The female partner is specifically assessed for ovarian reserve, one basic transvaginal ultrasound and evaluation for tubal patency. The various tests are described below:
1. Ovarian Reserve Assessment
(a) Age: Age is a very good indicator of ovarian reserve. The oocyte number and quality declines with age. The fertility peaks at 20-25 years of age and number of eggs declines sharply after 37 yers of age.
(b) Biochemical Tests:
- Serum Anti mullerian Hormone (S.AMH): She is evaluated for ovarian reserve by S.AMH. AMH is secreted by the developing follicles of 2-9 mm. It is quite a good indicator of ovarian reserve. Infact, S.AMH is more sensitive and specific than the antral follicular count (AFC) on ultrasound as it also reflects pre antral and small antral follicles (<2 mm), which are hardly seen in ultrasound. It has many advantages over other markers of ovarian reserve, like it can be done during any day of the cycle unlike AFC and S. FSH which can only be measured during the first five days of cycle and its values are stable from one cycle to another.
- Follicle Stimulating Hormone (S.FSH ): It is also commonly used for measuring ovarian reserve. S.FSH >12 IU/L indicates poor ovarian reserve. S. FSH is measured on day 2 /3/4 of cycle.
- Inhibin B: Its an hormone secreted by the preantral follicles .With advncing age, the number of folicles decreases hence there is a decrease in Inhibin – B levels is an ovarian hormone that inhibits FSH release.
- Estradiol: Day 3 E2 levels < 50pg/ml combined with normal FSH indicate good response to stimulation and better pregnancy rates. High E2 levels on day 2/3 of cycle suggest premature selection of follicles. This may occur as the ovary ages, or when ovarian follicular cysts remain from a prior menstrual cycle. This follicular cysts may interfere with egg selection in current cycle and might lead to poor response to fertility treatment.
(c) Ultrasound Imaging
Antral Follicular Count (AFC ): The antral follicular count describes the total number of follicles measurng 2-10 mm in both the ovaries. AFC is assessed preferably during early days of the cycle .Total AFC count of < 5, indicates poor ovarian reserve.
- Ovarian Volume: Ovarian volume of < 3 ml, predicts poor response to ovarian stimulation. Ovarian volume has a limited value for predicting ovarian reserve.
(d) Proactive Tests:
- Clomiphene Citrate Challenge Test (CCCT): In contrast to the static measurements of ovarian reserve mentioned previously, the clomiphene citrate challenge test (CCCT) is a dynamic approach.
When undergoing CCCT, the first step is to measure day 3 FSH and E2. Then 100 mg of clomiphene is administered on cycle days 5 through 9, and FSH and E2 measurements are repeated on cycle day 10. In general, a high day 10 FSH suggests poor ovarian reserve. Clomiphene stimulates follicles to grow which causes E2 secretion. This E2 via a negative feedback mechanism causes suppression of FSH secretion from pituitary. In patients with poor ovarian reserve, there is poor follicle growth hence low E2 which in turn causes more production of FSH.
2. Transvaginal Sonography
Infertility evaluation is incomplete without a transvaginal sonography. It is usually done to evaluate the uterus and the ovaries. Uterus is evaluated for size, shape and position and specially looked for any mass like fibroid, polyp, adenomyosis or any adhesions in the endometrial cavity. Simultaneously the ovaries are assessed for antral follicular count and ovrian volume and to rule out any ovarian mass like endometriosis. Tubes are generally not seen on ultrasonography unless they are diseased and dilated as in hydrosalpinx.
3. Evaluation of tubal patency
Hysterosapinography: It is the most common procedure to evaluate patency of fallopin tubes. This procedure visualizes the uterine cavity and the fallopian tubes under fluoroscopic guidance in an X Ray Room.
Sonosalpingography: It is another method for evaluating tubal patencancy. It is reliable, simple and well tolerated method to assess tubal patency in an outpatient setting.
Laproscopy: It is the best technique for diagnosing tubal and peritubal disease. In todays era of excellent ultrasonography combined with very high sensitivity and specificty of HSG, Laproscopy is prefered when there is associated pelvic pathology like endometriosis, fibroid or blocked tubes on HSG or Sonoslpinography where corrective surgery can be performed in the same sitting. Thus it is used more as a therapeutic modality for correcting pelvic pathologies rather than just a diagnostic tool.