Dr H Rahmanpour
Infertility specialists
Definition
 Infertility is defined as 1year of unnon-conception with
unprotected intercourse in the fertile phase of the
menstrual cycles (Evers,2002).
 In normal couples the fecundity, or the chance to
pregnancy with in one cycle is 20%(Evers,2002).
 On this Basis it is assumed that 85% of women should
be pregnant in 1 year.
 Common causes of infertility include
 male factor (25-45 %),
 ovulation disorders (30-40 %)
 and tubal damage (30-40 %).
 A combination of several factors is found in
approximately 10-20 % of all couples.
 Un explained infertility 10-15%of in whom standard
investigations –
 Including semen analysis ,tests of ovulation and tubal
patency have failed to detect any gross abnormality
Initial Consultation
 Infertile couples are usually advised to start their
investigations after 12 months of trying to conceive or
after 6 months .
Earlier evaluation
 Earlier evaluation is warranted for couples wherein the
male partner has known or suspected poor semen
quality or the female partner has irregular or
infrequent menses, a history of pelvic infection or
endometriosis, or is over 35 years of age.
basic infertility evaluation should include
tests aimed at the 4 most important causes
of infertility
 (1) ovulatory dysfunction
 , (2) abnormalities of semen
 , (3) abnormalities of the uterus and fallopian tubes,
 (4) reproductive aging.
tubal obstructions
 Proximal tubal obstructions prevent sperm from
reaching the distal fallopian tube where fertilization
normally occurs.
 Distal tubal occlusions prevent ovum capture from the
adjacent ovary.
 Whereas proximal tubal obstruction is essentially an
all or none phenomenon, distal tubal occlusive disease
exhibits a spectrum ranging from
 mild (fimbrial agglutination)
 moderate (varying degrees of fimbrial phimosis)
 severe (complete obstruction).
The etiology of tubal damage
 can be
 intrinsic : ascending salpingitis, salpingitis isthmica
nodosa),mucus pluck, polyp.
 extrinsic :peritonitis, endometriosis and pelvic
surgery).
Tubal factor evaluation
 The methods available for evaluating the fallopian




tubes include
traditional HSG,
laparoscopic “chromotubation,”
Sonohysterosalpingography
and the chlamydia antibody test (CAT).
hysterosalpingogram
 Assessment of tubal patency is one of the first steps in
fertility investigations.
 Hysterosalpingography (HSG) is the most common
first-line diagnostic test used for this purpose .
 In addition to assessing tubal patency, HSG also
provides an image of the outline of the uterine cavity.
 It has also been suggested that HSG has a therapeutic
role in enhancing subfertility
water-soluble or oil-soluble
contrast media
 Over the years, controversy has raged over the relative
advantages and disadvantages of water-soluble and
oil-soluble contrast media.
 both water-soluble and oil-soluble contrasts are
appropriate, depending on preference.
 test of tubal patency, HSG is approximately 60%
sensitive and 95% specific, meaning that when it
suggests obstruction, the tubes are often truly patent,
but when it demonstrates patency, the tubes are
almost always truly open.16
Normal HSG
 The relatively poor sensitivity of HSG as a test of tubal
patency results from the difference in test accuracy for
diagnosis of proximal and distal tubal occlusion. The
diagnosis of distal tubal obstruction generally is
accurate, but apparent proximal tubal occlusions are
often not real, representing artifacts of transient
uterine contractions, so-called “tubal spasm,” or
catheter placement (with the tip lying near one tubal
orifice).
 The HSG diagnosis of proximal tubal obstruction
must, therefore, be confirmed, either by repeating the
study, or by performing either fluoroscopic or
hysteroscopic selective tubal catheterization.
 Both false-negative (obstructions that are not real)
and false-positive results (patency that is not real)
occur, the former being much more common than the
latter.
 HSG is best scheduled during the 2–5 day interval
immediately following the end of men-ses, to
minimize risk for infection, avoid interference from
intrauterine blood and clot, and to prevent any
possibility that the procedure might be performed
after conception.
Bilateral tubal abstraction
Hydrosalpinx
Uterine cavity abnormalities
 can be a contributing cause of subfertility in 10 % of
women.
 Abnormal uterine findings are reported in as many as
50 % of women with recurrent implantation failure .
 These findings include endometrial polyps or fibroids,
intrauterine adhesions and congenital abnormalities .
Bicorn uterus
Uterus with Septume
Unicorn uterus
Uterine myoma
Severe Asherman
TB
Sonohysterography:
The Thickened endometrium may
be a Submucosal leiomyomas
Septate uterus
Sonohysterosalpingography
hysterosalpingo-contrast
sonography
Laparoscopic “Chromotubation
 Although generally more accurate than HSG, the
diagnosis of proximal tubal occlusion has the same
pitfalls as HSG and, ideally, should be confirmed by
selective tubal catheterization.
Chlamydia antibody test
 The most common causes of pelvic inflammatory
disease (PID) are Chlamydia trachomatis, Neisseria
gonorrhoeae .
 Studies have demonstrated that the severity of tubal
damage found in infertile women is directly related to
their serum chlamydia antibody IgG titer (CAT)
Chlamydia antibody test
 Most asymptomatic tubal pathology is mainly
 attributed to the history of pelvic inflammatory
disease (PID).
 past Chlamydia infection using serology is
 readily available and the test is simple and quick to
perform.
Chlamydia antibody test
 Several European studies have suggested that the
sensitivity of CAT for detection of tubal pathology
approaches that of HSG and laparoscopic
chromotubation.
 At least in theory, the CAT should help to identify
women with tubal pathology who might benefit most
from more specific tests, such as HSG or laparoscopic
chromotubation.
 However, at present, the diagnostic accuracy of the
CAT has not been established and the test is not used
widely in the United States.
Chlamydia antibody test
 So while a negative CAT can be reassuring, a positive
test would warrant more invasive diagnostic
procedures, such as laparoscopy, to assess the severity
of the disease even if there is no history of chlamydial
PID.
Chlamydia antibody test
 The Dutch Society for Obstetrics and Gynaecology
(NVOG) recommends the use of CAT as a first-line test
in the basic work-up of
 subfertile couples, with a fixed cut-off level
(immunoglobulin G MIF 1:32 or ELISA 1.1) above which
post-infectious pelvic disease should be ruled out with
laparoscopy and chromotubation.
Human Reproduction, Vol.26, No.5
pp. 967–971, 2011
 Should a hysterosalpingogram be a first-line
investigation to diagnose female tubal subfertility
in the modern subfertility workup?
Conclusion
 CAT is comparatively inexpensive, less invasive and can be
performed
 at any time during the menstrual cycle and can identify patients
who
 need further evaluation.
 Laparoscopy remains the gold standard in diagnosing tubal
pathology.
 We also suggest a flow chart of investigations for determining
tubal
 pathology in women with subfertility as a compromise between
invasiveness and diagnostic accuracy (Fig. 1), rather than a
blanket policy of using HSG.

 For CAT-positive patients, laparoscopy may be
warranted,
 whereas CAT-negative patients should have a HyCoSy
that carries a similar cost and has at least the same
accuracy as HSG while avoiding radiation.
 We feel that HSG is out of date and has no place in
modern evidence-based fertility investigations.
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