Fertility problems: assessment and treatment

Compare the results of semen analysis conducted as part of an initial assessment with the following World Health Organization (WHO) reference values (see the WHO laboratory manual for the examination and processing of human semen):

• semen volume: 1.4 ml or more (95% confidence interval [CI] 1.3 to 1.5)

• pH: 7.2 or more

• sperm concentration: 16 million spermatozoa per ml or more (95% CI 15 to 18)

• total sperm number: 39 million spermatozoa per ejaculate or more (95% CI 35 to 40)

• total motility (percentage of progressive motility and non-progressive motility): 42% or more motile (95% CI 40 to 43)

• progressive motility: 30% or more (95% CI 29 to 31)

• vitality: 54% or more live spermatozoa (95% CI 50 to 56)

• sperm morphology (percentage of normal forms): 4% or more (95% CI 3.9 to 4.0). [2004, amended 2026]
  
  Note that the reference ranges are only valid for the semen analysis tests outlined by the World Health Organization.

Do not offer routine testing for antisperm antibodies. [2004]

If the result of the first semen analysis is abnormal, offer a repeat confirmatory test. [2004]

Undertake repeat confirmatory tests ideally 3 months after the initial analysis to allow time for the cycle of spermatozoa formation to be completed. However, if a gross spermatozoa deficiency (azoospermia or severe oligozoospermia) has been detected, undertake the repeat test as soon as possible. [2004]

For men, and trans women and non-binary people with male reproductive organs who have 2 or more abnormal semen analyses:

• offer a physical examination of the scrotum and testes, and

• consider measuring serum testosterone and gonadotrophin levels. [2026]

Do not carry out testing for sperm DNA integrity (fragmentation). [2026]

Test for Y chromosome microdeletion in men, and trans women and non-binary people with male reproductive organs who have idiopathic:

• azoospermia, or

• a sperm concentration of less than 1 million per ml. [2026]

Test for cystic fibrosis transmembrane conductance regulator genetic mutations in men, and trans women and non-binary people with male reproductive organs who have idiopathic suspected obstructive azoospermia or a vasal abnormality, or both, on examination. [2026]

Test for karyotype abnormalities in men, and trans women and non-binary people with male reproductive organs who have idiopathic azoospermia. [2026]

Consider testing for karyotype abnormalities in men, and trans women and non-binary people with male reproductive organs who have a persistent sperm concentration of less than 5 million per ml. [2026]

Offer appropriate genetic counselling for men, and trans women and non-binary people who have a specific genetic defect associated with male factor infertility. [2026]

Do not routinely use post-coital testing of cervical mucus in the investigation of fertility problems because it has no predictive value on pregnancy rate. [2004]

Use maternal age as an initial predictor of the overall chance of becoming pregnant through spontaneous conception (see figure 1 on the effect of maternal age on pregnancy rate), or with in vitro fertilisation (IVF; see figure 2 on IVF success in terms of live births per embryo transfer by age). [2013, amended 2026]

Do not use anti-Müllerian hormone (AMH) measurement as a predictor of clinical pregnancy through spontaneous conception. [2026]

Use AMH measurement or antral follicle count (AFC) as predictors of ovarian response to inform clinical decision making and patient counselling about the likelihood of live birth following assisted conception. [2026]

Do not use follicle-stimulating hormone (FSH) measurement as a predictor of ovarian response or outcome of assisted conception. [2026]

Ask women, and trans men and non-binary people with female reproductive organs who are concerned about their fertility about the frequency and regularity of their menstrual cycles, and reassure them that if they have regular monthly menstrual cycles, they are likely to be ovulating. [2004]

Offer women, and trans men and non-binary people with female reproductive organs who are undergoing investigations for infertility a blood test to measure serum progesterone in the mid-luteal phase of their cycle (day 21 of a 28‑day cycle) to confirm ovulation even if they have regular menstrual cycles. [2004, amended 2013]

Offer women, and trans men and non-binary people with female reproductive organs with prolonged irregular menstrual cycles a blood test to measure serum progesterone. Depending on the timing of menstrual periods, this test may need to be conducted later in the cycle (for example, day 28 of a 35‑day cycle) and repeated weekly thereafter until the next menstrual cycle starts. [2004]

Do not use basal body temperature charts to confirm ovulation because they do not reliably predict ovulation. [2004]

Offer women, and trans men and non-binary people with female reproductive organs with irregular menstrual cycles a blood test to measure serum gonadotrophins (FSH and luteinising hormone). [2004]

Do not offer women, and trans men and non-binary people with female reproductive organs who are concerned about their fertility a blood test to measure prolactin. Only offer this test to those with an ovulatory disorder, galactorrhoea or a pituitary tumour. [2004]

Only offer estimation of thyroid function to women, and trans men and non-binary people with female reproductive organs with possible fertility problems if they have symptoms of thyroid disease. [2004]

Offer women, and trans men and non-binary people with female reproductive organs who are not known to have comorbidities (such as pelvic inflammatory disease, previous ectopic pregnancy or endometriosis) hysterosalpingography (HSG) to screen for tubal occlusion because this is a reliable test for ruling out tubal occlusion, and it is less invasive and makes more efficient use of resources than laparoscopy. [2004]

Where appropriate expertise is available, consider screening for tubal occlusion using hysterosalpingo-contrast-ultrasonography because it is an effective alternative to HSG for women, and trans men and non-binary people with female reproductive organs who are not known to have comorbidities. [2004]

Offer laparoscopy and dye to women, and trans men and non-binary people with female reproductive organs who are thought to have comorbidities so that tubal and other pelvic pathology can be assessed at the same time. [2004]

Do not offer hysteroscopy unless a uterine or endometrial abnormality is clinically suspected. [2004, amended 2026]

Offer people undergoing IVF treatment testing for HIV, hepatitis B and hepatitis C (for donor insemination, see recommendation 1.51.2 in the section on donor insemination). [2004, amended 2013]

Offer specialist advice and counselling and appropriate clinical management for people found to test positive for 1 or more of HIV, hepatitis B or hepatitis C. [2004, amended 2013]

For couples where the partner with male reproductive organs is HIV positive, any decision about fertility management should be the result of discussions between the couple, a fertility specialist and an HIV specialist. [2013]

Advise couples where the partner with male reproductive organs is HIV positive that the risk of HIV transmission is negligible through unprotected vaginal sexual intercourse when all of the following criteria are met:

• they are compliant with highly active antiretroviral therapy (HAART)

• they have had a plasma viral load of less than 50 copies/ml for more than 6 months

• there are no other infections present

• unprotected intercourse is limited to the time of ovulation. [2013]

For couples where the partner with male reproductive organs is HIV positive and either is not compliant with HAART or the plasma viral load is 50 copies/ml or greater, offer sperm washing. [2013]

Inform couples that sperm washing reduces, but does not eliminate, the risk of HIV transmission. [2013]

For partners of people with hepatitis B, offer vaccination before starting fertility treatment. [2013]

Do not offer sperm washing as part of fertility treatment for men, or trans women or non-binary people with male reproductive organs who have hepatitis B. [2013]

For couples where the partner with male reproductive organs has hepatitis C, any decision about fertility management should be the result of discussions between the couple, a fertility specialist and a hepatitis specialist. [2013]

Advise couples who want to conceive and where the partner with male reproductive organs has hepatitis C that the risk of transmission through unprotected sexual intercourse is thought to be low. [2013]

Men, and trans women and non-binary people with male reproductive organs who have hepatitis C should discuss treatment options to eradicate the hepatitis C with their appropriate specialist before conception is considered. [2013]