Infertility Evaluation
Current Guidance Update
Definition of Infertility
Infertility is defined as the failure to conceive after 12 months of regular unprotected intercourse, or after 6 months when the female partner is over 35 years of age.
Global Prevalence
Infertility affects approximately 17.5% of adults worldwide, meaning nearly 1 in 6 people experience infertility during their lifetime.
Complete Fertility Evaluation
A comprehensive infertility assessment should include ovarian reserve testing, semen analysis, and evaluation of both uterine anatomy and fallopian tube patency.
IVF Recommendation
Eligible women should be offered IVF after 2 years of regular unprotected intercourse if pregnancy has not been achieved and appropriate criteria are met.
Introduction
Infertility: Causes, Investigation & Treatment
Common Causes of Infertility
- Ovulatory dysfunction (25–30%) – PCOS, POI, thyroid disorders
- Tubal disease (20–25%) – PID, chlamydia, surgery, endometriosis
- Uterine factors (10–15%) – fibroids, polyps, Asherman's syndrome
- Endometriosis (25–50% of female infertility)
- Unexplained infertility (25–30%)
- Reduced ovarian reserve
Fertility Investigation
- Cycle history and ovulation confirmation
- FSH, LH, oestradiol, AMH, prolactin & TSH
- Pelvic ultrasound with antral follicle count
- HSG or HyCoSy for tubal patency
- Hysteroscopy for cavity abnormalities
- Laparoscopy when tubal or peritoneal disease is suspected
Male Factor Infertility
Male factor contributes to 40–50% of infertile couples and is the sole cause in 20–30%. Semen analysis is the essential first-line investigation, with WHO 2021 reference values including sperm concentration ≥16 million/mL and progressive motility ≥30%.
Treatment by Cause
- Ovulatory dysfunction – lifestyle changes, letrozole, gonadotropins
- Tubal disease – IVF for significant damage
- Uterine factors – hysteroscopic treatment
- Endometriosis – laparoscopic excision with IVF if required
- Male factor – IUI for mild cases and ICSI-IVF for moderate or severe infertility
Frequently Asked Questions
At what point should I seek a fertility assessment?
After 12 months for women under 35, 6 months for women 35 and over. Earlier assessment is appropriate with known risk factors.
Does stress cause infertility?
Extreme stress can suppress ovulation, but moderate stress in otherwise ovulating women does not directly cause infertility.
Conclusion
Infertility evaluation is the essential foundation of fertility treatment — accurate diagnosis directs effective management, with timely specialist referral when advanced interventions are required.
Sources & References
This article draws on guidance current at the time of writing from the following bodies and publications:
- ESHRE (2023 Unexplained Infertility)
- WHO (2023)
- ACOG (2022)
- NICE CG156 (updated 2023)
General reference bodies for women's health guidance:
RCOG
rcog.org.ukACOG
acog.orgFIGO
figo.orgWHO
who.intNICE
nice.org.uk⚠ IMPORTANT DISCLAIMER
This article is provided for general knowledge and reference purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. No medication, treatment, or change to your healthcare should be undertaken based on this content without first consulting a qualified doctor. Always seek the advice of your physician or another qualified health provider with any questions you may have regarding a medical condition.
