Managing Fertility Evaluations

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)

1. Duration of infertility — months of unprotected intercourse? Primary (never conceived) or secondary (prior pregnancy)? (Default: from history)
2. Female partner age — critical for prognosis and urgency of evaluation. (Default: from demographics)
3. Coital frequency and timing — intercourse frequency and relationship to ovulation? Use of ovulation prediction kits? (Default: from history)
4. Menstrual history — cycle length, regularity, signs of ovulatory dysfunction (oligomenorrhea, amenorrhea)? (Default: from menstrual calendar)
5. Obstetric and gynecologic history — prior pregnancies (with any partner), ectopic, PID, endometriosis, uterine surgery? (Default: from history)
6. Male partner history — prior paternity, testicular surgery, varicocele, medications, toxin exposure, ejaculatory dysfunction? (Default: from male partner history)
7. Medical comorbidities — thyroid disease, PCOS, hyperprolactinemia, DM, eating disorders, excessive exercise? (Default: from problem list)
8. 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.

Ovulatory Dysfunction Workup

Step 2: Ovarian Reserve Assessment

Ovarian reserve predicts the quantity (not quality) of remaining oocytes and guides treatment intensity.

Combine AMH + AFC for the most accurate reserve assessment. Document results with age-adjusted interpretation.

Step 3: Tubal and Uterine Evaluation

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:

• 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

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Are both partners evaluated — ovulatory function, tubal patency, ovarian reserve, and semen analysis all addressed?
2. Is ovarian reserve documented with age-adjusted interpretation?
3. Is the treatment recommendation matched to the specific diagnosis?
4. Are time-sensitive factors addressed — female age, duration of infertility, and declining reserve?
5. Is the referral to reproductive endocrinology documented when indicated (e.g., bilateral tubal disease, DOR, severe male factor)?

Quality Audit

• Duration and type (primary vs. secondary) of infertility documented
• Female partner age documented with prognostic implications noted
• Ovulatory assessment completed (menstrual history + mid-luteal progesterone or OPK)
• Ovarian reserve testing documented (AMH + AFC or day-3 FSH/E2)
• TSH and prolactin documented
• HSG or SIS performed and results documented
• Semen analysis performed with WHO 6th edition reference values applied
• Abnormal semen analysis repeated and/or urology referral documented
• Uterine cavity evaluation completed
• PCOS evaluation documented using Rotterdam criteria (if oligoovulation present)
• Treatment plan documented with tier-appropriate recommendation
• Genetic screening offered (carrier screening per ACOG, karyotype if indicated)
• Pre-conception counseling documented (folate, weight optimization, substance cessation)
• Timeline for treatment escalation documented

Guidelines

1. 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.
2. Age drives urgency — women ≥ 35 should be referred after 6 months; women ≥ 40 warrant immediate evaluation.
3. Letrozole is first-line for PCOS ovulation induction — the NICHD PPCOS II trial demonstrated higher live birth rates with letrozole vs. clomiphene.
4. Do not skip ovarian reserve testing — even in young patients, diminished reserve changes the treatment approach and timeline.
5. Document the AFC method — report bilateral antral follicle count with probe frequency and technique for reproducibility.
6. 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.
7. 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%).
8. Address lifestyle factors — BMI optimization (ideal 19–25), smoking cessation, alcohol limitation, and caffeine < 200 mg/day all impact fertility.