14.5 Initial Infertility Evaluation & Gynecologic Imaging Referral

Defining and Timing the Evaluation

Infertility is classically defined as failure to conceive after 12 months of regular unprotected intercourse, or after 6 months for patients aged 35 and older. ASRM has broadened the definition to include anyone who needs medical intervention — donor gametes or embryos — to conceive, which brings single patients and same-sex couples inside the definition rather than outside it.

Evaluate immediately, without waiting, when any of these is present: oligomenorrhea or amenorrhea, known or suspected tubal disease or uterine anomaly, stage III–IV endometriosis, prior pelvic infection or surgery, known male-factor infertility, age 40 or older, or a history of chemotherapy or pelvic radiation.

The initial evaluation is squarely within midwifery scope; it is the treatment that is referred.

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The Three-Domain Initial Workup

Every basic evaluation answers three questions: is she ovulating, is the anatomy patent, and is there sperm?

1. Ovulatory Function

• Cycle history is the best screening test. Regular cycles of 24 to 38 days with consistent molimina are ~95% predictive of ovulation.
• Midluteal serum progesterone drawn about 7 days before the expected period (day 21 of a 28-day cycle): a value above 3 ng/mL confirms ovulation occurred.
• Urinary LH ovulation predictor kits detect the surge 24 to 36 hours before ovulation.
• Ovarian reserve testing for patients 35 and older or with risk factors: anti-Müllerian hormone (AMH), antral follicle count on transvaginal ultrasound, and cycle day 3 FSH with estradiol. Reserve testing predicts response to stimulation — it does not predict natural fertility and should never be presented to a patient as a "fertility score."
• Add TSH and prolactin when cycles are irregular; check androgens if hirsutism or acne suggests PCOS.

2. Uterine Cavity and Tubal Patency

Timing and safety for HSG and sonohysterography: schedule in the early follicular phase, roughly cycle days 5 to 10, after bleeding has stopped and before ovulation, with pregnancy excluded. Contraindications: pregnancy, active pelvic infection or untreated cervicitis, and active uterine bleeding. Premedicate with an NSAID; doxycycline prophylaxis is used when tubal dilation is found or a history of pelvic infection exists.

3. Semen Analysis

A semen analysis is part of the initial workup, not a later step — male factor contributes to roughly 40–50% of cases and is the cheapest thing to rule out.

• Collect after 2 to 7 days of abstinence; repeat an abnormal result after at least 4 weeks.
• WHO 6th edition (2021) lower reference limits: volume 1.4 mL, concentration 16 million/mL, total count 39 million, total motility 42%, progressive motility 30%, normal morphology 4%.
• These are reference limits from fertile men, not thresholds of sterility — pregnancies occur below them and fail above them.

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Preconception Optimization and Referral

While the workup proceeds, address what is modifiable:

• 400 to 800 mcg folic acid daily, rubella and varicella immunity, hepatitis B and STI screening, and carrier screening.
• Weight: both a BMI below 18.5 and above 30 impair ovulation; a 5–10% weight reduction restores ovulatory cycles in many patients with PCOS.
• Tobacco cessation — smoking accelerates follicular depletion and reduces IVF success; limit alcohol and high-dose caffeine.
• Review medications for teratogens and for agents that impair ovulation or spermatogenesis (NSAIDs at ovulation, testosterone supplementation in the male partner, which suppresses spermatogenesis).
• Advise intercourse every 1 to 2 days during the fertile window, the 6 days ending on the day of ovulation; lubricants other than mineral-oil or hydroxyethylcellulose-based products can impair sperm motility.

Refer to reproductive endocrinology and infertility once the basic evaluation is complete, or sooner for age 40 or older, amenorrhea, known tubal occlusion, severe male factor, or recurrent pregnancy loss.

Endocrine Evaluation of Ovulatory Dysfunction

When the history or the midluteal progesterone points to anovulation, the next step is to identify which anovulation, because the treatments diverge completely:

Draw prolactin in the morning, fasting, and without recent breast stimulation, exercise, or intercourse, and repeat a mildly elevated value before acting on it — a single high result is frequently an artifact of the draw conditions.

Modifiable Factors Worth More Than Most Testing

These are within midwifery scope, cost nothing, and are routinely skipped in the rush to imaging:

• Intercourse timing. The fertile window is the 5 days before ovulation plus the day of ovulation, and intercourse every 1 to 2 days across that window is as effective as any timing method. Couples who "save up" for a single perfectly timed day conceive less often, not more.
• Weight at either extreme disrupts ovulation; in anovulatory patients with obesity, modest weight loss can restore ovulation without any medication.
• Tobacco accelerates follicular depletion and advances menopause; cessation is the single highest-yield intervention in a smoker.
• Alcohol, cannabis, and anabolic steroid use all impair fertility, and anabolic steroids suppress spermatogenesis for months after they are stopped.
• Folic acid supplementation and a review of teratogenic medications belong in the first infertility visit, not in the first prenatal visit — by then the exposure has already happened.

Male Factor & Referral Thresholds

Male factor contributes to roughly half of infertility, so the semen analysis is obtained at the start of the evaluation, in parallel with the female workup, never after it. Collect after 2 to 7 days of abstinence, and repeat any abnormal result after at least a few weeks before acting on it, since a single specimen is affected by recent illness, fever, and abstinence interval. An abnormality confirmed on repeat testing warrants referral to urology or reproductive endocrinology.

Also address fertility preservation counseling before any gonadotoxic therapy — chemotherapy, pelvic radiation, or planned gonadectomy — and before starting gender-affirming hormone therapy in a patient who may want genetic children. The conversation has to happen before treatment begins; afterward there is nothing to preserve.