8.Perform advanced tests on the woman: Some patients will require advanced investigations, such as laparoscopy, endocrine tests and/or ovarian reserve assessment, to establish a correct diagnosis and prognosis.
A laparoscopy may be indicated if the hysterosalpingography is inconclusive or shows proximal occlusion; or in the presence of co-morbidity such as chronic pelvic pain or suspected endometriosis. The diagnostic role of the laparoscopy to identify adhesions, tubal/fimbrial damage/obstruction, endometriosis, myomas, ovarian cysts/status, and/or congenital anomalies should always be combined with its therapeutic potential; in other words, the procedure should be performed by a surgeon who is competent to perform appropriate surgical intervention if pelvic pathology is encountered.
A hysteroscopy can establish the presence of intrauterine pathology, for example submucosal uterine fibroid(s), septum, polyp(s), adhesion(s) and/or congenital uterine anomaly. If pathology is present this should again be addressed surgically at the time of the diagnostic procedure.
In most women, midluteal progesterone has no advantages over a menstrual history to confirm ovulation. It is useful in women with irregular cycles and to confirm that pregnancy has not occurred prior to the initiation of ovulation induction.
Further endocrine investigations can assist in establishing a cause for chronic anovulation. These include blood tests for the measurement of gonadotropins, prolactin, androgens and thyroid stimulating hormone. Women with polycystic ovarian syndrome (PCOS) should also have metabolic investigations of glucose and lipid functions (Legro, 2013). A history should be obtained regarding possible exposure to endocrine disruptors (e.g. dioxin) in the woman’s living or work environment.
A common cause of ‘unexplained’ infertility is diminished ovarian reserve. This is physiological among women in their late 30s and early 40s; it can also affect young women who had ovarian surgery, chemotherapy, endometriomas or even in the absence of identifiable causes and risk factors. The following tests can be used to assess ovarian reserve: Antral Follicle Count (AFC), Anti-Mullerian Hormone (AMH) measurement, as well as early follicular phase Follicle-Stimulating Hormone (FSH) and estradiol (E2). However, these tests generally are not robust predictors of pregnancy and must be interpreted carefully. (ASRM, 2014)
Tuberculosis can cause serious uterine pathology and should be considered as a potential cause of infertility (WHO, 2007). Infertility is the most common presentation of female genital tuberculosis (FGTB) with a reported incidence of 40-80% (Bazaz-Malik, 1983, Bhide, 1987, Jindal, 2006). The actual incidence may be under-reported as the majority of FGTB infection is asymptomatic. The diagnosis of genital tuberculosis is often difficult and elusive and a high index of suspicion is the first step in most asymptomatic women. Moreover technical drawbacks involved with the available “Gold standards” such as AFB staining, culture of Mycobacterium tuberculosis and demonstration of tuberculous granulomas on histology make diagnosis and, therefore, management difficult. While active tuberculosis may be detected with available standard and ancillary tests, latent tuberculosis persists and continues to be missed with available Gold standard tests. While active genital tuberculosis may be diagnosed by HSG and laparoscopy, the diagnosis of latent FGTB may require tests at the molecular level. (Malhotra, 2014)
The interpretation of advanced tests in an infertile patient requires special expertise. (ASRM, 2008d; ASRM, 2008k; ASRM, 2008l; ASRM, 2012a; ASRM 2012b; ASRM 2012c; ASRM and SMRU, 2008)