a detailed understanding of the dynamics of cervical mucus as it relates to sperm survival and fertility.
Biochemical and biophysical changes in the cervical mucus in the preovulatory time period are understood as enabling sperm to acquire progressive movement through the cervix so as to gain access to the upper reproductive tract (including the fallopian tubes). These changes in the mucus are apparently a result of the influence of the sex steroids, estrogen and progesterone.
Estrogen generally has a positive effect on cervical mucus (with respect to sperm interaction). The effects of estrogen are countered (essentially reversed) by the effects of progesterone. Just prior to the release of the mature egg (ovulation) the estrogen to progesterone ratio is greatest so that the cervical mucus is optimal for sperm. Progesterone production rises rapidly with ovulation to disrupt the beneficial effects of estrogen at the level of the cervical mucus.
The mechanism of the beneficial effect of estrogen is complex, involving changes in the architectural arrangement of the mycelles (macromolecular cores that form mucin threads) to create longitudinal channels (tunnels) within the mucus that allow for progressive forward movement of sperm through the cervix. Progesterone results in obliteration of these channels to effectively prevent forward movement of sperm through the cervix.
The method of performing and interpreting the postcoital test varies. I have used a number of techniques in the past, with the most logical to me being the system developed by Dr. Moghessi (a past president of the American Society of Reproductive Medicine). This is also the system supported by the World Health Organization (WHO). Essentially, the test provides between 0 and 3 points for each of 5 variables in the evaluation of the mucus with a total of 10 points being considered normal. The test variables involve assessment of
- mucus volume (greater volume gives greater points)
- mucus consistency (less viscous gives greater points)
- ferning (greater fern structures give greater points)
- spinnbarkeit (greater stretch or elasticity gives greater points)
- cellularity (less cells give greater points)
The score on these variables assesses the quality of the cervical mucus. The number of motile sperm and their quality of movement (rapid linear progressive, sluggish linear or nonlinear, non progressive, nonmotile) is then assessed. The interpretation of “how many motile sperm” or “what quality of movement” is normal is widely debated due to apparent conflicts within the available literature. These reports include
- greater than 25 progressively motile sperm per microscopic high power field (400 x magnification) is normal and is also independently associated with a normal sperm count
- less than 5 motile sperm per high power field indicates either a decrease in the total motile number of sperm per ejaculate or abnormal cervical mucus
- no change in pregnancy rates regardless of the number of sperm identified in the mucus
- 20% of known fertile couples tested had less than 1 motile sperm per high power field
- 6 of 8 women with abnormal postcoital test results who then underwent laparoscopy 8-36 hours later had motile sperm found in the pelvic fluid (that is motile sperm still made it to and through the fallopian tubes into the fluid behind the uterus)
Abnormal cervical mucus can result from any process that interferes with the function of cervical glands (mucus is produced by these glands). This includes surgery to the cervix with destruction or removal of glands. These surgeries include cryosurgery (freezing), conization (removal of a cone shaped segment) or LEEP (cauterizing loop electrode removal of a segment) of the cervix for an abnormal pap smear.
(4) the hysterosalpingogram (HSG)
An abnormal uterine cavity can result in infertility. Sperm that enters the uterine cavity through the cervical mucus must then traverse this cavity and enter the fallopian tube to reach the egg. These structures should be confirmed to be normal early in the infertility evaluation. The most popular, safest and most cost effective way of doing this appears to be the hysterosalpingogram (HSG).
The HSG is a radiologic test performed under fluoroscopy by either a radiologist or an infertility specialist. The test requires a radioopaque distending media, which can be seen using xray during fluoroscopy and on film. During the HSG, physicians watch a monitor that (normally) shows the dye entering and filling the uterine cavity and then entering and spilling from the fallopian tubes.
There are two major types of HSG distending media, water soluble dye and oil based dye. Essentially, the water based dye is more rapidly absorbed yet is associated with a higher incidence of muscle spasm and discomfort. The oil based dye is much more slowly absorbed over possibly days to weeks (versus minutes to hours for the water based equivalent) and is associated with more serious (potentially fatal) complications if infused directly into the blood stream (as an oil embolus) under pressure through an open vessel.
There are anecdotal reports of increased pregnancy following HSG, possibly due to the opening of the tubes with dye (commonly referred to as “blowing out the tubes”). The use of oil based media is associated with a somewhat higher subsequent pregnancy rate than water based media. Despite this potential benefit, the HSG currently remains a diagnostic (and not a therapeutic) test.
The oil based dye has many supporters, and yet, I prefer use of the water based dye since there are less complications of a serious nature. Also, if oil based dye is used then ideally (for the quality of the study) the patient must return to the radiologic suite the day after initial injection for another xray of the pelvis to determine the location of the dye (to see whether there is free spillage or loculation of dye), which is inconvenient.
About 3-6 milliliters is normally required to fill the uterus and tubes. Image intensification with fluoroscopy allows direct viewing of the procedure on a monitor and limits the number of films that must be taken (consequently reducing the total amount of radiation used).
I recommend that an antibiotic, Doxycycline (when there is no history of allergy to Tetracycline or Doxycycline), be given around the time of the HSG since the flushing of these spaces (cavity and tubes) can reactivate a dormant infection to result in a clinically apparent infection (pelvic inflammatory disease). Research has indicated that there is up to an 11% risk of developing pelvic inflammatory disease (PID) in dilated or distally blocked tubes following an HSG if no antibiotics are used, a 3% risk of serious infection after HSG if there is a history suggestive of prior tubal infection or damage, and less than a 1% chance of infection if the patient is pretreated with Doxycycline regardless of history or findings of distal tubal disease. I give Doxycycline as 100 mg by mouth twice a day for a total of 4 tablets starting the evening prior to the test.
With water based dye, the patient often experiences what appears to be a large uterine cramp or contraction. This is thought to be a reaction of the uterine muscles to the rapid expansion and decompression of the uterine cavity with dye. The discomfort associated with this cramp may be largely prevented or relieved by taking a nonsteroidal antiinflamatory agent like Motrin or Alleve 30-60 minutes prior to the test.
High resolution ultrasonography is readily available and transvaginal probes allow the operator to place the transducer (end of the probe) immediately adjacent to (within a few centimeters of) the pelvic organs (uterus, fallopian tubes, ovaries) to provide very high quality images of these organs. Over the past 10 years, reports in the literature have suggested that filling the uterine cavity with either saline (salt water) or air during sonohysterography allows the operator to visualize the uterine cavity as well as (or better than) during hysterosalpingography (HSG). Reports correlating findings at HSG, sonohysterography and hysteroscopy (direct visualization of the uterine cavity) have (predominantly) confirmed these suggestions.
Sonosalpingography (visualization of the fallopian tubes with ultrasound) using a variety of media (saline, albuminex, air) has been investigated as a way to document tubal patency or the presence of hydrosalpinges. Apparently the use of special media (such as suspensions of galactose microparticles) is helpful for consistently visualizing tubal passage. A Sion procedure was described (from the Sion Hospital in India) in which the cul de sac behind the uterus (a potential space also called the pouch of Douglas) is filled with about 300 cc of sterile normal saline to better visualize patency of the tubes, tubal motility and peritubal pathology. The available information on the use of these techniques for documenting tubal patency and presence of hydrosalpinges is conflicting, with many pioneers in this field finding the sensitivity of this technique disappointing for the diagnosis of tubal pathology.
Due to the conflicting information available concerning the quality of the sonohysterogram for evaluating fallopian tubes and the critical importance of this evaluation, I currently prefer to use the HSG for a preliminary evaluation of the cavity and tubes and then proceed (when indicated) to hysteroscopy (the gold standard test for the cavity) and laparoscopy (the gold standard test for diagnosis of hydrosalpinges and most tubal pathology).
(6) pelvic evaluation
I may recommend a pelvic evaluation (laparoscopy and hysteroscopy) following the initial infertility evaluation. I initially focus on ovulation dysfunctions, semen analysis, and simpler tests to assess the pelvis (postcoital test and HSG). If this initial testing is normal, or a treatable anatomic abnormality is suggested on HSG, I then suggest a pelvic evaluation. Up to 75% of couples may have a significant pelvic factor that is treatable via minimally invasive surgery (pelvic evaluation) when the initial testing is entirely normal (since the only remaining diagnoses are pelvic factor and unexplained infertility).