Managing Fertility Evaluations

Documents to Request

• Prior fertility evaluation results (both partners)
• Semen analysis report(s)
• HSG or SHG reports
• Ovarian reserve testing (AMH, day-3 FSH/estradiol, antral follicle count)
• Thyroid function tests
• Prolactin level
• Prior operative reports (laparoscopy, hysteroscopy, tubal surgery)
• Genetic testing results (karyotype, FMR1, carrier screening)
• Partner medical records if available

Step 1: Ovulatory Assessment

Ovulatory dysfunction accounts for approximately 25–30% of female infertility.

Ovulatory Dysfunction Workup

Step 2: Ovarian Reserve Assessment

Ovarian reserve predicts the quantity (not quality) of remaining oocytes and guides treatment intensity.

Combine AMH + AFC for the most accurate reserve assessment. Document results with age-adjusted interpretation.

Step 3: Tubal and Uterine Evaluation

Uterine anomalies affecting fertility:

• Septate uterus — most common anomaly associated with pregnancy loss; hysteroscopic septum resection improves outcomes
• Unicornuate uterus — reduced cavity volume, associated with preterm delivery
• Asherman syndrome — intrauterine adhesions from prior instrumentation; hysteroscopic lysis

Step 4: Male Factor Evaluation

Semen analysis is the cornerstone of male factor assessment. Per WHO 6th edition (2021) reference values:

• Abnormal semen analysis → repeat in 4–12 weeks (values fluctuate)
• Persistently abnormal → urology referral for evaluation (hormonal — FSH, testosterone, prolactin; physical exam — varicocele; genetic — Y-microdeletion, karyotype if severe oligospermia < 5 million/mL)
• Azoospermia → obstructive vs. non-obstructive classification; refer to reproductive urologist

Step 5: Treatment Algorithm

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Are both partners evaluated — ovulatory function, tubal patency, ovarian reserve, and semen analysis all addressed?
2. Is ovarian reserve documented with age-adjusted interpretation?
3. Is the treatment recommendation matched to the specific diagnosis?
4. Are time-sensitive factors addressed — female age, duration of infertility, and declining reserve?
5. Is the referral to reproductive endocrinology documented when indicated (e.g., bilateral tubal disease, DOR, severe male factor)?

Quality Audit

• Duration and type (primary vs. secondary) of infertility documented
• Female partner age documented with prognostic implications noted
• Ovulatory assessment completed (menstrual history + mid-luteal progesterone or OPK)
• Ovarian reserve testing documented (AMH + AFC or day-3 FSH/E2)
• TSH and prolactin documented
• HSG or SIS performed and results documented
• Semen analysis performed with WHO 6th edition reference values applied
• Abnormal semen analysis repeated and/or urology referral documented
• Uterine cavity evaluation completed
• PCOS evaluation documented using Rotterdam criteria (if oligoovulation present)
• Treatment plan documented with tier-appropriate recommendation
• Genetic screening offered (carrier screening per ACOG, karyotype if indicated)
• Pre-conception counseling documented (folate, weight optimization, substance cessation)
• Timeline for treatment escalation documented

Guidelines

1. Evaluate both partners simultaneously — do not complete the full female workup before ordering a semen analysis; male factor is present in 40–50% of cases.
2. Age drives urgency — women ≥ 35 should be referred after 6 months; women ≥ 40 warrant immediate evaluation.
3. Letrozole is first-line for PCOS ovulation induction — the NICHD PPCOS II trial demonstrated higher live birth rates with letrozole vs. clomiphene.
4. Do not skip ovarian reserve testing — even in young patients, diminished reserve changes the treatment approach and timeline.
5. Document the AFC method — report bilateral antral follicle count with probe frequency and technique for reproducibility.
6. Recognize when to refer — bilateral tubal occlusion, severe male factor, diminished ovarian reserve, and age ≥ 38 with > 6 months of failed first-line treatment should be referred to a reproductive endocrinologist.
7. Counsel on realistic expectations — per-cycle success rates for IUI are 10–20%, and IVF success rates are age-dependent (age < 35: ~50% live birth per transfer; age 40–42: ~15%).
8. Address lifestyle factors — BMI optimization (ideal 19–25), smoking cessation, alcohol limitation, and caffeine < 200 mg/day all impact fertility.