Lesson
When and How to Begin Evaluation
Infertility evaluation begins on a timeline shaped by age and risk, then assesses both partners concurrently when applicable.
- 12-month threshold
- 6-month threshold
- Immediate evaluation
- Parallel assessment
- Shared goals
Begin sooner when a known risk or irregular cycle is present
Evaluate both partners concurrently when applicable
Preserve time while targeting the suspected barrier
Use age-sensitive timing
Begin evaluation after 12 months of regular unprotected intercourse when the female partner is younger than 35 and after 6 months at age 35 or older. Evaluation may be more immediate above age 40.
Do not wait when risk is known
Irregular or absent cycles, suspected uterine or tubal disease, endometriosis, prior gonadotoxic treatment, sexual dysfunction, or a known male factor supports earlier evaluation.
Begin prevention before conception
For people who could become pregnant, CDC recommends 400 mcg of folic acid daily, starting before conception. Check the folic-acid amount on supplements and fortified foods; do not substitute a general dietary-folate target for this prevention recommendation. After a prior neural-tube-defect pregnancy, clinician-guided recurrence prevention uses 4,000 mcg daily from one month before conception through the first three months of pregnancy.
Review health and medicines early
Before conception, review chronic disease control, prescriptions, OTC products, supplements and vitamins with the treating team. Do not stop essential treatment abruptly: uncontrolled illness or withdrawal can be more harmful than a carefully chosen medicine. Include both partners' health and exposures when applicable.
Address alcohol, nicotine and drug use
Recommend stopping alcohol while trying to conceive, rather than only avoiding heavy use. Offer smoking-cessation support and treatment for problematic substance use. If stopping is difficult, arrange clinical help; medication treatment for a substance-use disorder should not be stopped on one's own.
Plan vaccines before conception
Review immunity and vaccine records early. MMR and varicella vaccines are contraindicated during pregnancy; when indicated before pregnancy, avoid conception for 28 days after MMR and one month after each varicella dose. Inadvertent vaccination alone is not an indication to end a pregnancy. Coordinate the plan with current immunization guidance.
Reduce infection and workplace exposure
For toxoplasmosis prevention, cook meat to safe temperatures, wash produce, and use gloves plus handwashing for soil or litter contact; change litter daily. Review home and occupational hazards before conception. Healthcare workers handling hazardous drugs should consult occupational health about exposure controls and possible duty changes; do not assume a safe chemotherapy exposure level is known.
Evaluate in parallel
Obtain reproductive, medical, medication, sexual, family, exposure, and pregnancy histories for both partners when applicable. Clarify whether the goal is natural conception, fertility preservation, donor treatment, or another family-building path.
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Lesson
Fertile Window and Ovulation Assessment
Natural fertility counseling should improve timing without turning conception into a rigid collection of unsupported rules.
- Six-day window
- Intercourse frequency
- Cycle history
- LH testing
- Luteal progesterone
Use cycle history and optional LH tracking to anticipate ovulation
Intercourse every one to two days provides practical exposure
Time progesterone relative to expected menses when confirmation is needed
Find the window
The fertile window spans the six days ending on ovulation. Intercourse every one to two days during that interval provides high exposure without requiring a specific position, orgasm, or prolonged rest afterward.
Start with the cycle
Regular 21 to 35 day cycles usually support ovulation. Urinary LH kits and cervical-mucus changes can help time intercourse, but they do not prove that every released oocyte is viable.
Interpret tracking signals
Clear, slippery cervical mucus can identify higher-fertility days before ovulation. A urinary LH surge generally precedes ovulation by one to two days; false results occur, including false positives with elevated basal LH in PCOS. Basal temperature commonly rises after ovulation, making it a retrospective clue rather than a reliable advance forecast. ASRM does not recommend routine temperature charting for infertility evaluation.
Interpret home pregnancy testing
Urine pregnancy tests detect hCG, which rises after implantation. Testing too early can give a negative result despite pregnancy. Follow the selected kit instructions; first-morning urine can improve early detection. If pregnancy remains possible after a negative result, repeat after several days and seek clinical assessment if uncertainty persists. During fertility treatment, follow the clinic’s testing schedule because an hCG trigger can affect results.
Confirm only when useful
When confirmation is needed, measure progesterone about one week before the expected next period. A value above 3 ng/mL supports recent ovulation, but one result cannot grade luteal-phase quality because concentrations fluctuate. Do not impose cycle day 21 on every cycle length.
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Lesson
Female Evaluation and Ovarian Reserve
Female evaluation identifies ovulatory, uterine, tubal, ovarian, endocrine, and age-related barriers using targeted tests rather than an indiscriminate panel.
- Ovulation
- HSG and SHG
- Ultrasound
- AMH
- Antral follicle count
Use cycle pattern first and targeted endocrine tests second
Assess the cavity and tubal patency with appropriate imaging
Use AMH and antral count as adjuncts, not guarantees
Assess anatomy
HSG evaluates the uterine cavity and tubal passage. Apparent bilateral proximal obstruction needs confirmation: transient contractions or catheter position can mimic blockage. With saline sonohysterography, pelvic fluid shows at least one patent tube, not necessarily two; contrast sonography provides a more specific tubal assessment. Ultrasound assesses pelvic structure. Reserve laparoscopy for a separate clinical indication.
Target laboratory testing
Use endocrine tests to investigate the clinical pattern. Prolactin is not a routine infertility screen; galactorrhea or infrequent or absent periods support testing. TSH helps investigate ovulatory dysfunction, and androgen testing follows signs of excess. Regular 21 to 35 day cycles usually need no ovulation confirmation, except when hirsutism raises concern.
Interpret reserve correctly
AMH and antral follicle count help estimate ovarian response to stimulation. They do not measure egg quality, guarantee natural conception, or serve as screening tests for every person who has not met infertility criteria.
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Lesson
Male Evaluation and Semen Analysis
Male infertility evaluation combines history, examination, properly collected semen analyses, and targeted endocrine or genetic testing.
- Semen volume
- Concentration
- Motility
- Morphology
- Endocrine localization
Interpret quantity with collection conditions and reproductive history
Movement, viability, and shape describe different sperm features
Repeat abnormal testing and obtain focused specialist evaluation
Read the specimen as a profile
Volume, sperm concentration, total number, motility, morphology, vitality, and collection conditions contribute different information. A single borderline value does not establish sterility. Abnormal results warrant male reproductive specialist evaluation and repeat semen testing; AUA/ASRM describes at least two analyses, ideally at least one month apart, especially after an abnormal initial result.
Localize abnormalities
Oligozoospermia, azoospermia, atrophic testes, impaired libido, erectile dysfunction or other hormonal findings warrant FSH and testosterone evaluation; the indication is not restricted to severe oligospermia. Multiple abnormalities increase concern.
Preserve endogenous reproductive function
Do not prescribe exogenous testosterone for someone seeking current or future fertility. Selected infertile men with low testosterone may instead receive specialist-directed hCG, a SERM or an aromatase inhibitor. These are conditional, diagnosis-dependent options, not interchangeable treatments for every low sperm count; male SERM use is off-label.
Find medication causes
Testosterone and anabolic-androgenic steroids suppress gonadotropins and intratesticular testosterone. Other medications, heat, toxins, infection, surgery, varicocele, obstruction, and genetic conditions can contribute.
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Lesson
PCOS and First-Line Oral Ovulation Induction
For anovulatory infertility in PCOS without another infertility factor, current guidance places letrozole ahead of older clomiphene-first algorithms.
- PCOS
- Letrozole
- Aromatase inhibition
- Off-label use
- Cycle monitoring
Estradiol synthesis falls transiently
Reduced feedback supports follicular recruitment
Confirm no pregnancy and follow the cycle-specific protocol
Connect old and current terminology
In May 2026, ASRM endorsed polyendocrine metabolic ovarian syndrome (PMOS) as the new name for polycystic ovary syndrome (PCOS). The book and many drug labels use PCOS. Both terms here refer to the same condition; recognizing the alias prevents confusion when reading current guidance.
Select letrozole
Letrozole is first-line pharmacologic ovulation induction for PCOS-related anovulatory infertility when no other infertility factor is present. Fertility use is often off-label and requires informed counseling.
Trace the mechanism
Transient aromatase inhibition reduces estrogen feedback, increasing endogenous FSH and follicular recruitment. It does not act as injected FSH.
Monitor the cycle
Regimens are timed early in the cycle and adjusted by specialist protocol. Confirm that pregnancy is not present, assess response, and avoid casual dose escalation without monitoring.
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Lesson
Clomiphene and Metformin in Context
Clomiphene and metformin remain useful, but their place depends on the diagnosis, prior response, metabolic indication, and current evidence.
- SERM
- Clomiphene
- Visual toxicity
- Metformin
- Metabolic health
Aromatase inhibition improves ovulation outcomes in appropriate patients
Use a limited monitored course and stop for visual symptoms
Treat dysglycemia without overstating fertility efficacy
Use clomiphene deliberately
Clomiphene blocks estrogen feedback and raises endogenous FSH and LH. It can be used in selected patients, but repeated failure should trigger reassessment rather than endless cycles.
Counsel important harms
Hot flashes, ovarian enlargement, multiple gestation, and visual symptoms can occur. Visual changes require stopping treatment and prompt ophthalmologic assessment; impairment can persist or be irreversible. Avoid driving while affected.
Know the labeled course
Clomiphene starts at 50 mg daily for five days, typically beginning around cycle day five after bleeding. If ovulation fails, the label allows 100 mg daily for five days after reassessment; higher or longer courses exceed labeling. Do not escalate an effective ovulatory dose. Reassess after three unsuccessful courses or three ovulatory cycles without pregnancy; avoid treatment beyond about six total cycles.
Screen before each cycle
Exclude pregnancy and assess ovarian enlargement. Contraindications include liver disease or past dysfunction, unexplained uterine bleeding, non-PCOS ovarian cysts/enlargement, uncontrolled thyroid/adrenal disease, intracranial organic lesions and hypersensitivity. PCOS itself is not that ovarian-cyst contraindication. The label also recommends pretreatment triglyceride screening, with periodic monitoring for personal/family hyperlipidemia.
Understand combination therapy
For PCOS-related anovulatory infertility without another factor, clomiphene plus metformin may improve ovulation and clinical pregnancy compared with clomiphene alone. This does not displace letrozole as preferred first-line therapy. Combined cycles still need the monitoring used with clomiphene alone.
Place metformin correctly
Metformin supports metabolic health and can improve ovulation in selected PCOS patients, especially when dysglycemia is present. It should not be portrayed as more effective than first-line ovulation-induction therapy for fertility outcomes.
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Lesson
Gonadotropins and Controlled Stimulation
Gonadotropins directly stimulate follicular development, making ultrasound, laboratory response, individualized dosing, and cancellation criteria central to safety.
- Follitropin
- Menotropins
- Follicle count
- Estradiol
- Multiple gestation
Select the product and starting strategy from patient and protocol factors
Use ultrasound and laboratory trends to adjust exposure
Avoid unsafe multifollicular response, OHSS, and high-order multiples
Know the products
Recombinant follitropin provides FSH activity, while menotropins provide FSH and LH activity. Product, indication, device, storage, and protocol determine administration details.
Prepare menotropins correctly
Menopur supplies 75 IU each of FSH and LH activity per vial. It is a subcutaneous product reconstituted with its specified saline diluent; use immediately and discard unused solution. A missed dose warrants calling the clinic, not doubling the next dose. Its combination of activities is not a reason to double the prescribed vial count.
Respect the cartridge system
Follistim AQ contains follitropin beta and is used subcutaneously with its dedicated pen. Its label includes a conversion from reconstituted FSH delivered by conventional syringe; do not assume a switch preserves the same dose. After first needle puncture, discard the cartridge after 28 days; store at 2 to 25°C, protect from light and never freeze.
Identify the Gonal-f presentation
Gonal-f contains follitropin alfa. The RFF Redi-ject is a prefilled subcutaneous pen, distinct from reconstituted vial presentations. After first use, its label allows 28 days refrigerated at 2 to 8°C or at room temperature at 20 to 25°C. Protect from light and do not freeze. Teach the supplied device instructions; neither pen sharing nor needle reuse is appropriate.
Measure response
Transvaginal ultrasound and estradiol trends help assess follicular recruitment. Dose changes are individualized to ovarian reserve, age, diagnosis, prior response, and the treatment goal.
Prevent excess response
Too many mature follicles can require withholding the trigger or canceling timed intercourse or IUI. High-order multiple gestation is a serious treatment complication, not a marker of better care. In PCOS/PMOS gonadotropin ovulation induction, the international guideline advises considering cancellation when more than two follicles exceed 14 mm and avoiding unprotected intercourse. This is not an IVF retrieval cutoff; use the protocol-specific plan.
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Lesson
Triggering, Protocol Control, and Luteal Support
Fertility protocols coordinate final maturation, prevention of a premature LH surge, oocyte retrieval, and endometrial support on a precise timeline.
- hCG trigger
- GnRH antagonist
- GnRH agonist trigger
- Progesterone
- Luteal support
Block a premature LH surge during stimulation
Complete final maturation and coordinate retrieval or ovulation
Maintain an appropriate luteal environment after ART
Trigger final maturation
hCG activates the LH receptor and can trigger ovulation or time oocyte retrieval. A GnRH agonist trigger can reduce OHSS risk in suitable antagonist cycles, but fresh transfer requires adequate luteal support.
Distinguish Ovidrel from stimulation drugs
Ovidrel is recombinant hCG (choriogonadotropin alfa), supplied as a 250 mcg subcutaneous prefilled syringe. Its label schedules administration one day after the final follicle-stimulating dose, only after an adequate monitored response; withhold for excessive response. The clinic's exact trigger time coordinates the procedure. Exogenous hCG can interfere with pregnancy tests, so an early positive home result does not establish a new pregnancy.
Separate urinary hCG products
Pregnyl and Novarel contain urinary-derived chorionic gonadotropin; their U.S. labels specify intramuscular administration after reconstitution. Do not infer their route or preparation from Ovidrel. With the specified supplied diluent and refrigerated storage at 2 to 8°C, reconstituted Pregnyl has a 60-day limit and Novarel a 30-day limit. Verify the exact product and instructions each time; equal drug-class names do not establish identical handling.
Prevent a premature surge
Ganirelix or cetrorelix rapidly blocks pituitary GnRH receptors during controlled stimulation. Unlike an agonist, an antagonist does not require an initial flare before suppression.
Use antagonist products safely
Ganirelix labeling uses 250 mcg subcutaneously daily during the mid-to-late follicular phase through the hCG day, with timing directed by the clinic. Exclude pregnancy. Hypersensitivity, including anaphylaxis, can occur with the first dose: stop and obtain urgent treatment for systemic symptoms. Check the exact syringe components when assessing latex allergy; presentations differ.
Support the luteal phase
Progesterone is commonly used after oocyte retrieval or embryo transfer. Route, product, timing, dose, and duration belong to the reproductive protocol and should not be substituted casually. For example, Endometrin labeling specifies a 100 mg vaginal insert two or three times daily beginning the day after retrieval, for up to ten weeks total. Its efficacy and appropriate dose at age 35 or older are not clearly established in labeling; use the specialist plan. Other vaginal products can alter its release or absorption, so consult the clinic before adding an antifungal or another vaginal treatment.
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Lesson
Timed Intercourse, IUI, IVF, and ICSI
Reproductive procedures differ by where sperm and oocyte meet and which anatomic or fertilization barriers they can bypass.
- Timed intercourse
- IUI
- IVF
- ICSI
- Embryo transfer
Requires a route for sperm and oocyte to meet
Can bypass severe tubal disease and other selected barriers
Targets selected fertilization problems, not every cause
Use timed intercourse or IUI selectively
Timed intercourse can pair with ovulation induction when the remaining pathway is functional. IUI places prepared sperm in the uterus but still requires a usable tube and cannot overcome bilateral tubal occlusion.
Use IVF for broader barriers
IVF combines controlled stimulation, retrieval, laboratory fertilization, embryo culture, and transfer. It can bypass severe tubal disease and may be used for other indications after individualized evaluation.
Reserve ICSI for a fertilization need
ICSI injects a single sperm into an oocyte and is useful for selected severe male-factor or prior fertilization problems. It does not treat every cause of infertility or guarantee implantation. ASRM 2026 does not recommend routine ICSI solely for unexplained infertility, low oocyte yield, diminished reserve, advanced maternal age or preimplantation genetic testing for aneuploidy (PGT-A) without male factor. Selected nonmale indications include prior poor fertilization, cryopreserved oocytes or preimplantation genetic testing for monogenic disease (PGT-M); the aim and evidence differ from promising a higher live-birth rate for every IVF cycle.
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Lesson
OHSS Prevention and Longitudinal Care
OHSS prevention begins before the first injection and continues through trigger, embryo-transfer strategy, early pregnancy, and symptom surveillance.
- Risk stratification
- Agonist trigger
- Freeze-all
- Cabergoline
- Emergency symptoms
Use an individualized dose and antagonist-friendly prevention plan
Consider agonist trigger, cabergoline, and freeze-all when appropriate
Escalate dyspnea, oliguria, rapid weight gain, thrombosis, or severe distension
Identify high risk
PCOS, elevated AMH, high expected oocyte yield, and a strong follicular response increase risk. Individualized lower gonadotropin dosing and antagonist protocols can reduce risk before the trigger decision.
Layer prevention
In suitable cycles, a GnRH agonist trigger, cabergoline, and cryopreservation of all embryos can reduce moderate or severe OHSS. Lower-dose hCG alone and aspirin are not recommended as primary prevention strategies.
Apply prevention to the protocol
Cabergoline prevention generally starts with the hCG trigger or soon afterward and continues for several days. Metformin is not recommended solely to prevent OHSS in antagonist cycles; it may have that role in selected PCOS agonist protocols. Marked pituitary suppression can impair an agonist-trigger response. Adding hCG to rescue luteal function can restore OHSS risk, so fresh-transfer support requires individualized planning.
Escalate and support
Rapid weight gain, tense abdominal distension, vomiting, oliguria, dyspnea, chest pain, syncope, or neurologic symptoms require urgent assessment. Repeated treatment also warrants explicit attention to grief, anxiety, cost, autonomy, and the option to pause.
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Module practice
Check the connections.
Each attempt draws 10 questions from the complete 43 question bank.
Each attempt draws a fresh set and rearranges the answer choices.
References
Current clinical foundation.
Core source material was synthesized with the following contemporary guidance. Verify local policy and current guidance before applying clinical information.
- FDA. Home-use pregnancy tests: timing and interpretation.
- CDC. Planning for pregnancy.
- CDC. Medication review before and during pregnancy.
- CDC. Vaccination guidelines: MMR and varicella pregnancy precautions.
- CDC. Preventing toxoplasmosis.
- NIOSH. Antineoplastic drugs and reproductive health.
- ASRM. Intracytoplasmic sperm injection for nonmale factor indications (2026).
- DailyMed. Endometrin prescribing information.
- AUA/ASRM. Diagnosis and treatment of infertility in men, Part I (2020).
- AUA/ASRM. Diagnosis and treatment of infertility in men, Part II (2021).
- ASRM. PCOS is Now PMOS: Understanding the Name Change. May 27, 2026.
- DailyMed. Gonal-f RFF Redi-ject prescribing information.
- DailyMed. Pregnyl prescribing information.
- DailyMed. Novarel prescribing information.
- DailyMed. Menopur prescribing information and instructions for use.
- DailyMed. Follistim AQ Cartridge prescribing information and instructions for use.
- DailyMed. Ovidrel prescribing information.
- CDC. About Folic Acid. Reviewed September 18, 2026.
- ASRM. Optimizing natural fertility: a committee opinion (2022).
- ASRM Committee Opinion: Fertility Evaluation of Infertile Women, 2021
- AUA and ASRM Guideline: Diagnosis and Treatment of Infertility in Men, Amended 2024
- International Evidence-based Guideline for PCOS, 2023
- ASRM Guideline: Prevention of Moderate and Severe OHSS, 2023
- FDA GONAL-F Prescribing Information
- DailyMed. Clomid prescribing information, updated January 31, 2025.
- DailyMed Ganirelix Acetate Prescribing Information