Level 2 or Intermediate Care level services (all levels between level 1 and level 3):
5. Perform available tests on the woman: Basic imaging tests, including ultrasound and hysterosalpingography, and basic endocrine laboratory tests should be offered where available and indicated.
Tubal factor infertility is the leading cause of infertility in many low-resource settings and, hence, an assessment of tubal patency is valuable in many instances. Hysterosalpingography (HSG) is a useful screening test especially for the diagnosis of distal tubal occlusion with and without associated hydrosalpinges. The diagnosis of proximal tubal occlusion is less accurate as this may be due to tubal spasm rather than true occlusion. Ideally proximal occlusion should be confirmed by a second test, usually laparoscopy. HSG may also miss the presence of peritubal adhesions and cannot be used to diagnose endometriosis. HSGs have a therapeutic benefit as there is an increased chance of post-procedure pregnancy if an oil-soluble contrast medium is used. (ASRM, 2012a; NICE, 2012; Luttjebroer, et al, 2007; Lindgren, 2009)
Alternatively, fluid (saline) or contrast medium can be inserted into the uterus and tubal patency can be diagnosed with ultrasonography (hysterosalpingo-contrast-sonography or saline infusion sonography); but this requires a person who is very experienced in the technique. (ASRM, 2012a, NICE, 2012) Determine the chlamydia antibody titre, if possible, because high titres strongly suggest tubal pathology. (Mol, et al, 1997; ASRM and SRS, 2008b)
An ultrasound can assist in the diagnosis of polycystic ovarian syndrome, a common cause of anovulation, and demonstrate other pathology such as ovarian cysts, endometriomas (chocolate cysts of endometriosis), uterine fibroids and endometrial polyps. Some hydrosalpinges can also be visible on ultrasonography. (ASRM 2012c, NICE, 2012; ASRM 2006a; ASRM 2008f; ASRM & SRS, 2008a; ASRM and SRS, 2008b)
The majority of women with regular periods every 25-35 days are ovulating. However, where available, a mid-luteal phase serum progesterone test, done 7 days before the next menstrual period, is useful in confirming the presence or absence of ovulation. Basal body temperature charts are not very reliable in determining ovulation. (ASRM, 2012c; NICE, 2012)