Laboratory Evaluation for Fertility Issues
For male partners, order two semen analyses at least one month apart as the initial and most critical laboratory test, combined with endocrine evaluation (testosterone and FSH) if sperm concentration is <10 million/mL or if clinical findings suggest hormonal dysfunction. 1, 2, 3
Male Partner Laboratory Workup
Initial Required Testing
- Two semen analyses separated by at least one month are mandatory for accurate assessment, as single tests cannot account for biological variability 1, 2, 3
- Instruct patients to abstain from sexual activity for 2-3 days before collection 1, 3
- Sample must be examined within one hour of collection at room or body temperature 1, 3
- Evaluate volume (≥1.4-1.5 mL), pH (>7.2), sperm concentration (≥16-20 million/mL), total sperm count (≥39-40 million), motility (≥40-50%), and morphology 1, 3
Endocrine Evaluation (Conditional)
Order hormonal testing if:
- Sperm concentration <10 million/mL 1, 2, 3
- Sexual dysfunction is present 3
- Physical examination suggests endocrinopathy (abnormal body habitus, secondary sex characteristics, or testicular size) 1, 3
Specific hormones to measure:
- Serum testosterone 2, 3
- Follicle-stimulating hormone (FSH) 1, 2, 3
- Luteinizing hormone (LH) and prolactin if FSH is elevated to distinguish primary testicular failure from secondary hypogonadism 4
Genetic Testing (Conditional)
Order genetic studies if:
- Sperm concentration <5 million/mL (severe oligospermia) 1, 2, 3
- Azoospermia (no sperm) is present 1, 2
Specific genetic tests:
- Karyotype analysis (detects Klinefelter syndrome, translocations) 1, 2
- Y-chromosome microdeletion assay 1, 2
- Cystic fibrosis mutation analysis if congenital bilateral absence of vas deferens is suspected 1
Additional Male Testing
- Post-ejaculatory urinalysis if ejaculate volume <1 mL to evaluate for retrograde ejaculation 3
Female Partner Laboratory Workup
Ovulatory Function Assessment
- Serum progesterone level at cycle day 21 (mid-luteal phase) to document ovulation 5, 6, 7
- Day 3 FSH and estradiol levels for ovarian reserve testing, particularly if the woman is >35 years 8, 7
- Thyroid function tests (TSH) as thyroid dysfunction affects ovulation 2, 9
Ovarian Reserve Testing (Age-Dependent)
For women >35 years, order:
- Day 3 FSH and estradiol 8, 7
- Anti-Müllerian hormone (AMH) levels (implied by ovarian reserve assessment) 8
- Antral follicle count via pelvic ultrasonography 7
Structural and Tubal Assessment
- Hysterosalpingography (HSG) for women with no risk factors for tubal obstruction to evaluate uterine cavity and tubal patency 8, 5, 9
- Pelvic ultrasonography to assess uterine and ovarian anatomy 8, 9
- Hysteroscopy or laparoscopy if history of endometriosis, pelvic infections, or ectopic pregnancy exists 5, 9
Critical Timing Considerations
- Begin evaluation after 12 months of unprotected intercourse for women <35 years 8, 5, 9
- Begin evaluation after 6 months for women 35-40 years 8, 9
- Begin immediate evaluation for women >40 years or if known infertility risk factors exist 8, 9
Common Pitfalls to Avoid
- Never rely on a single semen analysis as biological variability is significant and two tests minimum are required 1, 2, 3
- Do not assume normal semen analysis equals fertility as 25% of infertility cases remain unexplained despite normal parameters 3
- Ensure laboratory quality control as many laboratories do not adhere to WHO standardized methods, leading to unreliable results 3
- Do not delay male evaluation as male factor contributes to 40-50% of infertility cases and should be assessed concurrently with female evaluation 8, 9
- Do not skip endocrine testing in severe oligospermia as this may reveal treatable hormonal causes 1, 2, 3