What is the approach to infertility evaluation?

Comprehensive Approach to Infertility Evaluation

Both partners in an infertile couple should undergo concurrent assessment, beginning with a thorough reproductive history and appropriate testing, with evaluation starting after 12 months of unprotected intercourse or sooner if risk factors exist. 1, 2

When to Initiate Evaluation

• After 12 months of unprotected intercourse without conception for couples with female partner <35 years
• After 6 months if female partner is ≥35 years
• Earlier evaluation if:
  • Male infertility risk factors exist (e.g., history of cryptorchidism)
  • Female infertility risk factors exist
  • Either partner questions fertility potential
  • Men concerned about fertility status without a current partner 1, 2

Male Evaluation

Initial Assessment

1. Reproductive history, including:

   • Frequency and timing of intercourse
   • Prior fertility and duration of current infertility
   • Childhood illnesses and developmental history
   • Systemic illnesses and previous surgeries
   • Sexual history including STIs
   • Gonadal toxin exposure (including heat)
   • Medication history (prescription and non-prescription)
   • Family reproductive history 1

2. Semen analysis (at least two samples, collected at least one month apart)

   • Collection parameters:
     • 2-3 days of sexual abstinence
     • Collection by masturbation or using non-toxic condoms
     • Specimen kept at body temperature during transport
     • Examination within one hour of collection 2
   • Standard parameters assessed:
     • Volume (1.5-5.0 mL)
     • pH (>7.2)
     • Sperm concentration (>20 million/mL)
     • Total sperm count (>40 million per ejaculate)
     • Motility (>50%)
     • Forward progression (>2 on scale of 0-4)
     • Morphology 2

3. Physical examination with focus on:

   • Penis, including urethral meatus location
   • Testicular measurement and palpation
   • Presence and consistency of vasa and epididymides
   • Presence of varicocele
   • Body habitus and secondary sex characteristics
   • Digital rectal examination 1

Further Evaluation

• Men with abnormal semen parameters should be referred to a male reproductive expert 1
• Endocrine testing (testosterone, FSH, LH, prolactin) for abnormal semen parameters or clinical findings suggesting endocrinopathy 2
• Scrotal ultrasound when physical examination is difficult or testicular mass suspected 2
• Transrectal ultrasound for azoospermic men with palpable vasa and low ejaculate volumes 2

Female Evaluation

Initial Assessment

1. Reproductive history, including:

   • Menstrual history and cycle regularity
   • Previous pregnancies and outcomes
   • Age at menarche
   • Duration of infertility
   • Coital frequency and timing relative to ovulation 2

2. Ovulation assessment:

   • Serum progesterone level at cycle day 21 3
   • Ovulation prediction methods (kits, digital applications) 2

3. Uterine and tubal evaluation:

   • Hysterosalpingography for women with no risk factors for tubal obstruction
   • Hysteroscopy or laparoscopy for women with history of endometriosis, pelvic infections, or ectopic pregnancy 2, 3

Common Pitfalls to Avoid

1. Focusing solely on female factors without concurrent male evaluation 2
2. Delaying evaluation in women over 35 years 2
3. Overlooking lifestyle factors that affect fertility:
   • Smoking status
   • Alcohol consumption
   • Caffeine intake
   • Recreational drug use
   • Weight management 2
4. Inadequate semen analysis due to poor laboratory technique or insufficient samples 2
5. Neglecting emotional and psychological support during evaluation and treatment 2

Treatment Considerations

• Treatment should be directed by the identified cause(s) of infertility
• For ovulatory dysfunction: clomiphene citrate starting at 50 mg daily for 5 days, increasing to 100 mg if needed 4
• For male factor: gonadotropin therapy, intrauterine insemination, or in vitro fertilization 3
• For unexplained infertility: another year of unprotected intercourse or assisted reproductive technologies 3
• Lifestyle modifications may improve success rates: limiting alcohol, avoiding tobacco and illicit drugs, consuming a fertility-supportive diet, and weight loss if obese 5

Remember that most cases of male infertility can be treated and reversed by medical or surgical interventions, with the goal of achieving natural pregnancy when possible 6.