What tests and evaluations are recommended for individuals or couples checking their fertility?

Fertility Testing Recommendations

For couples checking fertility, begin with concurrent evaluation of both partners, including two semen analyses at least one month apart for the male, combined with a detailed reproductive history and physical examination by a trained examiner. 1, 2

Timing of Initial Evaluation

• Initiate fertility evaluation after 12 months of unprotected intercourse without conception in couples where the female partner is under 35 years old. 1
• Begin evaluation earlier (at 6 months or immediately) if the female partner is over 35 years old, or if known male or female risk factors exist (such as history of cryptorchidism, irregular menses, or known reproductive disorders). 1
• Evaluate men concerned about their fertility status even without a current partner. 1, 2

Male Partner Evaluation Components

Reproductive History (Mandatory)

The reproductive history must document: 1, 2

• Frequency and timing of intercourse
• Duration of current infertility and any prior fertility
• Childhood illnesses (particularly cryptorchidism, mumps orchitis) and developmental history
• Systemic illnesses (diabetes, respiratory diseases) and previous surgeries (particularly hernia repairs, orchiopexy)
• Sexual history including sexually transmitted infections
• Gonadal toxin exposures (occupational chemicals, heat exposure, radiation)
• Current prescription and non-prescription medications
• Family reproductive history

Physical Examination (Mandatory)

All men should undergo physical examination by an examiner with appropriate training and expertise, as this identifies significant medical conditions missed by history and semen analysis alone. 1 The examination must assess: 1, 2

• Penis examination including urethral meatus location
• Testicular measurement and palpation for size and consistency
• Presence and consistency of vas deferens and epididymides bilaterally
• Presence of varicocele (examined while standing)
• Body habitus and secondary sex characteristics (hair distribution, breast development)
• Digital rectal examination

Semen Analysis Protocol (Mandatory)

Order two semen analyses at least one month apart as the initial screening. 1, 2 This is critical because:

Collection Instructions: 1, 2, 3

• Abstain from sexual activity for 2-3 days before collection (inadequate abstinence invalidates results)
• Collect by masturbation or using specialized semen collection condoms
• If collected at home, maintain specimen at room or body temperature during transport
• Examine within one hour of collection (delayed analysis affects motility assessment)

Interpretation Using WHO Reference Values: 1, 2, 3

• Volume ≥1.4-1.5 mL
• pH >7.2
• Sperm concentration ≥16-20 million/mL
• Total sperm number ≥40 million per ejaculate
• Progressive motility ≥30-50%
• Normal morphology ≥4% (strict Kruger criteria)

If the first semen analysis is normal by WHO criteria, a single test is sufficient; if abnormal, at least two abnormal tests are required before proceeding with further investigation. 1, 3

Mandatory Additional Testing Based on Abnormal Results

Endocrine Evaluation

Order hormonal testing if: 1, 2, 3

• Sperm concentration <10 million/mL
• Sexual dysfunction is present
• Clinical findings suggest endocrinopathy (abnormal secondary sex characteristics, gynecomastia)

Measure: 1, 2

• Serum testosterone (total)
• Follicle-stimulating hormone (FSH)
• Consider luteinizing hormone (LH) and prolactin if testosterone is low

Genetic Testing

Order genetic evaluation if: 1, 2

• Severe oligospermia (<5 million/mL)
• Azoospermia (no sperm in ejaculate)

Include: 1, 2

• Karyotype analysis
• Y-chromosome microdeletion testing

Post-Ejaculatory Urinalysis

Order if ejaculate volume <1.0-1.4 mL to exclude retrograde ejaculation, except in cases of bilateral vasal agenesis or hypogonadism. 2, 3

Female Partner Evaluation Components

While the evidence provided focuses primarily on male evaluation, both partners must undergo concurrent assessment as 50% of infertility involves male factors, often combined with female factors. 1

Basic Female Evaluation

• Ovulation confirmation (basal body temperature charting, ovulation predictor kits, or mid-luteal progesterone)
• Assessment of tubal patency (hysterosalpingography or laparoscopy)
• Evaluation for structural abnormalities (pelvic examination, ultrasound)
• Hormonal assessment if indicated by menstrual irregularity

Ovarian Reserve Testing (For Women ≥35 Years)

Early follicular phase (day 2-3) FSH and estradiol levels provide prognostic information about fertility potential, particularly in women over 35 with unexplained infertility. 4, 5 Elevated baseline FSH (>25 mIU/mL) correlates with significantly reduced pregnancy rates. 5

Critical Pitfalls to Avoid

• Never base clinical decisions on a single abnormal semen analysis—always obtain at least two samples. 1, 3
• Laboratory quality is crucial—many laboratories do not adhere to WHO standardized methods, leading to unreliable results. 2 Use certified andrology laboratories when possible.
• Do not assume normal semen analysis equals fertility—25% of infertility cases remain unexplained despite normal conventional parameters. 2
• Improper collection technique (wrong abstinence period, delayed analysis) invalidates all results. 2, 3
• Do not skip physical examination—significant medical conditions (0.16-6% of cases) are missed when evaluation is limited to history and semen analysis alone. 1
• Evaluate both partners concurrently from the start—sequential evaluation wastes time, particularly for couples where the female partner is over 35. 1

When to Refer to Specialists

Refer men to a male reproductive specialist (urologist with fertility expertise) if: 1

• One or more abnormal semen parameters are found
• Abnormal physical examination findings
• Failed assisted reproductive technology (ART) cycles
• Recurrent pregnancy losses (two or more)