Villegas, Jose Bernabe

GYNECOLOGY
Vinluan, Joseph David Dr.
Teresa Luna
Wong, Deo Adiel July 31,
2007
Yague, Glenn
3rd Year-D
Yang, Caprice

Case #9
A 25 year old, single nulligravid, came for consult with her live-in
partner because they finally decided to “settle down” and raise a family of
their own. They have been living-in for 1 year. Her partner is a 47y.o.
businessman and has a 12 y.o. son from a previous relationship. She has 2
previous casual partners. LMP: July 18-22, 2007 PMP: June 20-24, 2007 PPE:
Spec. exam (+) clear mucoid non-foul discharge; IE: cervix – firm, long,
closed; uterus – normal size, movable, non-tender; Adn: (-)mass (-)
tenderness

1. What other information should be extracted from the history?

Clinical assessment and a thorough history should be taken before the

couple is subjected to investigations, both invasive and non-invasive. Above
all, obtain a history of previous pregnancies and their outcomes; interval
between pregnancies; and detailed information about pregnancy loss,
duration of pregnancy, human chorionic gonadotropin (hCG) level, ultrasound
data, and the presence or absence of a fetal heartbeat. All of these will
establish the integrity of the female genital tract, its endocrine functions and
its ability to sustain normal cycles to efficiently support its function of
reproduction.

Most importantly, question female patients about their menstrual

history, frequency, and patterns since menarche, especially when considering
factors that might contribute or point out to anovulation as a cause.
Nonetheless, it cannot be overemphasized the importance of considering
other causes of problems in reproduction whether it is endocrine – a factor
that may point out to systemic conditions and immunologic factors,
unexplained factors like endometriosis, problems intrinsic in the female
genital tract, surgical causes like tubal injury or adhesions or just a decrease
in ovarian reserves. If this is the case, then a thorough history is needed as to
the history of weight changes, hirsutism, frontal balding, and acne; history of
connective tissue diseases and other chronic diseases (systemic lupus
erythematosus or chronic renal failure); a history of surgery involving the
abdomen or the genito-urinary tract or any complications from examinations
done in the past involving aforementioned systems; and especially any
recalled changes in the normal pattern of menses sustained in 3 to 4 months
should be delved upon when considering issues regarding problems in
fertility.

Specific questions should address the issues of frequency of

intercourse, use of lubricants (eg, K-Y gel) that could be spermicidal, use of
vaginal douches after intercourse, and the presence of any sexual
dysfunction such as anorgasmia or dyspareunia. This will more or less point
out to temporal and/or pertinent external factors working outside the couple
that may give us a clue on factors that may contribute, whether it be
modifiable and/or can be eliminated, to problems regarding reproduction.

Ask male patients about previous spermiogram results (if there is any),
history of impotence, premature ejaculation, change in libido, history of
testicular trauma, previous relationships, history of any previous pregnancy,
and the existence of offspring from previous partners. These will establish if
there can be no reason to attribute infertility on the part of the man,
especially if there is a history of previous pregnancy in his part. This will only
mean that there has been normal functioning from before. Now temporally
speaking, when considering external factors or changes which may be
attributed to increasing age, then inquire some more if the previous normal
functioning has been ushered by any recent observation of changes in the
functioning of the gonads like premature ejaculation, or any sudden incident
of trauma. This will point out to any recent causes that may contribute to
problems in fertility.

Ask the couple about their history of sexually transmitted diseases

(STDs) whenever considering infectious causes of infertility or any risk-taking
behaviors that might predispose to the mentioned problem; surgical
contraception (eg, vasectomy, tubal ligation) that might have been done in
the remote past; lifestyle factors as simple as having a hectic job/day that
requires long hours of work and late night overtimes that may reveal
problems in making time; consumption of alcohol, tobacco, and recreational
drugs (amount and frequency) which may all have side effects on the
functioning of the gonads that will consequently lead to infertility; occupation
that adversely expose either or both of them to hazardous chemicals, fumes,
or dyes in which through inhalation or direct contact may yield the same
problem of infertility; and physical activities. These may all contribute, either
partly or additively, to problems of reproduction.

More specifically, consider:

• Age of both the partners: A woman above the age of 40 years has
less than half the fertility potential of a woman of 20 years. And a
man above the age of 40 years can also show a lowering sperm
count, although, a man can father children for his lifetime.
• Previous children: If one of the partners has children from a
previous union, a rough idea of the cause of infertility can be made.
• Duration of the present union: If the couple has practiced
contraception at any time, if their occupations separate them for
any duration of time etc.
 • Frequency of intercourse – Coitus or sex must occur every 48 hours
from the 8th to the 18th day of the menstrual cycle for an optimum
chance at pregnancy. Too frequent coitus however is rarely a cause
for infertility. Rare occasions of sex or coitus is more likely to cause
infertility.
• Pain during intercourse: Many women avoid having sex or have
irregular intercourse due to vaginal pain and may complain of
infertility.
• Coital history : How often is coitus practiced? Is it normal or painful?
Is erection, penetration and ejaculation normal?
• Menstrual history : Is the menstrual cycle regular? Duration of flow,
amount of bleeding, pain during menses.
• Male partner's occupation: Constant heat can lower the sperm
count. So occupations that can cause the male partner to drive long
distance can cause infertility. Pesticides and certain anesthetic
drugs can also lower sperm count.
• Previous illnesses and operations: If either of them had ever had
any operations near or on the genital tracts, if either of them had
ever had any infections, especially infections by the chlamydia or
gonococci organisms.
• Family medical history of both partners: Certain conditions like
diabetes, high blood pressure, thyroid diseases can be genetically
transmitted and can lead to low fertility.
• Lubricants: Sometimes when coitus or sex is difficult due to a dry
vagina, many couples use lubricants like paraffin or lanolin. Many of
these lubricants have a toxic effect on sperm and prevent
pregnancy.
• Miscellaneous: Drugs, medicines. Alcohol and smoking habits.

The aim of treatment is to remove any of the identified factors causing

infertility. Both the male and female partner's should be explained about the
findings and a plan of treatment evolved accordingly.
Reassurance : Most couples appreciate a description of the
physiological process of fertilization and conception. A sympathetic hearing of
their difficulties goes a long way in decreasing the stress involved in visiting a
doctor for treatment.

CAUSES OF FEMALE INFERTILITY

About 40% of all cases of infertility are due to problems with the
female partner.
Another 30% are due to problems in the male partner.
The rest of the remaining 30% of cases are due either to a cause which
affects both the partners, or to a cause which cannot be identified.
For a pregnancy to occur, three things are vital. There are other issues
involved, but these 3 are the most important. So, if the couple cannot
conceive and suffers from infertility, there has to be one of these problems:
• Ovulation: In a normal menstrual cycle of 28 -30 days, a woman
ovulates (produces an egg from her ovary) at about the 14 -16th
day.
 • Patent Genital tract: The female genital tract has to be open and
free of any obstructions so that the sperm can reach the egg.
• Adequate Male sperm: The male partner needs to have adequate
sperms in his semen for pregnancy to occur.

Thus, the main causes of female infertility are Anovulation and Obstruction in
the genital tract.

A. Causes of Anovulation: This is the commonest cause of infertility in

women, accounting for 40% of all causes. It is unlikely in women who are
menstruating regularly but is not uncommon.
• Age: There is a steady decline in the rate of ovulation after the age
of 35 years. The rate of ovulation and successful pregnancy at the
age of 40 years is almost half that at the age of 20 years.
• Polycystic Ovarian Disease (PCOD): This is a condition characterized
by a number of minute cysts in the ovaries and a grossly reduced
ovulation rate. Ovulation may be irregular and not occur in every
month. In severe cases of PCOD, ovulation may stop altogether.
There is also associated hormonal imbalance with a high level of
hormones like insulin and androgen in this condition.
• Defects in the endocrine glands: Glands like the thyroid and the
pituitary are active participants in maintaining normal fertility . Both
hypo- and hyperthyroidism can cause anovulation. High levels of
prolactin secreted by the pituitary is also an indicator of irregular
ovulation. A high insulin level is frequently associated with PCOD.
• Endometriosis: This is a condition where bits of the endometrium
(inner uterine lining) grows in places other than inside the uterus. If
this growth occurs on the ovary, it can cause anovulation.
• Ovarian Infections / tumors: Both infections and tumors can not
only physically block ovulation but can also cause hormonal
imbalance leading to anovulation.
• Leutenized unruptured Follicles: This is a condition where the
graaffian follicles develop normally but fail to ovulate - usually
because of a lack of stimulus by a low LH level.
• Subclinical Adrenal Cortex Failure: The hormones of the adrenal
cortex is closely linked to the reproductive process. So any problem
with these hormones - either a low level or a high level - can cause
anovulation.
• Sex Chromosome defects: Sex chromosomal defects like XXY, XXXY,
XYY etc. can cause anovulation.

B. Obstruction in the Genital Tract: Obstruction can occur anywhere in

the genital tract - the tubes, the uterus, the cervix or the vagina. Adhesions
or scar tissue in the pelvis around the tubes can also cause obstruction and
prevent the sperm from reaching the ovum to fertilize it.

Tubal Obstructions – Tubal obstructions may be total or partial and may

account for 20% of all cases of female infertility. Endometriosis and
pelvic inflammatory diseases, usually as a result of Chlamydia
 infection are common culprits. Some important causes of tubal
obstruction are:
• Previous infections of the tubes: Infections can occur due to
abortions or previous childbirth. Common infecting organisms are S.
aureus, S. pyogenes. A very common infection is by the Chlamydia
trachomatis organism which causes no specific symptoms at the
time of infection, but the damage it causes to the tubes are
discovered only on investigating for infertility.
• Infections of the genital organs by N. gonorrhoea, Chlamydia
trachomatis or M. tuberculosis
• Congenital Absence of the tubes from birth usually as a result of sex
chromosomal defect.

Pelvic Adhesions – Adhesions are scar tissues formed as a result of

previous infections and may affect the tubes at different regions.
• Fimbrial Adhesions: Adhesions near the fimbria of the tube (part of
the tube near the ovaries) may pull the tube out of its proper
position and prevent ‘picking up’ of the ovum by the tube.
• Peritubal adhesions: Strands of adhesions may create a mechanical
barrier between the tube and the ovary.
• Buried ovary: The ovary may be completely or partially buried in
dense adhesions preventing ovulation or ovum pickup.

Uterine Factors - Certain conditions in the uterus may affect

fertilization and implantation of the ovum.
• Absence of the uterus: from birth or by surgery.
• Atrophy: or small size of the uterus, insufficient to support
pregnancy, usually a result of surgery on the uterus or radiation.
• Uterine synechia: Synechia are adhesions inside the uterus causing
the two walls of the uterus to fuse together, totally or partially, thus
obliterating the endometrial cavity.
• Uterine tumors: Certain uterine tumors like fibroids may block the
tubal opening, or prevent implantation of the fertilized ovum.

Cervical Factors - Cervical factors may affect the upward movement of

the sperm and prevent pregnancy.
• Poor cervical mucous – The cervical mucous may be thick and
impenetrable due to low estrogenic stimulation. This will act as a
barrier or obstruction to the sperm. Acidic mucous or the presence
of anti-sperm antibodies in the mucous can also prevent ascent of
the sperm.
• Loss of cervical mucous: due to surgery and amputation of the
cervix, or excessive cervical diathermy.
• Faulty direction of the cervix: The cervix normally faces into the
posterior vaginal vault where the sperm tends to pool. In some
patients, the position of the cervix may be abnormal due to faulty
direction of the uterus (retroversion), uterine prolapse or cochleate
uterus.
• Cervical Tumors: Tumors like polyps or cervical fibroids can block
the cervical canal.
 Vaginal Factors:
• Vaginal tumors
• Vaginal septa: Vaginal septa or membranes can cause a mechanical
barrier to the sperm.
• Vaginal infection with purulent pus: Infections such as by the
trichomonas organism is believed to cause infertility. But this is still
under research and has not been proved conclusively.

INFERTILITY by Soniya Patel (Madrid 28011, Spain)

100cm x 200cm. Oil and mixed media on canvas.
Commissioned art work portraying the anguish, hope, eroticism
and obsession that accompanies the desperate search for an
elusive child. Year 2006

2. What initial investigative procedures should be done?

Semen analysis, confirmation of ovulation, and documentation of tubal

patency are the basic investigations that should be performed before starting
any infertility treatment.

A. Semen Analysis:

The basic semen analysis measures the semen volume, sperm concentration,
sperm motility, and sperm morphology.

Specimen collection- sexual abstinence of 2 to 3 days before semen analysis

is recommended because a decrease in sperm concentration is associated
with frequent ejaculation. The specimen should be delivered to the laboratory
within 30 minutes to 1 hour, and should be kept at body temperature;
otherwise this might alter the results.

Normal seminal fluid analysis (WHO)

 Volume >2 mL

Sperm concentration > 20 M/mL

Sperm motility >50% progressive or

>25% rapidly
progressive

Morphology (strict >15% normal forms

criteria)

WBC > 1 M/mL

Immunobead or mixed <10% coated

antiglobulin reaction
B. test
Assessment
for Ovulation :

• Basal Body temperature (BBT) : this is the least expensive

method of confirming ovulation. The patient records her
temperature each morning on a BBT chart. The body temperature is
raised by progesterone (progesterone is thermogenic) and is thus
higher after ovulation in the luteal phase, than in the follicular
phase. The difference in temperature may be between 0.5 - 1
degrees. This change in temperature can be recorded on a chart and
gives a fair indication of ovulation.

The temperature is recorded from the 1st day of the menstrual cycle.
The oral temperature should be taken first thing in the morning while the
woman is still in bed, before taking any food or even rinsing the mouth.
There may be a sharp drop of about 0.5 degrees just at the time of
ovulation. Then the temperature rises and stays more than 1 degree above
the pre-ovulation temperature. If pregnancy occurs, it continues to remain
high throughout pregnancy. But if pregnancy does not occur, it begins to
drop again 2 – 3 days before the start of the next menstrual cycle.

The BBT can be altered by lack of sleep, stress or fever. It is not very
reliable in women with irregular cycles. But its advantage is that it can be
done by the couple themselves in the privacy of their home. The drawback
of this method is that presumptive ovulation can only be identified
retrospectively, that is, it merely confirms that ovulation has occurred.

• Cervical Mucous : At the time of ovulation the cervical mucous

changes from a thick consistency to a thin, watery consistency. It
can be drawn out into threads more than 10 – 15 cm long. This is the
Spinnbarkeit test. If the mucous is spread out thickly on a glass slide
and allowed to dry, it shows a typical ‘fern pattern’ under the
 microscope. Both these tests indicate a level of estrogen adequate
to cause ovulation.

• Ovulation Kits (LH monitoring) : Ovulation kits are commercially

available in the market to test for ovulation. Ovulation occurs 34 to
36 hours after the onset of LH surge and 10 to 12 hours after the LH
peak. These kits test for the LH surge just before ovulation using
ELISA (40 mIU/mL) as the threshold for detection. In 5-10% of
women, ELISA test cannot detect urinary LH; serum LH is used in
these cases.

• Hormone levels : If ovulation occurs, the serum progesterone

level in the blood on the 5 – 8th day after ovulation (approximately
21st day of the menstrual cycle) becomes high, around 10 – 60
nmol/L.

• Ultrasonography (USG) : USG is used for real-time visualization

of the gradual growth of the follicles, the number and size of the
follicles and the corpus luteum after rupture of the dominant
follicle. Ovulation is characterized by a decrease in size of
monitored ovarian follicle and appearance of fluid in the cul-de-sac.

C. Tubal Patency Tests :

• Hysterosalpingograhpy (HSG) – the initial diagnostic test and

most widely used test for tubal patency in the investigation for
female infertility. HSG is usually performed between cycle days 6
and 11. During menses, HSG avoided because of incidence of
vascular intravasation caused by dilation of periuterine veins. A
non-irritant radio-opaque dye is injected through the cervix into the
uterus. X-rays are taken of the movement of the dye through the
uterus, the tubes and then the spillage into the abdominal cavity
through the fimbrial end of the tubes. Any block in the passage is
shown up in the X-rays.

The advantage of a HSG is that not only does it reveal whether a

block is present, it also reveals the position of the block in the
reproductive tract, and also the presence of adhesions around the
tubes.

 Falloposcopy- allows direct fiberoptic visualization of the tubal

ostia and intratubal architecture. It also allows the visual
identification of tubal ostia spasm, abnormal tubal mucosal patterns,
and even intraluminal debris causing tubal obstruction.

 Sonohysterography with contrast media- a less invasive

method of diagnosing fallopian tube obstruction; sensitivity and
specificity similar to laparoscopic chromotubation.
 • Laparoscopy : Dye injected into the cervix during a laparoscopy
operation can be observed spilling out of the tube if patent. This is a
most reliable test as it is directly visualized. Advantage of the test is
that identified abnormalities such as tubal obstruction, pelvic
adhesions, and endometriosis, can be treated at the time of
diagnosis. Disadvantages are that it is an operative procedure and
requires the patient to be admitted to the hospital for at least one
day.

3. What work-ups are necessary?

The following algorithms are from the National Guideline Clearinghouse’s

Diagnosis and Management of basic infertility.

Additionally:
  Post-Coital test :
• Sims-Huhner test : In this test, a drop of mucous is removed
from the cervix not later than 12 hours (preferably within 2
hours) after coitus. The mucous is examined under a microscope
for sperm and their motility, if any. The test is said to be
positive, if there are at least 5 motile sperms found in the
cervical mucous.

• Kremer Test : A drop of mucous at the time of ovulation is

collected and placed on a glass slide. A drop of the husband’s
semen is placed near it. Invasion of the mucous by the sperm is
examined under a microscope. Donor semen with the wife’s
mucous and donor mucous with the husband’s semen can also
be used for differential diagnosis.

 Hormone assays : Tests for TSH, T3, T4, prolactin level, insulin level and
androgen level should be done. Conditions like hypothyroidism,
hyperprolactinemia, and PCOD can cause infertility by interfering with normal
ovulation.

• Blood tests : VDRL test, ESR for any infections, blood glucose test.

References:

• Berek, J. Novak’s Gynecology, 14th edition.

• http://www.aafp.org/afp/20070315/857ph.html

• http://www.gynaeonline.com/infertility.htm

• http://www.gynaeonline.com/causesfemaleinfertility.htm

• http://www.gynaeonline.com/investigationsfemaleinfertility.htm#investigation
s

• http://www.gynaeonline.com/treatmentfemaleinfertility.htm#treatment

• http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=5567&strin
g= Institute for Clinical Systems Improvement (ICSI). Diagnosis and
management of basic infertility. Bloomington (MN): Institute for Clinical
Systems Improvement (ICSI); 2004 Jul. 47 p. [85 references]