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.
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.
Confirm only when useful
A luteal progesterone can support recent ovulation when timed roughly one week before the expected next menses. A fixed cycle day 21 is not correct for 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
Hysterosalpingography or sonographic methods can assess tubal patency and the uterine cavity. Ultrasound evaluates ovarian and uterine structure. Laparoscopy is not routine initial screening without another indication.
Target laboratory testing
TSH, prolactin, androgen assessment, or other endocrine tests follow cycle pattern and clinical findings. Regular cycles without suggestive symptoms often do not require extensive ovulation testing.
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
Find testicular, endocrine, genetic, medication, and exposure causes
Repeat a variable specimen when clinical context supports it
Refer significant abnormalities for focused reproductive 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.
Localize abnormalities
Severe oligospermia, azoospermia, testicular findings, impaired libido, or erectile dysfunction can justify FSH, testosterone, and targeted specialist evaluation. Multiple abnormalities increase concern.
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
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. New flashes, spots, or blurred vision require drug discontinuation and prompt evaluation.
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.
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.
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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.
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.
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.
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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.
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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.
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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