Sperm Function Tests

The sperm mucus penetration test – this test checks if a man’s sperm can move through the cervical mucus. This test is not done very often because there are other fertility tests that give more information about the fertility problem.

ROS ( reactive oxygen species)

Reactive oxygen species (ROS) are an integral component of sperm developmental physiology, capacitation, and function. When the ROS levels exceed that of the antioxidant activity due to infection or inflammation, it can be associated with abnormalities of sperm development, function, and capacity to fertilize the egg.  ROS may be estimated in whole ejaculate using various chemiluminance methods or by semi-quantitative assays using oxidative indicators.

Hypo-osmotic swelling test (HOS TEST)

The hypoosmotic swelling (HOS) test evaluates the functional integrity of the sperm’s plasma membrane and also serves as a useful indicator of its fertility potential. The functional integrity can be demonstrated by allowing sperm to react in a hypoosmotic medium. The hypoosmotic swelling test presumes that only cells with intact membranes (live cells) will swell in hypotonic solutions. The results of the HOS test correlate closely with the hamster egg penetration test. Spermatozoa with intact membranes swell within 5 min in hypoosmotic medium, and all flagellar shapes are stabilized in 30 min.

Zona binding assay

As binding of the sperm to the zona pellucida is essential for fertilization, a test to assess the sperm’s ability to bind to the zona has the potential to predict a defect in sperm function that may be the cause of infertility. Because of species specificity, human oocytes are required to test for zona binding ability. This test uses non-living oocytes from surgically removed ovarian tissue ( oophorectomy ), so that the ethical problems of fertilization are avoided. The oocyte is halved and the patient’s sample is tested on one half  and a fertile sample on the other, to provide a control. The score for the assay, the hemizona index (HZ) is the number of test sperm bound, to zona, expressed as a percentage of the control sperm. An HZ of less than 30 percent is considered abnormal and is associated with a decreased probability of fertilization.

Anti-Sperm Antibodies

An anti sperm antibody test looks for special proteins (antibodies) that fight against a man’s sperm in blood, vaginal fluids, or semen. The test uses a sample of sperm and adds a substance that binds only to affected sperm.

Semen can cause an immune system response in either the man’s or woman’s body. The antibodies can damage or kill sperm. If a high number of sperm antibodies come into contact with a man’s sperm, it may be hard for the sperm to fertilize an egg. The couple has a hard time becoming pregnant. This is called immunologic infertility.

A man can make sperm antibodies when his sperm come into contact with his immune system. This can happen when the testicles are injured or after surgeries (such as a biopsyor vasectomy) or after a prostate gland infection. The testicles normally keep the sperm away from the rest of the body and the immune system.

A woman can have an allergic reaction to her partner’s semen and make sperm antibodies. This kind of immune response is not fully understood but may affect fertility. This is a rare cause of infertility.

Sperm penetration assay

The sperm penetration assay, or zona-free hamster oocyte penetration assay is utilized to measure the ability of sperm to  fuse with the egg membrane and be able to fertilise it. The test is scored by calculation of the percentage of oocytes that are penetrated  by sperm or the average number of sperm penetrations per ovum.a normal test indicates a penetration of 10-20% and lower values indicate a poor results in IVF. It has been used to identify those couples who will have a high likelihood of success with in vitro fertilization.

DFI (DNA Fragmentation Index)

This test provides information about the genetic constitution of the sperm. Men with abnormal sperm parameters may have a high DNA fragmentation even though this can be found in men with normal semen parameters who are diagnosed with unexplained infertility.

High DNA fragmentation is associated with poor embryo quality and high rate of miscarriages.

Indications for DNA fragmentation testing:

  • Unexplained or persistent infertility
  • Failure to conceive after 5–6 intrauterine insemination (IUI) cycles despite good count and motility
  • Low fertilization rates or poor embryo quality in IVF cycles
  • IR failure after IVF
  • Recurrent miscarriage
  • Prolonged stay in an environment that exposes to reproductive toxins
  • Abnormal semen analysis
  • Advancing male age (>45 years).

Scrotal Ultrasound and Doppler

This is done with the help of an ultrasound scanning machine to study the scrotal sacs and testes.

For who? – To detect / rule out conditions like varicocele, hydrocele, location of undescended testes, cysts, small size of the testes, tumors, testicular torsion , to diagnose results of trauma to the scrotal area. diagnose causes of testicular pain or swelling such as inflammation or torsion.

Laparoscopy & Hysteroscopy

Laparoscopy – this is a minimally invasive surgical procedure in which a fiber -optic instrument called the laparoscope is inserted through the abdominal wall to view the organs inside the abdomen and pelvic cavity for diagnostic or operative purposes.

For who ? – for diagnosing and /or surgical repair of uterine abnormalities, tubal disease, endometriosis, uterine fibroids, polycystic ovaries, ovarian cysts/ tumours, for checking the patency of fallopian tubes .

Hysteroscopy – This is a procedure where the inside of the uterus and cervix is visualised with the help of a small fibre optic device called the hysteroscope . This can be a diagnostic or an operative procedure to diagnose abnormalities of the uterus and cervical canal like polyps, fibroids, adhesions, uterine anomalies, endometrial biopsy.

Recurrent Pregnancy Loss

RECURRENT PREGNANCY LOSS ( recurrent miscarriage or habitual abortion)

Spontaneous pregnancy loss is a surprisingly common occurrence, with approximately 15% of all clinically recognized pregnancies resulting in pregnancy failure. Recurrent pregnancy loss (RPL) has been inconsistently defined. When defined as 2 or more  consecutive pregnancy losses prior to 20 weeks from the last menstrual period, it affects approximately 1% to 2% of women.

The majority of miscarriages are sporadic and most result from genetic causes that are greatly influenced by maternal age.

Recurrent pregnancy loss (RPL) is defined by two or more failed clinical pregnancies, and up to 50% of cases of RPL will not have a clearly identifiable cause.

Causes of RPL

These include parental chromosomal abnormalities, untreated hypothyroidism, Luteal phase defect (LPD), polycystic ovarian syndrome (PCOS) uncontrolled diabetes mellitus, certain uterine anatomic abnormalities,hyperprolactinemia  and antiphospholipid antibody syndrome (APS), systemic lupus erythematosis. Other probable or possible etiologies include additional endocrine disorders, heritable and/or acquired thrombophilias, immunologic abnormalities, infections (Listeria monocytogenes, Toxoplasma gondii, rubella, herpes simplex virus (HSV), measles, cytomegalovirus, and coxsackieviruses,mycoplasma, ureaplasma, Chlamydia trachomatis, L monocytogenes )  and environmental factors. approximately half of all cases will remain unexplained.

 Suggested diagnostic evaluation in RPL

  • ANATOMIC CAUSES –  HSG, SSG, 2D/3D Ultrasound scan, hysteroscopy, laparoscopy
  • ENDOCRINE CAUSES – Thyroid profile , testing for insulin resistance and diabetes, prolactin levels, ovarian reserve testing, antithyroid antibodies
  • Infections – no evaluation recommended unless patient has evidence of chronic endometritis/cervicitis on examination, or is immunocompromised. The common tests include testing for TORCH INFECTIONS, tuberculosis and  cervical / vaginal swabs for culture.
  • Autoimmune diseases – Tests for anticardiolipin antibodies, lupus anticoagulant, antiphospholipid antibodies, antinuclear antibodies.
  • Genetic causes – test for karyotyping of couple
  • Thrombophilias – Homocysteine, factor V leiden mutations, prothrombin promoter mutation, activated protein C and S resistance, MTHFR mutations , Beta 2 glycoprotein.

Management/ treatment of RPL

Management of RPL depends on the cause detected.

Hormonal Disorders

The most common hormone disorders in a female are PCOD, hypo or hyper thyroidism, elevated prolactin.THE LESS COMMON ONES are HYPOPITUITARISM, DISORDERS OF ADRENAL GLAND ( adrenal insufficiency or cushing’s syndrome), tumors of the pituitary gland.

  • Blood tests are done as per the specific condition suspected.
  • OTHER rare tests that may be required to rule out these would be Ultrasound , CT scan or MRI scan.


Diagnosis of PCOS/PCOD

How to diagnose pcos?

2 of the below 3 criteria need to be present in a woman to diagnose pcos:

  1. Oligo or anovulation ( infrequent/delayed periods with no ovulation)

2. Clinical and or biochemical hyperandrogenism ( raised androgen levels in blood and or abnormal /excessive male pattern hair growth, acne, male type of baldness/hair loss)

3. Polycystic ovaries on ultrasound

Tests for Evaluation of PCOS.

  • Day 2 or 3 Pelvic scan – to diagnose polycystic ovaries.
  • Day 2 or 3 serum FSH and LH levels – RAISED LH TO FSH ratio of 3 or more is indicative of PCOD AMH – elevated levels suggest the possibility and severity of PCOD.
  • Fasting insulin levels – Elevated levels suggest insulin resistance.
  • Fasting and post lunch blood glucose levels – Elevated levels suggest diabetes.
  • Lipid profile – for elevated cholesterol and triglycerides.
  • Serum androgens – testosterone, DHEAS and androstenedione.

Infections

Infections of the female reproductive tract can be of 3 types.

1) Sexually transmitted diseases (STDs), such as chlamydia, gonorrhea, chancroid, and human immunodeficiency virus(HIV), syphilis, bacterial vaginosis (BV), lymphogranuloma venereum (LGV), trichomoniasis , hepatitis B virus (HBV), herpes genitalis (herpes simplex virus [HSV], primarily type HSV-2).

2) Endogenous infections, which are acquired from others like genital tuberculosis or which are caused by overgrowth of organisms normally present in the genital tract of healthy women, such as bacterial vaginosis or vulvovaginal candidiasis;

3) Iatrogenic infections, which are associated with improperly performed medical procedures such as unsafe • abortion or poor delivery practices.

Any one of these infections may RESULT in infertility by causing Pelvic inflammatory disease (PID) , damage of the uterine lining( endometrium), tubal block, tubal motility , tubal mass/disease, ectopic pregnancy, creating a hostile environment for sperm, ovulation, etc.

Infections of the female reproductive tract can be detected by examination, high vaginal / cervical swab, endometrial sampling/biopsy, sampling through laparoscopy/hysteroscopy, blood testing.

Anti-Sperm Antibodies( ASA)

Anti-sperm antibodies are antibodies produced against sperm antigens. They are found both in men and women. ASA can be detected in semen, cervical mucus, follicular fluid, and blood.

  • ASA can arise whenever sperm encounter the immune system. ASA have been considered as infertility cause in around 10–30% of infertile couples, and in males, about 12–13 of all diagnosed infertility is related to an immunological reason.
  • These antibodies can also be present in fertile men and women ( approximately 1–2.5 % of fertile men and in 4 % of fertile women).
  • The presence of ASA in the fertile population suggests that not all ASA cause infertility.
  • While around 75% of vasectomized men who have the process.
  • Risk factors for the formation of antisperm antibodies in men include the breakdown of the blood-testis barrier, trauma and surgery, orchitis , varicocele, infections, prostatitis, testicular cancer, failure of immunosuppression and unprotected anal or oral sex with men.
  • Women whose male partners have ASA in their semen are more likely to have ASA, and women with ASA tend to react only to their partner’s sperm and not to other men’s sperm.
  • In women, spermatozoa in the genital tract after intercourse are not a factor in the production of antisperm antibodies. But this is possible with a trauma to the vaginal mucosa during intercourse or the deposition of sperm in the gastrointestinal tract by oral or anal intercourse.
  • In both men and women, ASA production are directed against surface antigens on sperm, which can interfere with sperm motility and transport through the female reproductive tract, inhibiting capacitation and acrosome reaction, impaired fertilization, influence on the implantation process, and impaired growth and development of the embryo.

Ovarian Reserve Testing

  • Antral follicle count
  • ( AMH)Anti-mullerian hormone
  • Basal FSH levels

AFC ( ANTRAL FOLLICLE COUNT)

ANTRAL FOLLICLES are SMALL IMMATURE FOLLICLES in the ovaries measuring 2- 9 mm. antral follicle count is measured by transvaginal ultrasonography between day 2 to day 3 of the menstrual cycle. The numbers of follicles in both ovaries are added for the total AFC.
A count of more than 10 follicles is considered normal. Assessment of AFC is a low cost and effective method of assessing ovarian reserve .

AMH( anti-mullerian hormone)

Anti-Mullerian hormone (AMH) is exclusively produced by granulosa cells of preantral (primary and secondary) and small antral follicles (AFs) in the ovary. The production of AMH starts following follicular transition from the primordial to the primary stage, and it continues until the follicles reach the antral stages, with diameters of 2-6 mm.The number of the small AFs is related to the size of the primordial follicle pool.

The number of the antral follicles decrease with age and hence AMH production appears to decrease and become undetectable at and after menopause . AMH levels strongly correlate with basal antral follicle count (AFC) measured by transvaginal ultrasonography.

BASAL FSH LEVELS

Follicle stimulating hormone (FSH) is a reproductive hormone . It is measured on day 2to day 3 of the menstrual cycle. It is the most widely used ovarian reserve test to assess the ovarian reserve, and response to stimulation. An increase in FSH levels occurs due to follicle depletion and decreased ovarian reserve.
The measurement of FSH is easy, and inexpensive and provides a valuable information in the assessment and management of infertile woman.

Tests For Uterine Abnormalities

Conditions like Developmental abnormalities of the uterus , uterine fibroids, polyps, intrauterine adhesions can be diagnosed by procedures like ULTRASOUND, HSG,SSG and laprohysteroscopy.

For who? – suspected pathology of the uterus and tubes , unexplained infertility.

Tests for tubal patency

  • HSG (hysterosalpingography)

Hysterosalpingography also called uterosalpingography, is a basic, low-cost and a helpful step in evaluation of tubal patency and uterine abnormalities. A contrast medium ( dye) is injected into the uterus and serial x-ray films are taken to produce pictures of the inside of the uterus and tubes. X-rays are the oldest and most frequently used form of medical imaging.

This test is typically done between day 7 to day 11 of the menstrual cycle once the menstrual bleeding stops.

For who? – couples with unexplained infertility, suspected pelvic disease like chronic pelvic infections, endometriosis, tuberculosis, uterine fibroids, polyps, tumors, hydrosalphynx , intrauterine adhesions etc.

This is routinely done as a basic evaluation of couples with difficulty conceiving in-spite of having a normal semen parameters and ovulatory cycles.

SSG (sonosalpingography)

Sonosalpingography is an ultrasound guided procedure used for evaluating patency of fallopian tubes and to detect abnormalities of uterine cavity. Sterile normal saline is introduced into the uterine cavity with the help of a catheter .By visualizing the flow of saline through the uterine cavity and along the tubes with the help of an ultrasound scan , one can identify conditions like uterine fibroids, polyps, developmental abnormalities of uterus ,intrauterine adhesions, tubal block , tubal disease, hydrosalphynx etc.

For who?, suspected pelvic disease like chronic pelvic infections, endometriosis, tuberculosis, uterine fibroids, polyps, tumours, hydrosalpinx , intrauterine adhesions etc.

– couples with unexplained infertility

laparohysteroscopy

Chromopertubation, or instilling dye through the fallopian tubes to assess tubal patency, is a common part of laparoscopy performed for diagnostic or therapeutic purposes in women with infertility.  This procedure provides accurate assessment of tubal patency by allowing direct visualization thus gives precise diagnosis.

For who? – Suspected tubal block on HSG OR SSG , suspected tubal disease like hydrosalpinx on ultrasound scan , HSG OR SSG.