Infertility and sexual dysfunction

Investigate both partners and identify urgency

Infertility evaluation commonly begins after twelve months of regular unprotected intercourse, with earlier assessment, often at six months, when the female partner is older than thirty-five. Known reproductive disease, irregular ovulation, suspected male-factor problems or other risk can justify immediate investigation. These time frames are assessment prompts, not barriers preventing earlier support. Ask about pregnancy history, cycle pattern, intercourse, contraception cessation, infections, surgery, chronic illness and medicines. Avoid assuming that the problem resides in the woman or that every couple has the same anatomy or reproductive goals.

Assess both partners in parallel where relevant. Semen analysis is a central first-line male test, interpreted with collection conditions, illness and biological variability; an abnormal result often needs repeat and specialist assessment. Severe abnormalities prompt timely referral. Testicular examination and directed hormones can identify causes. Exogenous testosterone can suppress sperm production and should not be prescribed to improve fertility. Erectile/ejaculatory problems, previous undescended testes, chemotherapy and genetic disease can affect the pathway. A normal-looking healthy male partner does not rule out male-factor infertility.

Ovulation, tubes and ovarian reserve

Regular cycles often imply ovulation, but the history and appropriate testing determine uncertainty. Progesterone is timed relative to the expected next period, often about seven days beforehand, rather than automatically “day twenty-one” for every cycle. Irregular cycles require assessment for PCOS, thyroid/prolactin disease, energy deficiency and ovarian insufficiency. Ultrasound and tubal assessment are selected according to history and specialist guidance. Prior PID or ectopic pregnancy raises tubal factors. A normal ultrasound does not show that tubes are patent.

AMH can inform ovarian-reserve and assisted-treatment planning but cannot reliably predict natural conception or the exact time remaining to become pregnant. Avoid selling it as a universal “fertility test.” Age, clinical context and treatment goals remain important. Counsel about folate, smoking, alcohol, weight/nutrition and medication safety without promising lifestyle change cures every cause. Screening/vaccination and genetic counselling may be relevant before conception. Respect informed choices about assisted reproduction, donor gametes or alternatives; explain success and risks with appropriate absolute measures.

Sexual symptoms require a biopsychosocial history

Ask about desire, arousal, erection, orgasm, ejaculation, pain, onset and relationship/context. Use permission and neutral questions, with a private opportunity to discuss coercion, trauma or distress. Medicines such as antidepressants, antipsychotics and antihypertensives can contribute, alongside diabetes, vascular, endocrine and neurological disease. A sexual symptom is not automatically psychological, and the presence of chronic disease does not exclude relationship or mood factors. Assess depression, substance use and safety without assuming a partner should hear every detail.

Erectile dysfunction can be a marker of vascular risk. Examine and investigate according to age, symptoms and risk; hormone testing is selected rather than routine treatment with testosterone. PDE5 inhibitors can help appropriate patients but are contraindicated with nitrates because of dangerous hypotension. Review cardiovascular suitability for sexual activity and drug interactions. Explain correct use and realistic expectations before declaring failure. Priapism is a different emergency requiring urgent urological assessment, especially when painful and prolonged; do not manage it as routine erectile dysfunction.

Pain, desire and treatment goals

Superficial dyspareunia can follow dryness, infection, vulval dermatoses or pelvic-floor dysfunction. Deep pain can reflect endometriosis, PID or other pelvic pathology. Examine when indicated with consent and a trauma-informed approach; do not force an examination simply because it is diagnostically useful. Treat contributing disease and consider pelvic-floor or psychosexual support. Postpartum and menopausal changes can affect comfort and desire. Normal variation in desire is not a disorder without relevant distress/context, and a patient's goal may be comfort rather than increased frequency.

Premature or delayed ejaculation, orgasm difficulties and low desire require symptom-specific assessment and shared decisions. Address reversible causes, medication effects, communication and specialist therapy when helpful. Avoid prescribing a product promoted online without assessing evidence and interactions. Gender-affirming hormones, surgery and fertility preservation can intersect with sexual function; discuss anatomy and preferences respectfully and refer within competence. Fertility and sexual counselling should include partners only with consent, especially where domestic violence or coercion is possible.

Applied cases and continuity

A couple with eighteen months of infertility needs parallel assessment, not months of female investigations before a semen sample is requested. A forty-year-old with irregular cycles should not wait another year to meet a rigid definition. A patient on nitrates seeking erectile medication requires an alternative plan, not a standard PDE5 prescription. A patient with painful intercourse and recurrent bleeding needs investigation rather than reassurance that symptoms are normal after childbirth. These scenarios test whether the next action addresses the relevant risk and the person's goals.

Clarify who will receive results, explain uncertainty and arrange follow-up rather than sending sensitive findings through an insecure channel. Fertility treatment can create substantial emotional and financial strain; offer appropriate counselling and realistic information. Reassess the plan as investigations clarify the cause, and do not let a normal single test terminate an otherwise indicated evaluation.

RACGP male infertility and fertility assistance review.

Review checkpoints

• Assess both partners rather than investigating only the person planning pregnancy.
• AMH does not reliably predict spontaneous pregnancy for an individual.
• Earlier fertility assessment is appropriate with older age or known reproductive risks.