Laboratory Tests for Infertility Evaluation
Both partners require concurrent laboratory evaluation from the outset, with the male partner undergoing at least two semen analyses separated by one month, and the female partner receiving thyroid function testing, ovarian reserve assessment, and imaging to evaluate tubal patency and uterine anatomy. 1, 2
Male Partner Laboratory Workup
Essential Initial Testing
- Two semen analyses separated by at least one month are mandatory to confirm persistent abnormalities, as semen parameters fluctuate substantially between tests 3, 4, 1, 2
- Assess ejaculate volume, pH, sperm concentration, total motile sperm count, and sperm morphology using strict Kruger criteria 1
- WHO lower limits represent the lowest fifth percentile of values for fertile males whose partners conceived within 12 months 3
Endocrine Testing (When Indicated)
- Measure serum FSH, LH, and total testosterone if sperm concentration is less than 10 million/mL, if sexual dysfunction is present, or if clinical findings suggest endocrinopathy 3, 2
- Endocrine testing is not recommended as first-line for all men, only when specific indications exist 3
Genetic Testing (Critical Thresholds)
- Karyotype and Y-chromosome microdeletion analysis are mandatory before considering intracytoplasmic sperm injection (ICSI) if sperm concentration is less than 5 million/mL or if azoospermia is present 4, 2
- Consider karyotype and sperm DNA fragmentation testing in couples with failed assisted reproductive technology cycles or two or more recurrent pregnancy losses 3
Female Partner Laboratory Workup
Endocrine Evaluation
- Thyroid function tests (TSH) are essential initial screening, as both hypothyroidism and hyperthyroidism disrupt ovulation 4, 1, 2
- Serum progesterone level at cycle day 21 documents ovulation in women with regular cycles 5, 6
- Serum FSH level on cycle day 2-3 assesses ovarian reserve 5
- Consider clomiphene citrate challenge test for additional ovarian reserve assessment in women over 35 years 5
Imaging Studies
- Transvaginal ultrasound serves as initial imaging to evaluate the uterine cavity, assess for fibroids or polyps, and count antral follicles for ovarian reserve 1, 2
- Hysterosalpingography or sonohysterography with tubal contrast agent evaluates tubal patency in women with no history suggesting tubal obstruction 2, 6
- For women with history of endometriosis, pelvic inflammatory disease, or ectopic pregnancy, hysteroscopy or laparoscopy is recommended instead of hysterosalpingography 6
Timing of Evaluation
- Begin evaluation after 12 months of unprotected intercourse in women under 35 years 1, 7
- Begin evaluation after only 6 months in women 35 years or older 1, 7
- Immediate evaluation is warranted if either partner has known risk factors including bilateral cryptorchidism, irregular menstrual cycles, prior pelvic inflammatory disease, or known endometriosis 1
Critical Clinical Pitfalls
- Never evaluate only one partner—male factor contributes to 40-50% of infertility cases, and over 50% of male infertility stems from specific medical conditions with health implications beyond fertility 4, 1, 7
- Men with abnormal semen parameters have significantly higher rates of testicular cancer and overall mortality compared to fertile men, making thorough evaluation critical for the patient's general health 4
- Any abnormal semen parameters require referral to a male reproductive specialist for complete evaluation 4, 1, 2
- Point-of-care and mail-in semen tests cannot substitute for comprehensive evaluation in a specialized andrology laboratory 3
- Most commercially available vaginal lubricants reduce fertility and should be avoided during the fertile window 1, 2