Both the partners should come for the initial interview and should be evaluated and treated together, as infertility is not the disease of only the woman.

TYPICAL SEQUENCE OF INFERTILITY WORK UP

STEP I

Initial Interview and Examination

•        Both partners should be present.

•        History and general physical examination of both partners.

•        Outline tests and investigations.

•        Answer questions.

•        Tests for Ureaplasma and chy madia.

STEP II

Laboratory Evaluations

MEN

Semen analysis (after suitable abstinence)

WOMEN (Beginning with next menstruation)

•        BBT

•        Ovulation detection kit

•        Hormone assays is indicated

•        Hysterosalpingography / Sonosalpigography

•        Follicular Ultrasonography

•        Post Coital Test

•        For ammenorhea / digomenorrhea begin with hormone studies.

•        After induction ofovulation proceed to above studies.

STEP III

Specialised Test

MEN

•        Abnormal semen analysis

•        Serum FSH, LH, TSH, Testosterone

•        Tructose content of semen

•        Prostatic massage and culture sensitivity of the fluid

WOMEN

•        Hysterosalpingogram shows comual patency

•        Laparoscopy (during luteal phase)

•        Endometrial biopsy

•        Above are done 9-12 days after LH surge

•        Hysterosalpingogram shows possible comeal block

•        Laparoscopy (during early follicular phase)

STEP IV

Continue investigations based on positive findings

MEN

•        Testicular biopsy

•        Sex chromatin study

•        Immunological tests

WOMEN

•        Hysteroscopy and Laparoscopy for pelvic or after pathology

•        Antisperm antibody test

•        CT scant and MRI for tumors of pituitary / hypothalmus / adrenal glands

Clinical Approach To Investigation

MALE

History

•        Age

•        Duration of Marriage

•        History of proven fertility if any

•        General medical history especially of

•        Sexually transmitted disease and treatment taken, of

•        Muneps orchetes after puberty, history of

•        Diabetes mellitus, tuberculosis

•        Relevant surgery done eg herniorapply, operation on testis or any other genital operation

•        Occupationae history towards exposure to radiation / excessive heat

•        Sexual history—frequency of intercourse, full penetration of penis inside the vagina, orgasm at the right time (premature ejaculation)

•        Social habits, heavy smoking, alcohol, drug abuse

Examination

•        General Physical examination

•        Reproductive system examination

•        Inspection and palpation of genitalia

•        Presence ofvaricoupele

Special Investigation

Routine Investigations

Routine blood examination

•        Complete urine examination

•        B. Sugar       

•        VDRL

•        Seminal fluid analysis collected by masturbation into a clean wide mouthed bottle preferably in thelaboratory with a prior abstinence for 2 days. A normal spermino gram is tabulated below:

Parameter      SOH 1912

Volume (ml)    >2.0

Density (x 106 / ml)  >20

Motility (%)    >50

Viability (%)   >75

Normal Forms (%)     >30

Leucocytes (x 106 / ml)       <1.0

In case of abnormal seminal analysis we can follow the following routine of investigation.

ABNORMAL SEMINOGRAM

Female

History

•        Age

•        Duration of Marriage

•        History of previous marriage with proven fertility

•        Medical history esp. of tuberculosis, sexually transmitted disease, diabetes

•        Surgical history especially of abdominal or pelvic surgery

•        Menstrual history in detail

•        Previous obstetric history

•        Contraceptive practice especially of IUCD insertions

•        Sexual history with problems such as dysparuenia, loss of libido Examination

•        General Physical examination

•        Reproductive system examination

•        Distribution of hair

•        Development of secondary sexual characters

•        Per speculum examination

•        Per vaginal examination of evidence of vaginal infection, cervical tear or infection, uterine size, mobility, abnormality presence of adnexal masses, and presence of modules in pouch of Douglas.

•        Physical features pertaining to endrocrinopathies.

MANAGEMENT OF INFERTILITY COUPLE- Should be investigated and treated together.

HISTORY

PHYSICAL EXAMINATION

Semen analysis

Evidence of ovulation

Hormonal Profile