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Investigation

Blood Hormone assays
These tests should be performed during the first three days of the cycle, preferably on an empty stomach. Some tests can be done on the 21st day of the period. If the woman has no period, then the test can be performed anytime
 
 
Sonography of the Pelvis
 

Ultrasound is a process whereby high-frequency sound waves, not radiation, are transmitted through tissue. A thin ultrasound probe is inserted into the vagina and the images on the screen are examined to evaluate the uterus and ovaries. 

  A transvaginal ultrasound (TV USG) is the preferred route for gynaecological evaluation as it gives more accurate information. Another advantage is that it does not require a full bladder which can be very uncomfortable for the patient. In fact, the bladder has to be emptied prior to the scan. A thin ultrasound probe is inserted into the vagina and the images on the screen are examined to evaluate the uterus and ovaries. The Fallopian tubes cannot be evaluated by USG. Early Endometriosis and adhesions may not be picked up on USG.

 
 
Follicle Monitoring
TV USG is started on day 1,2 or 3 and then from day 9 onwards, every alternate day, until ovulation. As the ultrasound waves strike the tissues, they project a white image on the ultrasound screen. Follicles are round sacs of fluid within the ovaries. Therefore, the follicles appear as dark circles on the ultrasound screen. Each follicle contains an egg; however, the eggs cannot be seen during the ultrasound. Ovulation, if occurring, would take place usually by day 14 – 18. On an average, 5-6 visits are required to complete an evaluation.

 
 
Post Coital Test
This is done 10-12 hrs after intercourse, around ovulation time, to check whether the sperm is able to swim through the mucus at the mouth of the uterus into the uterus to fertilise the egg. It is not a painful procedure. A speculum is inserted into the vagina and the mucus sucked out very gently with a syringe and placed on a slide. The slide is then examined under the microscope to look for sperm and the test is graded.

 
 
Semen Test

It is performed preferably after 2-3 days of abstinence. The semen should be collected in a clean, sterilised bottle, provided by the laboratory. It should be brought to the laboratory within ˝ hr of ejaculation, at room temperature. Do not use ice while transporting the semen sample or collect the semen in a condom and then transfer into the bottle for examination. Do not use any lubricants locally.

 
 
Hysterosalpingogram
This is a short minor procedure ( approx. 15 mins), wherein radio opaque dye is injected into the uterus,( via the vagina, through the mouth of the uterus) and an X-Ray is taken to visualise the uterus and tubes. This gives indirect information on the patency of the tubes and the shape of the uterine cavity. It does not give information on the external surface of the uterus, tubes and ovaries or of the pelvis behind these organs. It is usually well tolerated and does not require anaesthesia and hence there is no need to come fasting. Antibiotics are given routinely after the procedure and the patient goes home immediately.

 
 
Laparoscopy

This is a minimally invasive surgery and is also known as Band-aid surgery. It is a day care surgical procedure. While the patient is under general anesthesia, ( on an empty stomach) a one-half-inch incision is made in the skin below the navel (umbilicus). Carbon dioxide is pumped into the abdomen to make the organs of the pelvic cavity more easily visible.

The laparoscope, a narrow instrument similar to a telescope attached to a fiberoptic flexible light cable, is inserted, allowing visual inspection of the pelvic organs through a very tiny incision. This allows us to look for abnormalities that lead to infertility without the need for major surgery. Many conditions can be treated surgically too through additional small incisions in the lower abdomen. The carbon dioxide gas is then released and the incisions are stitched. There will be 1-2 stitches for a diagnostic laparoscopy and 3-4 stitches totally at the points of entry of the instruments for an operative laparoscopic surgery. Patients are usually able to go home within 4-6 hours of surgery.

Postoperative pain may be experienced (usually in the form of shoulder pain) as a little carbon dioxide may remain and until it is absorbed, will irritate the diaphragm( muscle separating the chest from the abdomen). Since the diaphragm has the same nerve supply as the shoulder, the ‘referred pain’ will be experienced there.

Often a hysteroscopy is performed at the same time as a laparoscopy especially in women who are undergoing an infertility investigation.

 
 
Hysteroscopy

This is another form of a minimally invasive surgery. It is an outpatient procedure , performed under general anaesthesia. An Hysteroscope, a narrow fiberoptic telescope is inserted into the uterus through the mouth of the uterus to look inside. Therefore, it is not necessary to make an incision. Either fluid or gas is used to distend the uterine cavity during hysteroscopy. The uterine cavity is then inspected for any abnormality on a video monitor. The shape of the uterus and the lining of the uterus are examined. Any evidence of intrauterine pathology is looked for. The openings to the fallopian tubes (tubal ostia) are also visualised.

Several different instruments may be inserted through the hysteroscope to help treat any intrauterine pathology - operative hysteroscopy . The recovery time is very quick. There is no abdominal wound so there are no stitches and the postoperative pain is minimal. Sexual intercourse is not advised for two weeks following the procedure. It is advisable not to insert anything (besides the prescribed medication) into the vagina for at least 2 weeks, including tampons.

Most women can return to work within 2 – 3 days.

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