1. Complete history and physical examination: as previously outlined.
a. An HSG is a fluoroscopic examination used to demonstrate uterotubal disease.
b. An HSG should be performed early in the workup of the infertile female. Laparoscopy and HSG are complementary procedures. Chromotubation at the time of laparoscopy does not replace the HSG. Valuable information about the uterine cavity, such as intrauterine filling defects and the status of the fallopian tubes (i.e., the location of tubal occlusion), can be delineated by HSG.
c. HSG should be done before laparoscopy to verify and treat (if possible) at the time of surgery.
d. The timing of HSG should be just after the patient finishes her menses and well before the time of ovulation.
e. Indications for HSG.
(2) Abnormal uterine bleeding
(3) Repetitive pregnancy loss
(4) Confirmation of uterine myomas
(1) Current or suspected pelvic infection: HSG can lead to salpingitis or endometritis if performed during an active infection. Patients with a history of pelvic inflammatory disease (PID) have a 1% to 3% risk of recurrent infection after an HSG and therefore should be treated with antibiotics (doxcycline 100 mg, bid) beginning 24 hours before the examination.
(2) Active bleeding: Active bleeding at the time of HSG can lead to contrast extravasation; passage of blood into the peritoneal cavity, possibly leading to endometriosis; and an inaccurate diagnosis of an intrauterine filling defect because of the presence of blood clots in the cavity.
(3) Pregnancy: When HSG is inadvertently done during an early pregnancy, it is usually an “all-or-none phenomenon.” If the fetus survives (which is usually the case), it will not be affected by the exposure.
g. Procedure technique.
(1) The physician inquires as to allergies to shellfish or iodine.
(2) The physician inserts speculum and cleans cervix with betadine.
(3) The physician places a single-tooth tenaculum on the anterior lip of the cervix and introduces the Kahn cannula into the os.
(4) The speculum is removed slowly to avoid disrupting the cannula.
(5) Contrast is injected slowly while always visualizing the uterine cavity for filling defects and the tubes for abnormal contour.
(6) The physician should attempt to demonstrate tubal patency. However, the patient should not be tortured in the attempt.
3. Semen analysis.
4. Hormonal development: The menstrual cycle consists of three distinct phases.
a. Follicular phase (time during which the follicle develops): This phase is characterized by a rising estradiol.
(1) The estradiol should peak at the time of ovulation at approximately 300 pg/mL.
(2) Progesterone in the follicular phase is always less than 1.
(3) It should be remembered that actual ovulation occurs 36 hours after the onset of the LH surge.
(4) An easy way to determine the day of ovulation is to subtract 14 days from the total cycle length to give the day of ovulation.
b. Luteal phase (begins after ovulation, which is brought about by the LH surge).
(1) Any time the LH level rises two to four times above the baseline level, it is considered to be the ovulatory surge.
(2) This phase is characterized by rising progesterone levels (>2 ng/mL) and also by a secondary peak of the estradiol level on day 21.
(3) If a pregnancy occurs, then the hormone levels remain elevated.
(4) If no pregnancy occurs, then the hormone levels drop and menses begin.
(5) The basal body temperature (BBT) will rise 0.3° to 0.5° during the luteal phase and is associated with progesterone levels greater than 4 ng/mL.
(6) Care must be taken because BBT charts can be misleading.
c. Menstrual phase: A drop in hormones leads to the onset of menses.
5. Follicular development.
a. The follicle is a fluid-filled sac that contains the oocyte. It should be 18 to 25 mm at the time of ovulation.
b. The development of the follicle can easily be followed by transvaginal ultrasound.
c. An easy way to determine whether follicles of the correct size are being produced is to scan the patient 15 days before her expected menses. This should be just before ovulation.
6. Cervical mucus or postcoital testing.
a. Cervical mucus is estrogen dependent. There should be an increase in production at the time of ovulation.
b. Mucus is evaluated for the following:
(1) Consistency: should be thin, clear
(2) Spinnbarkeit: thready stretchability
(3) Ferning: product of estrogen influence
(5) Volume: should be abundant
(6) pH: 6.4 to 8.0
c. A postcoital test (PCT) should be done 6 to 10 hours after inter-I course. The endocervical specimen should contain 25 sperm per high-power field (HPF). Ten or more sperm with progressive motility should be considered an adequate PCT.
7. Endometrial biopsy.
a. The endometrial biopsy is used to diagnose a luteal phase defect (LFD). LFD is defined in one of the two following ways:
(1) An inadequate amount of progesterone being secreted by the corpus luteum
(2) The inability of the endometrium to respond to adequate progesterone concentrations
b. The diagnosis of LFD is made by two endometrial biopsies greater than 2 days out of phase.
c. Endometrial biopsy should be done 12 days after the LH surge.
d. Samples should be removed via a small pipette (Pipelle) from the anterior uterine wall to avoid possibly disrupting an early implantation, because the posterior surface is the most common site of implantation.
e. Pretreatment of patients with acetaminophen or Naprosyn is advised.
a. Surgery should be the last step in the workup.
(1) Laparoscopy can be both diagnostic and therapeutic.
(2) Visualization of the pelvis must be done to make the diagnosis of endometriosis or pelvic adhesions.
(3) Laparoscopy can be done in the follicular or the luteal phase of the cycle. If chromotubation is planned, it should not be done during the menstrual cycle.
(1) Hysteroscopy should be done when there is a suspected or known intrauterine defect. This is why hysterosalpingography is so important.
(2) Tubal cannulation of proximal obstruction of the fallopian tubes can be accomplished hysteroscopically.
(3) Intraoperative HSG can be done to assess the uterine cavity during an operative hysteroscopic procedure.