Managing Fertility Evaluations
Structures infertility workup with ovarian reserve testing, semen analysis, tubal assessment, and stepped treatment algorithms per ASRM and ACOG Practice Bulletin No. 217.
Why This Skill Exists
Infertility — defined as failure to conceive after 12 months of unprotected intercourse (or 6 months if female partner is ≥ 35) — affects approximately 12–15% of couples. The American Society for Reproductive Medicine (ASRM) recommends a systematic, simultaneous evaluation of both partners, as male factor contributes to approximately 40–50% of infertility cases (sole male factor ~20%, combined male + female ~20–30%). Delays in evaluation lead to age-related decline in ovarian reserve, diminishing treatment success.
ACOG Practice Bulletin No. 217 (Infertility Workup for the Women's Health Specialist) outlines the standard evaluation components. This skill ensures a complete, concurrent evaluation of ovulatory function, tubal patency, uterine anatomy, ovarian reserve, and male factor — then maps findings to the appropriate treatment tier.
Checkpoint A: Pre-Draft Intake (Mandatory)
- Duration of infertility — months of unprotected intercourse? Primary (never conceived) or secondary (prior pregnancy)? (Default: from history)
- Female partner age — critical for prognosis and urgency of evaluation. (Default: from demographics)
- Coital frequency and timing — intercourse frequency and relationship to ovulation? Use of ovulation prediction kits? (Default: from history)
- Menstrual history — cycle length, regularity, signs of ovulatory dysfunction (oligomenorrhea, amenorrhea)? (Default: from menstrual calendar)
- Obstetric and gynecologic history — prior pregnancies (with any partner), ectopic, PID, endometriosis, uterine surgery? (Default: from history)
- Male partner history — prior paternity, testicular surgery, varicocele, medications, toxin exposure, ejaculatory dysfunction? (Default: from male partner history)
- Medical comorbidities — thyroid disease, PCOS, hyperprolactinemia, DM, eating disorders, excessive exercise? (Default: from problem list)
- Social factors — tobacco, alcohol, marijuana, occupation, environmental exposures? (Default: from social history)
Documents to Request
- Prior fertility evaluation results (both partners)
- Semen analysis report(s)
- HSG or SHG reports
- Ovarian reserve testing (AMH, day-3 FSH/estradiol, antral follicle count)
- Thyroid function tests
- Prolactin level
- Prior operative reports (laparoscopy, hysteroscopy, tubal surgery)
- Genetic testing results (karyotype, FMR1, carrier screening)
- Partner medical records if available
Step 1: Ovulatory Assessment
Ovulatory dysfunction accounts for approximately 25–30% of female infertility.
| Assessment Method |
Timing |
Interpretation |
| Menstrual history |
Ongoing |
Regular 24–35 day cycles strongly suggest ovulation |
| Basal body temperature (BBT) |
Daily |
Biphasic pattern (0.2–0.5°C rise) confirms ovulation retrospectively |
| Urine LH surge (OPK) |
Mid-cycle |
Positive predicts ovulation in ~24–36 hours |
| Mid-luteal progesterone |
Day 21 (or 7 days post-expected ovulation) |
> 3 ng/mL confirms ovulation |
| Endometrial biopsy |
Luteal phase |
No longer routinely recommended for dating; useful if endometrial pathology suspected |
Ovulatory Dysfunction Workup
| Condition |
Testing |
Findings |
| PCOS |
Rotterdam criteria: 2 of 3 — oligo/anovulation, clinical/biochemical hyperandrogenism, polycystic ovarian morphology on US |
Elevated free testosterone, DHEA-S; LH:FSH ratio > 2:1 (supportive but not required) |
| Hypothalamic amenorrhea |
FSH, LH, estradiol |
Low/normal FSH, low LH, low estradiol |
| Hyperprolactinemia |
Prolactin |
> 25 ng/mL — repeat; if persistent, consider MRI pituitary |
| Thyroid dysfunction |
TSH |
Abnormal TSH → treat before fertility intervention |
| Premature ovarian insufficiency |
FSH, AMH, estradiol |
FSH > 40 IU/L (× 2 samples), low AMH, low estradiol |
Step 2: Ovarian Reserve Assessment
Ovarian reserve predicts the quantity (not quality) of remaining oocytes and guides treatment intensity.
| Test |
Timing |
Normal Values |
Interpretation |
| AMH (anti-Müllerian hormone) |
Any cycle day |
1.0–3.5 ng/mL |
< 1.0 = diminished reserve; > 3.5 = possible PCOS |
| Day 3 FSH |
Cycle day 2–4 |
< 10 IU/L |
> 10 = diminished reserve; > 15 = poor prognosis |
| Day 3 estradiol |
Cycle day 2–4 |
< 80 pg/mL |
Elevated E2 with normal FSH may mask diminished reserve |
| Antral follicle count (AFC) |
Cycle day 2–5 (TVUS) |
10–20 total |
< 5–7 = diminished reserve; > 20 = high responder / PCOS risk |
Combine AMH + AFC for the most accurate reserve assessment. Document results with age-adjusted interpretation.
Step 3: Tubal and Uterine Evaluation
| Test |
What It Assesses |
Findings |
| Hysterosalpingogram (HSG) |
Tubal patency, uterine cavity contour |
Bilateral spill = patent tubes; filling defects = polyps/fibroids/synechiae; proximal vs. distal tubal occlusion |
| Saline infusion sonohysterogram (SIS) |
Uterine cavity detail |
Polyps, submucosal fibroids, Asherman syndrome |
| Hysteroscopy |
Direct cavity visualization |
Gold standard for intracavitary pathology — see and treat |
| Laparoscopy with chromopertubation |
Tubal patency + peritoneal disease |
Reserve for suspected endometriosis, PID, or equivocal HSG |
Uterine anomalies affecting fertility:
- Septate uterus — most common anomaly associated with pregnancy loss; hysteroscopic septum resection improves outcomes
- Unicornuate uterus — reduced cavity volume, associated with preterm delivery
- Asherman syndrome — intrauterine adhesions from prior instrumentation; hysteroscopic lysis
Step 4: Male Factor Evaluation
Semen analysis is the cornerstone of male factor assessment. Per WHO 6th edition (2021) reference values:
| Parameter |
Lower Reference Limit (5th percentile) |
| Volume |
≥ 1.4 mL |
| Sperm concentration |
≥ 16 million/mL |
| Total sperm count |
≥ 39 million per ejaculate |
| Progressive motility |
≥ 30% |
| Total motility |
≥ 42% |
| Normal morphology (strict Kruger) |
≥ 4% |
- Abnormal semen analysis → repeat in 4–12 weeks (values fluctuate)
- Persistently abnormal → urology referral for evaluation (hormonal — FSH, testosterone, prolactin; physical exam — varicocele; genetic — Y-microdeletion, karyotype if severe oligospermia < 5 million/mL)
- Azoospermia → obstructive vs. non-obstructive classification; refer to reproductive urologist
Step 5: Treatment Algorithm
| Diagnosis |
First-Line Treatment |
Second-Line |
Third-Line |
| Ovulatory dysfunction (PCOS) |
Letrozole 2.5–7.5 mg CD 3–7 (superior to clomiphene per NICHD trial) |
Clomiphene 50–150 mg CD 5–9; gonadotropins |
IVF |
| Unexplained infertility |
Timed intercourse × 3–6 cycles → letrozole/clomiphene + IUI × 3 |
Gonadotropins + IUI (up to 3 cycles) |
IVF |
| Tubal factor (bilateral occlusion) |
IVF (bypass tubal disease) |
Tubal surgery (selected cases with mild distal disease) |
— |
| Male factor (mild-moderate) |
IUI with sperm wash (requires ≥ 5–10 million TMSC) |
IVF |
IVF-ICSI |
| Male factor (severe / azoospermia) |
IVF-ICSI with TESE/micro-TESE if needed |
Donor sperm |
— |
| Diminished ovarian reserve |
Aggressive stimulation → IVF |
Donor oocytes |
— |
| Endometriosis |
Surgical excision + spontaneous attempt × 6 months |
IUI with controlled stimulation |
IVF |
Checkpoint B: Post-Draft Alignment (Mandatory)
- Are both partners evaluated — ovulatory function, tubal patency, ovarian reserve, and semen analysis all addressed?
- Is ovarian reserve documented with age-adjusted interpretation?
- Is the treatment recommendation matched to the specific diagnosis?
- Are time-sensitive factors addressed — female age, duration of infertility, and declining reserve?
- Is the referral to reproductive endocrinology documented when indicated (e.g., bilateral tubal disease, DOR, severe male factor)?
Quality Audit
Guidelines
- Evaluate both partners simultaneously — do not complete the full female workup before ordering a semen analysis; male factor is present in 40–50% of cases.
- Age drives urgency — women ≥ 35 should be referred after 6 months; women ≥ 40 warrant immediate evaluation.
- Letrozole is first-line for PCOS ovulation induction — the NICHD PPCOS II trial demonstrated higher live birth rates with letrozole vs. clomiphene.
- Do not skip ovarian reserve testing — even in young patients, diminished reserve changes the treatment approach and timeline.
- Document the AFC method — report bilateral antral follicle count with probe frequency and technique for reproducibility.
- Recognize when to refer — bilateral tubal occlusion, severe male factor, diminished ovarian reserve, and age ≥ 38 with > 6 months of failed first-line treatment should be referred to a reproductive endocrinologist.
- Counsel on realistic expectations — per-cycle success rates for IUI are 10–20%, and IVF success rates are age-dependent (age < 35: ~50% live birth per transfer; age 40–42: ~15%).
- Address lifestyle factors — BMI optimization (ideal 19–25), smoking cessation, alcohol limitation, and caffeine < 200 mg/day all impact fertility.
1---2name: managing-fertility-evaluations3description: Structures infertility workup with ovarian reserve testing, semen analysis, and treatment algorithms. Use when evaluating infertility, ordering fertility workup, or managing reproductive planning.4---5
6# Managing Fertility Evaluations
7
8Structures infertility workup with ovarian reserve testing, semen analysis, tubal assessment, and stepped treatment algorithms per ASRM and ACOG Practice Bulletin No. 217.
9
10## Why This Skill Exists
11
12Infertility — defined as failure to conceive after 12 months of unprotected intercourse (or 6 months if female partner is ≥ 35) — affects approximately 12–15% of couples. The American Society for Reproductive Medicine (ASRM) recommends a systematic, simultaneous evaluation of both partners, as male factor contributes to approximately 40–50% of infertility cases (sole male factor ~20%, combined male + female ~20–30%). Delays in evaluation lead to age-related decline in ovarian reserve, diminishing treatment success.
13
14ACOG Practice Bulletin No. 217 (Infertility Workup for the Women's Health Specialist) outlines the standard evaluation components. This skill ensures a complete, concurrent evaluation of ovulatory function, tubal patency, uterine anatomy, ovarian reserve, and male factor — then maps findings to the appropriate treatment tier.
15
16---
17
18## Checkpoint A: Pre-Draft Intake (Mandatory)
19
201. **Duration of infertility** — months of unprotected intercourse? Primary (never conceived) or secondary (prior pregnancy)? (Default: from history)
212. **Female partner age** — critical for prognosis and urgency of evaluation. (Default: from demographics)
223. **Coital frequency and timing** — intercourse frequency and relationship to ovulation? Use of ovulation prediction kits? (Default: from history)
234. **Menstrual history** — cycle length, regularity, signs of ovulatory dysfunction (oligomenorrhea, amenorrhea)? (Default: from menstrual calendar)
245. **Obstetric and gynecologic history** — prior pregnancies (with any partner), ectopic, PID, endometriosis, uterine surgery? (Default: from history)
256. **Male partner history** — prior paternity, testicular surgery, varicocele, medications, toxin exposure, ejaculatory dysfunction? (Default: from male partner history)
267. **Medical comorbidities** — thyroid disease, PCOS, hyperprolactinemia, DM, eating disorders, excessive exercise? (Default: from problem list)
278. **Social factors** — tobacco, alcohol, marijuana, occupation, environmental exposures? (Default: from social history)
28
29### Documents to Request
30
31- Prior fertility evaluation results (both partners)
32- Semen analysis report(s)
33- HSG or SHG reports
34- Ovarian reserve testing (AMH, day-3 FSH/estradiol, antral follicle count)
35- Thyroid function tests
36- Prolactin level
37- Prior operative reports (laparoscopy, hysteroscopy, tubal surgery)
38- Genetic testing results (karyotype, FMR1, carrier screening)
39- Partner medical records if available
40
41---
42
43## Step 1: Ovulatory Assessment
44
45Ovulatory dysfunction accounts for approximately 25–30% of female infertility.
46
47| Assessment Method | Timing | Interpretation |
48|---|---|---|
49| Menstrual history | Ongoing | Regular 24–35 day cycles strongly suggest ovulation |
50| Basal body temperature (BBT) | Daily | Biphasic pattern (0.2–0.5°C rise) confirms ovulation retrospectively |
51| Urine LH surge (OPK) | Mid-cycle | Positive predicts ovulation in ~24–36 hours |
52| Mid-luteal progesterone | Day 21 (or 7 days post-expected ovulation) | > 3 ng/mL confirms ovulation |
53| Endometrial biopsy | Luteal phase | No longer routinely recommended for dating; useful if endometrial pathology suspected |
54
55### Ovulatory Dysfunction Workup
56
57| Condition | Testing | Findings |
58|---|---|---|
59| PCOS | Rotterdam criteria: 2 of 3 — oligo/anovulation, clinical/biochemical hyperandrogenism, polycystic ovarian morphology on US | Elevated free testosterone, DHEA-S; LH:FSH ratio > 2:1 (supportive but not required) |
60| Hypothalamic amenorrhea | FSH, LH, estradiol | Low/normal FSH, low LH, low estradiol |
61| Hyperprolactinemia | Prolactin | > 25 ng/mL — repeat; if persistent, consider MRI pituitary |
62| Thyroid dysfunction | TSH | Abnormal TSH → treat before fertility intervention |
63| Premature ovarian insufficiency | FSH, AMH, estradiol | FSH > 40 IU/L (× 2 samples), low AMH, low estradiol |
64
65---
66
67## Step 2: Ovarian Reserve Assessment
68
69Ovarian reserve predicts the quantity (not quality) of remaining oocytes and guides treatment intensity.
70
71| Test | Timing | Normal Values | Interpretation |
72|---|---|---|---|
73| **AMH** (anti-Müllerian hormone) | Any cycle day | 1.0–3.5 ng/mL | < 1.0 = diminished reserve; > 3.5 = possible PCOS |
74| **Day 3 FSH** | Cycle day 2–4 | < 10 IU/L | > 10 = diminished reserve; > 15 = poor prognosis |
75| **Day 3 estradiol** | Cycle day 2–4 | < 80 pg/mL | Elevated E2 with normal FSH may mask diminished reserve |
76| **Antral follicle count (AFC)** | Cycle day 2–5 (TVUS) | 10–20 total | < 5–7 = diminished reserve; > 20 = high responder / PCOS risk |
77
78Combine AMH + AFC for the most accurate reserve assessment. Document results with age-adjusted interpretation.
79
80---
81
82## Step 3: Tubal and Uterine Evaluation
83
84| Test | What It Assesses | Findings |
85|---|---|---|
86| **Hysterosalpingogram (HSG)** | Tubal patency, uterine cavity contour | Bilateral spill = patent tubes; filling defects = polyps/fibroids/synechiae; proximal vs. distal tubal occlusion |
87| **Saline infusion sonohysterogram (SIS)** | Uterine cavity detail | Polyps, submucosal fibroids, Asherman syndrome |
88| **Hysteroscopy** | Direct cavity visualization | Gold standard for intracavitary pathology — see and treat |
89| **Laparoscopy with chromopertubation** | Tubal patency + peritoneal disease | Reserve for suspected endometriosis, PID, or equivocal HSG |
90
91Uterine anomalies affecting fertility:
92- **Septate uterus** — most common anomaly associated with pregnancy loss; hysteroscopic septum resection improves outcomes
93- **Unicornuate uterus** — reduced cavity volume, associated with preterm delivery
94- **Asherman syndrome** — intrauterine adhesions from prior instrumentation; hysteroscopic lysis
95
96---
97
98## Step 4: Male Factor Evaluation
99
100Semen analysis is the cornerstone of male factor assessment. Per WHO 6th edition (2021) reference values:
101
102| Parameter | Lower Reference Limit (5th percentile) |
103|---|---|
104| Volume | ≥ 1.4 mL |
105| Sperm concentration | ≥ 16 million/mL |
106| Total sperm count | ≥ 39 million per ejaculate |
107| Progressive motility | ≥ 30% |
108| Total motility | ≥ 42% |
109| Normal morphology (strict Kruger) | ≥ 4% |
110
111- Abnormal semen analysis → repeat in 4–12 weeks (values fluctuate)
112- Persistently abnormal → urology referral for evaluation (hormonal — FSH, testosterone, prolactin; physical exam — varicocele; genetic — Y-microdeletion, karyotype if severe oligospermia < 5 million/mL)
113- Azoospermia → obstructive vs. non-obstructive classification; refer to reproductive urologist
114
115---
116
117## Step 5: Treatment Algorithm
118
119| Diagnosis | First-Line Treatment | Second-Line | Third-Line |
120|---|---|---|---|
121| **Ovulatory dysfunction (PCOS)** | Letrozole 2.5–7.5 mg CD 3–7 (superior to clomiphene per NICHD trial) | Clomiphene 50–150 mg CD 5–9; gonadotropins | IVF |
122| **Unexplained infertility** | Timed intercourse × 3–6 cycles → letrozole/clomiphene + IUI × 3 | Gonadotropins + IUI (up to 3 cycles) | IVF |
123| **Tubal factor (bilateral occlusion)** | IVF (bypass tubal disease) | Tubal surgery (selected cases with mild distal disease) | — |
124| **Male factor (mild-moderate)** | IUI with sperm wash (requires ≥ 5–10 million TMSC) | IVF | IVF-ICSI |
125| **Male factor (severe / azoospermia)** | IVF-ICSI with TESE/micro-TESE if needed | Donor sperm | — |
126| **Diminished ovarian reserve** | Aggressive stimulation → IVF | Donor oocytes | — |
127| **Endometriosis** | Surgical excision + spontaneous attempt × 6 months | IUI with controlled stimulation | IVF |
128
129---
130
131## Checkpoint B: Post-Draft Alignment (Mandatory)
132
1331. **Are both partners evaluated** — ovulatory function, tubal patency, ovarian reserve, and semen analysis all addressed?
1342. **Is ovarian reserve documented** with age-adjusted interpretation?
1353. **Is the treatment recommendation matched** to the specific diagnosis?
1364. **Are time-sensitive factors addressed** — female age, duration of infertility, and declining reserve?
1375. **Is the referral to reproductive endocrinology documented** when indicated (e.g., bilateral tubal disease, DOR, severe male factor)?
138
139---
140
141## Quality Audit
142
143- [ ] Duration and type (primary vs. secondary) of infertility documented
144- [ ] Female partner age documented with prognostic implications noted
145- [ ] Ovulatory assessment completed (menstrual history + mid-luteal progesterone or OPK)
146- [ ] Ovarian reserve testing documented (AMH + AFC or day-3 FSH/E2)
147- [ ] TSH and prolactin documented
148- [ ] HSG or SIS performed and results documented
149- [ ] Semen analysis performed with WHO 6th edition reference values applied
150- [ ] Abnormal semen analysis repeated and/or urology referral documented
151- [ ] Uterine cavity evaluation completed
152- [ ] PCOS evaluation documented using Rotterdam criteria (if oligoovulation present)
153- [ ] Treatment plan documented with tier-appropriate recommendation
154- [ ] Genetic screening offered (carrier screening per ACOG, karyotype if indicated)
155- [ ] Pre-conception counseling documented (folate, weight optimization, substance cessation)
156- [ ] Timeline for treatment escalation documented
157
158---
159
160## Guidelines
161
1621. **Evaluate both partners simultaneously** — do not complete the full female workup before ordering a semen analysis; male factor is present in 40–50% of cases.
1632. **Age drives urgency** — women ≥ 35 should be referred after 6 months; women ≥ 40 warrant immediate evaluation.
1643. **Letrozole is first-line for PCOS ovulation induction** — the NICHD PPCOS II trial demonstrated higher live birth rates with letrozole vs. clomiphene.
1654. **Do not skip ovarian reserve testing** — even in young patients, diminished reserve changes the treatment approach and timeline.
1665. **Document the AFC method** — report bilateral antral follicle count with probe frequency and technique for reproducibility.
1676. **Recognize when to refer** — bilateral tubal occlusion, severe male factor, diminished ovarian reserve, and age ≥ 38 with > 6 months of failed first-line treatment should be referred to a reproductive endocrinologist.
1687. **Counsel on realistic expectations** — per-cycle success rates for IUI are 10–20%, and IVF success rates are age-dependent (age < 35: ~50% live birth per transfer; age 40–42: ~15%).
1698. **Address lifestyle factors** — BMI optimization (ideal 19–25), smoking cessation, alcohol limitation, and caffeine < 200 mg/day all impact fertility.
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