Research concerning females consists of a series of exams some of which are very uncomfortable demanding patient’s fortitude and cooperation. Usually in the first consultation we issue the patient complete records including common ailments, menstrual historic, early diseases, surgeries and family history. From these data we are seldom able to guide our research to reach a diagnostic.
In many cases, however, the initial interview only is not enough to provide sufficient data and demand further research. We start with a complete evaluation of the patient’s anatomical structure beginning at the external genitalia, including vulva, specular exam to observe the vagina and womb wall and collection of material for the pap smear exam.
Then we proceed to the transvaginal ultrasound to observe the uterus and ovary for their shape, position, size and texture. In this exam we are able to evaluate the endometrium, which is the internal uterine lining where embryos will be implanted after the fertilization process.
Sometimes invasive exams are required such as hysterossalpingography through which a canula is placed at the cervical oos and a contrast is injected inside the uterus. The contrast penetrates entirely the uterine cavity, flows to the two fallopian and falls into the abdominal cavity. The contrast evolution process is x-rayed step by step so we can evaluate the uterine cavity and the tubes permeability.
Another exam is the hysteroscopy. A thin telescope is introduced in the vagina through the cervical oos to better view the uterine cavity and the tubes. To get the image a liquid solution or a gas is injected through this telescope thus distending the uterine cavity allowing for a precise visualization of the whole uterus.
Endometrium biopsy is another exam to evaluate the uterus conditions for the embryo implantation process. We know that the uterus and the endometrium react to hormonal variations during the menstrual cycle. During this exam a small indented canula is placed inside the womb at the endometrium in a specific day of the menstrual cycle. Through suction a small fragment of the endometrium is removed and sent to pathology. Thus we know whether the endometrium is in accordance to the hormonal cycle.
Next we evaluate the patient’s ovulatory hormonal cycle. Blood samples are collected and tested on the 2nd or 3rd days, on the 10th or 11th and from the 21st to the 23rd days of the cycle. Through this analysis we evaluate if the hormonal curves are perfect. Usually blood tests are carried in association with transvaginal ultrasound monitoring. The exams are: estradiol, LH, FSH, Prolactin, S-DHEA, Progesterone, T3, free T4, TSH, Androstenedione, Testosterone, DHT, CA 125 Inhibin, Cortisol and Insulin.
The basal body temperature (BBT) and the vaginal serial cytology are other useful exams in hormonal evaluation. However, as they are indirect and difficult tests they are less required. In the BBT a chart is designed by measuring body temperature in the morning at wake up time. If the cycle is ovulatory, right before the ovulation there is a discrete drop in the temperature followed by an elevation of 1ºC, which remains throughout the rest of the cycle second stage. This occurs usually between the 12th and 16th days of the cycle. In the serial vaginal cytology scraps are collected throughout several days of the cycle (on the 6th, 10th, 14th, 17th, and 24th days). The cellular variations show whether the hormonal activity is correctly present.
At another stage, husband/wife compatibility is assessed in relation to intercourse in the ovulatory period. Post-coitus test is carried out some 8 to 12 hours after intercourse and evaluates sperm presence, number and motility in the cervical oos. Material is collected from the cervical canal and viewed under the microscope for sperm presence and its interaction with the mucus. Vaginal pH and cervical mucus quality, volume and consistency and the presence of anti-sperm antibodies evaluations also help in finding on the spermatozoa migration toward the uterus.
Another useful test is the so-called mucus versus semen cross testing. Mucus is collected during the ovulatory period and samples of sperm are sent to the lab. Mucus is placed inside a small capillary tube and the sperm migration is observed through it. A standard, ideal laboratory sample is thus compared to the samples we’ve sent. Depending on the results a double crossing is done placing the standard mucus in touch with the husband’s semen and similarly the wife’s mucus with the standard semen. We can thus safely evaluate whether the sperm migration is perfect otherwise we’ll look for the problem either in the husband’s semen or the wife’s mucus.
Given that all this exams are normal, endoscope viewing may be necessary. The indication is a laparoscopy to check for adhesions, pelvic inflammatory disease and minimal endometriosis. Such conditions may not be diagnosed by other exams, only with a telescope probe with a video-camera piercing through the umbilical scar where we are able to have a panoramic view of the pelvic cavity.
In researching the male factor the spermogram is the main exam. In a full spermogram if everything is evaluated as normal the husband factor is practically removed as the cause of infertility. However, even with a perfect spermogram we observe failures in reaching gestation. When those cases are submitted to IVF they produce fertilization failures due to unknown factors, which are usually solved through ICSI (intra-cytoplasmic sperm injection). There several spermogram methods. We adopted the WHO method with morphology following Krugger’s strict classification (see chart below) for normality standards:
Liquefaction: less than 30 minutes
Volume: 2,0 a 5,0 mL
Sperm count: above 20 million/mL. and greater than 40 million total
Motility: Type A (fast linear motility) + B (slow linear motility) greater than 70% in the 1st hour.
Survival: Motility in 24 hours some 50% of the initial motility under ideal culture conditions.
Leucocytes: Amount inferior to 1 million/mL.
Germinative cells: amount inferior to 1 million/ mL.
Krugger’s strict morphology: percent of normal spermatozoids; Greater then 14% : fertile
5% to 14% - Sub-fertile
0 to 4% - infertile
Antibodies (IgA, IgG and IgM): Less than 20% connected to antibodies.
Fructose: 90 to 500 mg/dL
Several conditions may bring alterations to the spermogram. Exams are available and should be required in such cases. Scrotum sac ultrasound for evaluation of testes and epididimys and Doppler flux for varicocele should be conducted. Blood samples for LH, FSH, Prolactin, S-DHEA, T3, Free T4, TSH, Testosterone, DHT are also important as are the presence of anti-sperm antibodies and ureaplasma, mycoplasma and gonococcus markers.
Another important issue is the genetic evaluation with evaluations of sexual chromatin, kariotype and corpuscle-Y. We also conduct blood test to assess the SRY gene located in the Y-chromossome short arm. Mutations in this gene are related to infertility cases.