Initial Approach to Infertility Workup
The initial infertility workup should include a comprehensive reproductive history, physical examination, and appropriate laboratory testing for both partners simultaneously, with evaluation beginning after one year of unprotected intercourse in couples under 35 years or after six months in couples where the female partner is over 35 years. 1, 2
When to Initiate Evaluation
- Evaluation should begin after one year of unprotected intercourse without conception in couples where the female partner is under 35 years 3, 1
- For couples where the female partner is over 35 years, evaluation should begin after six months of unsuccessful attempts 1, 2
- Earlier evaluation is warranted if risk factors for infertility exist, such as:
Female Partner Evaluation
Medical and Reproductive History
- Duration of attempting pregnancy and frequency/timing of intercourse 1
- Menstrual history (regularity, duration, flow characteristics) 1
- Previous pregnancies and outcomes 1
- Medical conditions associated with reproductive failure 1
- Current medications, allergies, and family history of reproductive issues 1
- Lifestyle factors (smoking, alcohol, caffeine intake) 1
Physical Examination
- Height, weight, and BMI calculation 1
- Thyroid examination 1
- Clinical breast examination 1
- Pelvic examination to assess for:
Initial Laboratory and Diagnostic Testing
- Ovarian reserve testing (follicle-stimulating hormone levels) 1
- Transvaginal ultrasound to evaluate uterine anatomy 1
- Assessment of ovulatory function 2
- Evaluation of tubal patency (hysterosalpingography when indicated) 2, 4
Male Partner Evaluation
Medical and Reproductive History
- Prior fertility and duration of current infertility 3
- Childhood illnesses and developmental history 3
- Systemic illnesses and previous surgeries 3
- Sexual history, including sexually transmitted diseases 3
- Gonadal toxin exposure, including heat 3
- Current medications and family reproductive history 3
Physical Examination
- Examination of the penis, including location of the urethral meatus 3
- Measurement and palpation of the testes 3
- Assessment for presence and consistency of vas deferens and epididymides 3
- Checking for presence of varicocele 3
- Evaluation of body habitus and secondary sex characteristics 3
- Digital rectal examination 3
Semen Analysis
- At least two semen analyses performed at least one month apart 3, 5
- Collection after 2-3 days of abstinence 5
- Key parameters to assess:
- Volume (lower reference limit: 1.4 mL) 5
- pH (should be >7.2) 5
- Sperm concentration (lower reference limit: 16 million/mL) 5
- Total sperm number (lower reference limit: 39 million per ejaculate) 5
- Motility (lower reference limit: 42% for total motility) 5
- Morphology (lower reference limit: 4.0% normal forms) 5
Common Pitfalls to Avoid
- Failing to evaluate both partners simultaneously, which may delay diagnosis 1
- Incomplete evaluation of the male partner, as male factor contributes to 40-50% of infertility cases 2
- Overlooking medical conditions that may be causing or associated with infertility 3
- Inadequate abstinence period before semen collection, affecting volume and concentration 5
- Improper semen collection technique or delayed analysis 5
Next Steps After Initial Evaluation
- If abnormalities are detected in semen analysis, a second confirmatory analysis should be performed at least one month after the first 5
- For azoospermia, laboratories should centrifuge the ejaculate and examine for rare sperm 5
- Genetic testing (karyotype, Y-chromosome microdeletion) should be considered for males with severe oligospermia (<5 million/mL) 5
- If three ovulatory responses occur with treatment but pregnancy is not achieved, further evaluation is warranted 6
- Unexplained infertility (diagnosed in up to 30% of infertile couples) requires, at minimum, evidence of ovulation, tubal patency, and normal semen analysis 2