Tubal Patency Test Research Articles

The Prognostic Value of Tubal Patency Test After Medical Treatment of an Ectopic Pregnancy

The Prognostic Value of Tubal Patency Test After Medical Treatment of an Ectopic Pregnancy

First experiences with hysterosalpingo-foam sonography (HyFoSy) for office tubal patency testing

First experiences with hysterosalpingo-foam sonography (HyFoSy) for office tubal patency testing

First experiences with hysterosalpingo-foam sonography (HyFoSy) for office tubal patency testing

This study was conducted to describe the first experiences with hysterosalpingo-foam sonography (HyFoSy) as a first step routine office procedure for tubal patency testing. A prospective observational cohort study was started in a university affiliated teaching hospital. In 2010, 73 patients with subfertility and a low risk of tubal pathology were examined. A non-toxic foam containing hydroxymethylcellulose and glycerol was applicated through a cervical applicator for contrast sonography (HyFoSy). Tubal patency was determined by transvaginal ultrasonographic demonstration of echogenic dispersion of foam in the Fallopian tube and/or the peritoneal cavity. Only in case patency could not be demonstrated, a hysterosalpingography (HSG) was performed as a control. In 67 out of 73 (92%) patients, a successful procedure was performed. In 57 out of 73 (78%) cases, there was no further need for a HSG. In five patients (5/73; 7%) tubal occlusion was confirmed by HSG and in five patients (5/73; 7%) there was discordance between HyFoSy and HSG. Of 73 patients, 14 (19%) conceived within a median of 3 months after the procedure. HyFoSy is a successful procedure to demonstrate tubal patency as a first step office procedure.

A simple and relatively painless technique for hysterosalpingography, using a thin catheter and closing the cervix with the vaginal speculum: a pilot study

ObjectiveTo evaluate the use of a thin catheter for hysterosalpingography (HSG) for reducing the pain experienced during the procedure.MethodsInfertile women undergoing tubal patency tests were randomised into two groups. In...

Laparoscopia na decisão da estratégia terapêutica para o casal infértil

to evaluate the contribution of diagnostic laparoscopy to approach the infertile couple.retrospective analysis of 86 consecutive cases of patients who were accompanied in the infertility appointments and were submitted to diagnostic laparoscopy from January 2004 to December 2006. Eighty-two of these patients had been submitted to hysterosalpingography (HSG) prior to laparoscopy. The laparoscopic findings were analyzed, as well as the accessory procedures, and the results of the hysterosalpingography and of the laparoscopy were correlated. Statistical analysis was performed by the use of the Statistical Package for the Social Sciences 15. The sensitivity and the specificity of HSG were determined and the confidence intervals were calculated with an alpha error of 0.05 (95%CI).the laparoscopy revealed 21 cases of endometriosis (24.4%), 14 cases of uni/bilateral inflammatory disease of the salpinx (16.3%), and 16 cases of pelvic inflammatory disease (18.6%). Adhesiolysis and ablation of endometrial lesions were performed in eight patients. There were also other accessory procedures: two salpingostomies, two paraovarian cystectomies, two ovarian cystectomies and three ovarian drillings. The tubal patency test during laparoscopy was normal in 44 cases (53%), revealed unilateral obstruction in 21 cases (25.3%) and bilateral obstruction in 17 cases (20.5%). The results of the hysterosalpingography were similar to those of the laparoscopy in 44 out of the 82 cases (53.7%). HSG sensitivity was 0.79 (95%CI=0.62-0.9) and its specificity was 0.58 (95%CI=0.42-0.73) when the disease was defined as any form of tubal occlusion detected with the laparoscopy, whether this occlusion was one-sided or two-sided. HSG sensitivity and specificity were 0.47 (95%CI=0.24-0.71) and 0.77 (95%CI=0.64-0.86), respectively, when the definition of the disease was limited to two-sided tubal occlusion. In nine cases (15.3%) in which HSG had shown normal findings or only a unilateral occlusion, laparoscopy revealed a two-sided occlusion. And in 15 cases (65.2%) in which HSG had shown a two-sided occlusion, laparoscopy revealed normal findings or one-sided occlusion.the laparoscopy demonstrated its diagnostic and therapeutic relevance, proving to have fundamental importance for the clarification of the tuboperitoneal status. It has permitted the development of concomitant accessory therapeutic procedures, thus defining the best treatment strategy for the infertile couples.

Use of Contrast Sonography to Test for Tubal Patency in Dairy Cattle

Hysterosalpingo-contrast sonography is an accurate first-line method used to test for tubal patency in human gynecology. Tubal pathology occurs in dairy cattle and is a reason for infertility, but easy and accurate methods to test for tubal patency are not available in the living cow. In this study it was thus investigated if contrast sonography (CS) using Echovist-200 as the echo-contrast medium is a feasible procedure to test for tubal patency in dairy cattle. In eight repeat breeder Holstein Frisian cows, all of them being in behavioral estrus, Echovist-200 was given into the uterus and its exit into the abdominal cavity then imaged by transrectal conventional B-mode ultrasound, and used as indicator for tubal patency. Animals were slaughtered one day later and the genital tracts subjected to gross morphology and histology in order to confirm the results of CS. In two cows, CS was prematurely terminated after examination of one oviduct because of rectal bleeding, while CS completely failed in another cow because of poor image quality. In five cows, both oviducts could be examined by CS, respectively. A total of five oviducts were found patent by CS and confirmed by post mortem examination. Two out of five oviducts diagnosed as occluded by CS were morphologically intact and thus misdiagnosed. Of the three non-patent oviducts, two were occluded because of a hydrosalpings, respectively, while the third was inflamed. In conclusion, CS has been shown a feasible procedure to test for tubal patency in dairy cattle. Further studies with more animals are however recommended to warrant this result.

Pelvic Factor Infertility: Diagnosis and Prognosis of Various Procedures

Infertile women are examined to exclude tubal occlusion or a pelvic factor through indirect tests, such as hysterosalpingography (HSG), sonohysterosalpingography/hysterosalpingosonography (SH), and/or laparoscopy (Lps). Assisted reproductive technologies (ART) are proposed to resolve infertility according to the results of the above-mentioned diagnostic procedures. Today, Lps still represents the second option after several failures of in vivo attempts and before moving to conceive in vitro. The aim of this study was to establish the diagnostic power of HSG and SH compared with that of Lps and the efficacy of ART when each single test is used as an inclusion criterion. We recruited 2560 infertile women (aged 20 to 35) to undergo diagnostic and therapeutic procedures to address their infertility in our clinical theatre. Of these, 1080 women underwent Lps and hysteroscopy (Group 1), 525 underwent HSG (Group 2), and 955 underwent SH (Group 3). The positive and negative predictive values of sonosalpingosonography were 75.8% and 91.2% and those of hysterosalpingography were 71.8% and 88.2%, respectively. Endometriosis (stage II-IV of the revised American Society for Reproductive Medicine [ASRM] classification) was diagnosed laparoscopically in 344 out of 1080 women (32%). Only 44 women (13%) with endometriosis showed bilateral tubal occlusion. Pelvic factors other than tubal occlusions are neither diagnosed nor treated in a timely manner by indirect tubal patency tests. The conventional use of HSG and/or SH may increase the time required to find an adequate treatment by which to achieve a successful pregnancy.

History of induced abortion and the risk of tubal pathology

Tubal pathology is a common cause of subfertility. Identifying risk factors for tubal pathology in the medical history is important to distinguish between those couples who benefit from early tubal patency tests and those in whom presence of tubal pathology is less likely and delaying tubal tests is justified. This study evaluated whether a medical history of induced abortion is associated with an increased risk of tubal disease among subfertile couples. The reproductive history was determined for each couple. Tubal disease was diagnosed by hysterosalpingography and/or diagnostic laparoscopy. The association between reproductive history and the presence of tubal disease was assessed by calculating odds ratios (OR) and 95% confidence intervals (CI). Data from 6149 couples were available for analysis. The OR for tubal pathology after a previous induced abortion was 1.6 (95% CI 1.3 to 1.9), after a previous ectopic pregnancy, 8.4 (95% CI 6.3 to 12), after a previous spontaneous miscarriage, 1.1 (95% CI 0.87 to 1.3), and after a previous live birth, 1.0 (95% CI 0.88 to 1.2). A history of induced abortion is associated with an increased risk of tubal pathology in subfertile couples. As a consequence, in subfertile women with a history of induced abortion, tubal patency tests should be considered early in the diagnostic work-up.

Epilogue

A consequence of assisted reproduction technology in infertility management has been a decline in tubal surgery. Microsurgery to correct localized damage has the advantage of long-standing restoration of fertility. A simple prognostic classification is lacking. The severity of the tubal damage and the health of the mucosa is key in determining outcome. Visualization of the tube by hysterosalpingography (HSG) or by hysterocontrastsonography (HyCoSy) has limitations. Laparoscopy has the advantage of inspecting the tube and its relation to other pelvic organs. Differentiating between anatomical obstruction or spasm at the uterine end of the tube might be achieved by selective salpingography and tubal catheterization (SSTC) and should precede IVF. Microsurgery should be provided, if the skills are available, where cannulation has failed. Assessment of mucosal health by fertiloscopy is claimed to be less invasive. Fertiloscopy includes hydrolaparoscopy, tubal patency testing by dye hydrotubation, salpingoscopy and demonstration if the mucosa is healthy. Where the mucosa is unhealthy, surgery is not justified; early referral for IVF is indicated. In the management of ectopic pregnancy, there is a paucity of objective data of the relative merits of medical regimens and various surgical procedures.

Identifying subfertile ovulatory women for timely tubal patency testing: a clinical decision rule based on medical history

The aim of tubal testing is to identify women with bilateral tubal pathology in a timely manner, so they can be treated with IVF or tubal surgery. At present, it is unclear for which women early tubal testing is indicated, and in whom it can be deferred. Data on 3716 women who underwent tubal patency testing as a part of their routine fertility workup were used to relate elements in their medical history to the presence of tubal pathology. With multivariable logistic regression, we constructed two diagnostic models. One in which tubal disease was defined as occlusion and/or severe adhesions of at least one tube, whereas in a second model, tubal disease was defined as the presence of bilateral abnormalities. Both models discriminated moderately well between women with and women without tubal disease with an area under the receiver-operating characteristic curve (AUC) of 0.65 (95% CI: 0.63-0.68) for any tubal pathology and 0.68 (95% CI: 0.65-0.71) for bilateral tubal pathology, respectively. However, the models could make an almost perfect distinction between women with a high and a low probability of tubal pathology. A decision rule in the form of a simple diagnostic score chart was developed for application of the models in clinical practice. In conclusion, the present study provides two easy to use decision rules that can accurately express a woman's probability of (severe) tubal pathology at the couple's first consultation. They could be used to select women for tubal testing more efficiently.

Re-evaluation of the indication for and limitation of laparoscopic salpingotomy for tubal pregnancy

Objective We investigated the outcome of laparoscopic salpingotomy for tubal pregnancy by follow-up hysterosalpingography (HSG) or second-look laparoscopy (SLL) and reexamined the indication for and limitation of this conservative surgery. Study design From April 1991 to December 2003, we treated 181 cases of tubal pregnancy using laparoscopic salpingotomy. The tubal patency was assessed by either HSG or SLL performed at 3 months post-surgery. The patients with a successful initial operation and confirmed ipsilateral patent tubes at follow-up were classified as truly successful cases (group I). Even after successful operation, if the treated tubes were found to be occluded, they were considered as unsuccessful cases. Therefore, those cases that were unsuccessful at initial surgery as well as at follow-up were categorized as group II. Results One hundred and thirty-four cases (74%) were successfully treated by salpingotomy at initial laparoscopy and 85 of them (63.4%) were found to be truly successful at follow-up (group I). The remaining 47 cases (26.0%) were unsuccessful at initial surgery and 18 (13.4%) cases at follow-up (group II). Thirty-one other patients refused to accept a tubal patency test or were not examined for personal reasons or were lost to follow-up. No difference in surgical outcome was observed between these two groups of patients with regard to gestational age, intra-operative hemorrhage, size or anatomic location of the pregnancy mass, and pre-operative adhesions of the fallopian tube. However, pre-operative serum levels of hCG were significantly higher in group II than in group I. In addition, the unsuccessful cases were more frequently associated with positive fetal heart beat (FHB), tubal rupture, and pre-operative serum levels of hCG of more than 10,000 IU/l ( p < 0.05, χ 2 test). The log-rank test indicated a higher pregnancy success rate in group I ( p < 0.05) than in group II in those who desired future pregnancy. Conclusion Laparoscopic salpingotomy may be practised as conservative surgery for proximal ectopic pregnancy, and gestational mass size is not as important and is not a relative contraindication for conservative laparoscopic surgery, as previously reported. Low pre-operative HCG levels, absence of FHB, absence of tubal rupture initially or minimal rupture may be considered suitable parameters for successful surgery and for achieving future pregnancy.

The predictive value of medical history taking and Chlamydia IgG ELISA antibody testing (CAT) in the selection of subfertile women for diagnostic laparoscopy: a clinical prediction model approach

Medical history taking as well as Chlamydia antibody titre (CAT) testing are currently used in the selection of patients for diagnostic laparoscopy with tubal patency testing. Most research has focused on the predictive value of CAT in isolation from medical history. We assessed therefore whether the combination of medical history and CAT improves the efficiency of selecting patients for laparoscopy as compared to the use of either medical history or CAT. Data of 207 consecutive subfertile women were used to create multivariable logistic regression models for the prediction of tubal disease as diagnosed by diagnostic laparoscopy. The model with data of medical history only had an area under the receiver operating characteristic curve (AUC) of 0.65 (95% CI 0.56-0.74). Addition of CAT increased the AUC to 0.70 (95% CI 0.62-0.78) (P = 0.065). CAT was positive in 40 women and showed a sensitivity of 0.37 (95% CI 0.26-0.49) for a specificity of 0.88 (95% CI 0.82-0.93). In CAT positive women, a blank medical history did not decrease the probability of tubal disease. Of the 167 women tested CAT negative, 23 (14%) still had a high probability of disease due to their medical history and 11 of them (48%) showed tubal abnormalities on diagnostic laparoscopy. CAT testing adds valuable information to a woman's risk profile based on her medical history. The combination of medical history taking and CAT testing has a better yield for diagnosing tubal disease than either of these alone.

Operative laparoscopy in The Netherlands: Diffusion and acceptance

Objective To evaluate and update the current status of the implementation of operative laparoscopy in gynaecology in The Netherlands by assessing diffusion and acceptance of each specific procedure per hospital. Study design In 2003 a questionnaire was sent to all hospitals ( n = 102), which addressed the total number and type of laparoscopic procedures performed in 2002 stratified by level of difficulty (level 1: diagnostic laparoscopy, sterilization, tubal patency tests; level 2: adhesiolysis, ectopic pregnancy (EP), laparoscopic treatment of endometriosis, cystectomy, oophorectomy, LAVH, tubal surgery for infertility; level 3: myomectomy, total laparoscopic hysterectomy (TLH) and sacropexy). Data were compared to previously published data of 1994. Results Response rate was 79% (81/102). Diffusion and acceptance of level 2 procedures increased significantly, except endometriosis and tubal surgery for infertility. Diffusion of LAVH was only 58%. Four percent of hysterectomies were LAVH. TLH and sacropexy were not performed. The diffusion of myomectomy increased significantly ( p = 0.01), whereas its acceptance remained low. Conclusions Although the diffusion of operative procedures has increased over the last decade, acceptance is still limited, especially for laparoscopic hysterectomy. The implementation of operative gynaecological laparoscopy in The Netherlands seems to develop at a slow pace.

Diagnostic tests in reproductive medicine

The aim of the fertility work-up is to exclude recognised causes of infertility and to distinguish those couples who have good spontaneous pregnancy prospects from those who have poor prospects. Information gathered by medical history, clinical findings and results of the diagnostic tests should help the clinician in counselling subfertile couples. The initial diagnostic tests for infertility should include a basal body temperature chart or midluteal phase progesterone level, a semen analysis and a test for tubal patency. Ovarian reserve tests can be used in selected cases. More research is needed in the predictive value of the outcome of diagnostic tests in reproductive medicine.

Comparison of three‐dimensional hysterosalpingo‐contrast‐sonography and diagnostic laparoscopy with chromopertubation in the assessment of tubal patency for the investigation of subfertility

Two-dimensional hysterosalpingo-contrast-sonography, as a screening test for tubal patency for subfertile patients, is limited by the difficulty in visualizing the entire Fallopian tube owing to its tortuosity. This major disadvantage can be overcome by means of the three-dimensional hysterosalpingo-contrast-sonography (3D-HyCoSy). The current study compared the efficacy of 3D-HyCoSy with diagnostic laparoscopy and its feasibility as a screening test for tubal patency. Twenty-one consecutive patients scheduled to have laparoscopy were recruited to undergo the 3D-HyCoSy 2 days before the scheduled laparoscopy. Echovist (Schering AG, Berlin, Germany), the ultrasound contrast medium, was injected into the uterine cavity via a Foley's catheter. The flow of the medium in the Fallopian tube was captured by using three-dimensional power Doppler mode and was stored for later analysis. The person analyzing the images, the surgeon performing the laparoscopy, and the patients were blinded to the patients' identity and the sonography findings. The sonography and the laparoscopy findings were compared. The duration for the ultrasound examination, pain score, and patient acceptability were assessed. Thirty-four of 42 (81%) Fallopian tubes were assessed. The sensitivity of 3D-HyCoSy for detecting tubal patency was 100% with a specificity of 67%. The positive and negative predictive values were 89 and 100%, respectively; the concordance rate was 91%. The mean duration (+/- SD) for the 3D-HyCoSy was 13.4 +/- 5.5 min. Fifteen patients (71%) regarded the sonography examination as at least acceptable. This study confirmed the feasibility of using 3D-HyCoSy as an initial investigation for tubal patency.

Comparison of three-dimensional hysterosalpingo-contrast-sonography and diagnostic laparoscopy with chromopertubation in the assessment of tubal patency for the investigation of subfertility

Background. Two-dimensional hysterosalpingo-contrast-sonography, as a screening test for tubal patency for subfertile patients, is limited by the difficulty in visualizing the entire Fallopian tube owing to its tortuosity. This major disadvantage can be overcome by means of the three-dimensional hysterosalpingo-contrast-sonography (3D-HyCoSy). The current study compared the efficacy of 3D-HyCoSy with diagnostic laparoscopy and its feasibility as a screening test for tubal patency. Methods. Twenty-one consecutive patients scheduled to have laparoscopy were recruited to undergo the 3D-HyCoSy 2 days before the scheduled laparoscopy. Echovist® (Schering AG, Berlin, Germany), the ultrasound contrast medium, was injected into the uterine cavity via a Foley's catheter. The flow of the medium in the Fallopian tube was captured by using three-dimensional power Doppler mode and was stored for later analysis. The person analyzing the images, the surgeon performing the laparoscopy, and the patients were blinded to the patients' identity and the sonography findings. The sonography and the laparoscopy findings were compared. The duration for the ultrasound examination, pain score, and patient acceptability were assessed. Results. Thirty-four of 42 (81%) Fallopian tubes were assessed. The sensitivity of 3D-HyCoSy for detecting tubal patency was 100% with a specificity of 67%. The positive and negative predictive values were 89 and 100%, respectively; the concordance rate was 91%. The mean duration (± SD) for the 3D-HyCoSy was 13.4 ± 5.5 min. Fifteen patients (71%) regarded the sonography examination as at least acceptable. Conclusions. This study confirmed the feasibility of using 3D-HyCoSy as an initial investigation for tubal patency.

Prevalence of polycystic ovaries and polycystic ovary syndrome in lesbian women compared with heterosexual women

To determine the prevalence of polycystic ovaries (PCO) and polycystic ovarian syndrome (PCOS) in lesbian women compared with heterosexual women undergoing fertility treatment. A prospective observational study. The London Women's clinic and The Hallam Medical Center. Tertiary referral fertility setup. Six hundred eighteen women undergoing ovarian stimulation with or without IUI treatment between November 2001 and January 2003. Of these, 254 were self-identified as lesbians and 364 were heterosexual women. Baseline pelvic ultrasound examination and blood tests conducted to measure biochemical parameters such as FSH, LH, E(2), PRL, T, androstenedione (A), sex hormone-binding globulin (SHBG), and DHEAS were performed between day 2 and 3 of each woman's menstrual cycle. Tubal patency tests were performed by hysterosalpingography or laparoscopy. Biochemical parameters. Eighty percent of lesbian women, compared with 32% of the heterosexual women, had PCO on pelvic ultrasound examination. Thirty-eight percent of lesbian women, compared with 14% of heterosexual women, had PCOS. There were no significant differences in the androgen concentrations between lesbian and heterosexual women with normal ovaries. However, lesbian women with PCO and PCOS had significantly higher androgen concentrations compared with heterosexual women with PCO and PCOS. Tubal disease was as common in lesbian women as in heterosexual women. There is a significantly higher prevalence of PCO and PCOS in lesbian compared with heterosexual women. Lesbian women with either PCO or PCOS had more pronounced hyperandrogenism than did heterosexual women with either PCO or PCOS.

Evidence-based infertility: evaluation of the female partner

Infertility, involving at least 1 year of attempted conception without success, affects 10,000 couples per million populations. Evaluation of a couple is generally indicated after a year, by which time most normal couples attempting conception would have been successful. The principles of evidence-based medicine indicate that the diagnostic tests should correlate with the outcome of interest to couples, that is live birth. In the female partner, these tests are assessment of ovulation by cycle history or mid-luteal progesterone and of tubal pathology by Chlamydia antibody testing, tubal patency tests or laparoscopy. The chief female categories of infertility are ovulation disorders (25%), tubal disease (15%) and endometriosis (10%). Male infertility is the primary diagnosis in approximately 25% of cases and contributes to a further 15% to 25% of the remaining cases. The infertility remains unexplained in at least 20% of cases because numerous reproductive defects are undetectable with current methods. Undetectable deficiencies in oocyte or sperm quality and tubal function may contribute to fertilization failure and diminished embryo quality. Even high quality embryos may undergo implantation failure by means that are poorly understood. Research is needed to improve awareness of potential fertility defects before and after fertilization and possible errors in embryonic development.

Lessons learned from infertility investigations in the public sector.

To determine the main factors causing infertility in an urban, tertiary hospital population. To establish if any such major causal factor could be used to rationalise and improve the service for infertile couples in the public sector. A retrospective analysis of the hospital records of 206 women who had a tubal patency test (hysterosalpingogram) performed and the results of the investigations performed in the couples with infertility. Of the 206 women 38 (18.5%) had normal fallopian tubes on hysterosalpingogram; 33 (16%) had unilateral obstruction and 135 (65.5%) had bilateral tubal obstruction. Of the latter group 81 (60%) had significant hydrosalpinges. Semen analysis results in 148 partners (71.8%) demonstrated a normal count in 85 (62%), normal motility in 70 (51%) and normal morphology in only 25 (18%). Testing for ovulation (mid-luteal phase progesterone) was positive in 91 of 124 women tested (73%). Compliance, technical and logistical problems were encountered with both semen analysis and mid-luteal phase progesterone tests. Infertility is a major problem in South Africa, with limited resources for investigation and treatment in the public sector. Tubal factor infertility was the most common cause of infertility demonstrated in this study. In the presence of bilateral tubal obstruction with hydrosalpinges the prognosis is so poor that unless assisted reproductive techniques are available and affordable, further infertility investigations do not seem justified. Recommendations on an approach to the infertile couple in the public sector is outlined.

Diagnosing infertility in a district general hospital: A case-note and cost analysis

This study aimed to observe diagnostic work-up and cost evaluation of infertile couples to identify opportunities for improvement. One hundred and seventy-four new referrals to the gynaecology clinic in a District General Hospital during 1996 and 1997 provided the cohort for analysis. Data from case notes were transferred on to data collection sheets. Data were inputted into SPSS for analysis. Primary infertility accounted for 62% of couples. One hundred and forty-two couples (81.6%) had a definitive diagnosis, and the analyses relate to these couples only. There was no single investigation performed on the whole cohort studied. Semen analysis was undertaken in 80.3% of the couples; couples with suspected male infertility were over four times more likely to have had more than two semen tests (P = 0.0005); 77.5% of couples had FSH and LH tests; and midluteal progesterone was tested in 76.1%. An increased intensity of FSH-LH hormone testing was associated with couples with anovulation (x2 = 6.79, P = 0.03). Serial repeat progesterone tended to be given to women with irregular or prolonged cycles (35 days or more), although this tendency was not statistically significant. The most common test for tubal patency was hysteros-alpingography. Higher costs are generally associated with diagnosing endometriosis and tubal factor because of the relatively high cost of laparoscopy. The average cost of diagnosis for each patient was £365 and ranged from £64 to £851. In conclusion, a standard protocol of basic investigative procedures should be offered in secondary centres to all couples. Avoiding duplication and unnecessary investigations (for example, serial progesterone) may reduce costs, although offering all couples a standard protocol of tests would probably offset this observation.