What is the recommended initial evaluation and treatment approach for individuals or couples experiencing fertility issues at a fertility lab?

Initial Fertility Laboratory Evaluation

Both partners must undergo concurrent evaluation from the outset, with the male partner receiving a comprehensive reproductive history, physical examination by a trained examiner, and at least two semen analyses performed one month apart. 1, 2, 3

Timing to Initiate Evaluation

• Begin evaluation after 12 months of unprotected intercourse in women under 35 years 2, 4
• Begin evaluation after 6 months in women 35 years or older 2, 4
• Initiate immediate evaluation in women over 40 years or those with known conditions causing infertility 2, 4
• After 5 unsuccessful ovulation cycles, both partners require concurrent evaluation immediately, particularly if the female partner is over 35 or either partner has identifiable risk factors 1

Male Partner Evaluation

Essential History Components 2, 3

• Sexual history: coital frequency/timing, duration of infertility, prior fertility
• Medical history: childhood illnesses (cryptorchidism), systemic illnesses (diabetes mellitus, upper respiratory diseases), previous surgeries
• Medication and exposure history: current medications, allergies, anabolic steroid use, gonadotoxin exposures (environmental/chemical toxins, heat exposure)
• Family reproductive history: genetic conditions, infertility in family members

Physical Examination 5, 2

All subfertile men should undergo physical examination by an examiner with appropriate training and expertise, as this approach identifies significant medical conditions that would be missed by history and semen analysis alone (0.16% of men have significant medical conditions despite normal semen parameters). 5

The examination must assess:

• Penis and urethral meatus location 2
• Testicular size measurement and palpation (normal volume >15 mL) 2
• Presence and consistency of vasa deferentia and epididymides 2
• Varicocele presence (palpable abnormality affecting sperm production and quality) 1, 2
• Body habitus and secondary sex characteristics 2
• Digital rectal examination 2

Semen Analysis 2, 3

• Obtain at least two semen analyses performed at least one month apart for accurate assessment 1, 2, 3
• Require 2-3 days abstinence before collection 2
• Keep specimens at room/body temperature and examine within one hour 2

WHO reference values include: 3

• Volume ≥1.4 mL
• pH >7.2
• Sperm concentration ≥16 million/mL
• Total sperm number ≥39 million per ejaculate
• Progressive motility ≥30%
• Total motility ≥42%
• Normal morphology ≥4.0%
• Vitality ≥54% live spermatozoa

Advanced Male Testing (When Indicated)

Any abnormal semen parameters require referral to a male reproductive specialist for complete evaluation. 1, 2

Hormonal evaluation (FSH and testosterone) is indicated when: 2, 3

• Sperm concentration <10 million/mL
• Azoospermia is confirmed
• Impaired sexual function is present
• Physical examination reveals findings suggesting endocrinopathy

Genetic testing (karyotyping and Y-chromosome microdeletion analysis) is mandatory for: 1, 2

• Azoospermia or severe oligospermia <5 million/mL before considering intracytoplasmic sperm injection
• Congenital absence of vas deferens

Scrotal/testicular ultrasonography is indicated when: 2

• Physical examination of scrotum is difficult or inadequate
• Testicular mass is suspected
• Azoospermia is confirmed

Female Partner Evaluation

Essential History Components 2

• Duration attempting pregnancy
• Coital frequency and timing
• Previous pregnancies and outcomes
• Menstrual history (regularity, duration, flow)
• Medical conditions (thyroid dysfunction affects ovulation) 1
• Current medications and allergies
• Lifestyle factors (smoking, alcohol, obesity)

Physical Examination 2

• Height, weight, BMI calculation
• Thyroid examination
• Clinical breast examination
• Assessment for signs of androgen excess (hirsutism, acne)
• Pelvic examination

Laboratory and Imaging 2

• Ovarian reserve testing
• Midluteal phase progesterone assay (cycle day 21) to confirm ovulation 6, 7
• Transvaginal ultrasound to evaluate uterine anatomy
• Hysterosalpingography to assess tubal patency in women with no risk of obstruction 6, 7
• Hysteroscopy or laparoscopy for patients with history of endometriosis, pelvic infections, or ectopic pregnancy 6

Critical Health Implications

Men with abnormal semen parameters have significantly higher rates of testicular cancer and overall mortality compared to fertile men. 1, 3 Over 50% of male infertility cases stem from specific medical conditions with health implications beyond fertility, making thorough evaluation critical for the patient's overall health. 1

Common Pitfalls to Avoid

• Do not delay male evaluation – male factors contribute to 40-50% of infertility cases 2, 4
• Do not order routine hormonal testing or imaging for all infertile men – use a stepwise approach reserving these tests for those with abnormal semen parameters or physical examination findings 2
• Do not miss significant medical conditions – limiting male assessment to reproductive history and semen analysis alone will miss 0.16% of men with significant medical conditions but normal semen parameters 5
• Do not overlook genetic implications – genetic causes can affect treatment success and offspring health if assisted reproductive technologies are utilized 2

Goals of Evaluation 5, 2

• Identify correctable conditions that can be treated
• Identify irreversible conditions amenable to assisted reproductive technologies using partner's sperm
• Identify irreversible conditions requiring donor sperm or adoption
• Identify genetic causes affecting treatment success or offspring health