Initial Steps and Treatment Options for Fertility Treatment
The initial evaluation for fertility treatment should include concurrent assessment of both male and female partners, with a comprehensive reproductive history and appropriate diagnostic testing for each partner. 1
Initial Evaluation
When to Initiate Fertility Testing
- Fertility evaluation should begin after 12 months of regular unprotected intercourse without conception in couples with female partners under 35 years of age 2
- For couples with female partners over 35 years of age, evaluation should begin after 6 months of unsuccessful attempts 2, 3
- Earlier evaluation is warranted for individuals with known risk factors for infertility 2, 3
Male Partner Evaluation
- Initial evaluation should include a comprehensive reproductive history 1
- One or more semen analyses should be performed as part of the initial evaluation 1
- Men with abnormal semen parameters should be referred to a male reproductive specialist for complete history, physical examination, and additional directed testing 1
- Evaluation should include assessment for potentially correctable conditions and irreversible conditions that may be amenable to assisted reproductive technologies 1
Female Partner Evaluation
- Comprehensive medical and reproductive history should include menstrual history, previous pregnancies, and medical conditions associated with reproductive failure 2
- Physical examination should assess BMI, thyroid function, and signs of androgen excess 2
- Laboratory testing should include assessment of ovarian reserve with follicle-stimulating hormone (FSH) levels 2
- Imaging of reproductive organs should be performed to evaluate uterine anatomy and tubal patency 2, 3
Treatment Options
Male Factor Infertility Treatment
Medical Interventions
- For men with hypogonadotropic hypogonadism, evaluation to determine the etiology and appropriate treatment is essential 1
- For men with low serum testosterone, aromatase inhibitors, human chorionic gonadotropin, or selective estrogen receptor modulators may be used 1
- Testosterone monotherapy should not be prescribed for men interested in current or future fertility 1
- For men with idiopathic infertility, FSH analogues may be considered to improve sperm concentration, pregnancy rate, and live birth rate 1
- Benefits of supplements and antioxidants are of questionable clinical utility in treating male infertility 1
Surgical Interventions
- For men with obstructive azoospermia, sperm may be extracted from either the testis or epididymis 1
- For men with aspermia, surgical sperm extraction or induced ejaculation techniques may be performed 1
- For men with retrograde ejaculation, treatment options include sympathomimetics, alkalinization of urine, or surgical sperm retrieval 1
Female Factor Infertility Treatment
Ovulation Induction
- For women with ovulatory dysfunction, clomiphene citrate may be used to induce ovulation 4
- Treatment should begin with a low dose (50 mg daily for 5 days) 4
- If ovulation does not occur after the first course, a second course of 100 mg daily for 5 days may be given 4
- Treatment beyond three courses is not recommended if ovulation does not occur 4
Assisted Reproductive Technologies
- Male infertility may be managed with assisted reproductive technologies (ART) 1
- For couples with low total motile sperm count, intrauterine insemination (IUI) success rates may be reduced, and in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) may be considered 1
- For unexplained infertility, treatment options include continued attempts at natural conception, IUI, or IVF 5, 6, 7
Common Pitfalls to Avoid
- Failing to evaluate both partners simultaneously can delay diagnosis 2
- Incomplete evaluation of the male partner is common despite male factors contributing to approximately 50% of infertility cases 1, 8
- Prescribing testosterone for male infertility, which can suppress spermatogenesis 1
- Continuing treatment with clomiphene citrate beyond recommended cycles without reassessment 4
- Proceeding directly to ART without identifying potentially correctable conditions 8
Lifestyle Modifications
- Couples should be advised to have intercourse every 1-2 days beginning soon after menstruation ends to increase pregnancy likelihood 2
- Patients should be counseled to avoid smoking and excessive alcohol consumption 2, 6
- Weight management should be addressed, as extreme body weights can impact fertility 2, 6