Basic Infertility Services and Fertility Support
In alignment with ASRM guidelines, the pace and extent of the infertility evaluation should consider the patient’s preferences, age, duration of infertility, relationship circumstances, medical history, and, in some cases, geographic location and access to higher levels of care.137
This includes people who experience infertility while attempting to achieve pregnancy through penis-in-vagina sex with sperm involved as well as people who require donor gametes or medical assistance to build their family due to their gender, sexual orientation, and/ or partner status. It is important that services are not only inclusive, but specifically oriented toward the needs of LGBTQI+ people when indicated.
Clinics can provide basic evaluation and counseling, share resources, and make referrals for people desiring to build a family through pregnancy—with or without the use of medically assisted reproduction (MAR)—or though foster care or adoption. Sites can also provide education about TDI, IUI, donor ova, donor sperm, donor embryo, and gestational carriers as well as MAR procedures such as IVF.137 All MAR technology options available to heterosexual cisgender people are also available to LGBTQI+ persons. Prompt referrals to specialty care should be made for people who want or would benefit from MAR. For patients pursuing TDI, avoid delays to treatment. TDI recipients using cryopreserved sperm have higher success rates with IUI over intracervical insemination and do not benefit from ovarian reserve testing or ovarian stimulation.138 Age is the most predictive factor for IUI success,138 although timing of the IUI procedure is also a vital factor.139
All persons attempting to achieve pregnancy should be screened for infertility, and sites are encouraged to follow the recommendations outlined in “Enabling Healthy Pregnancy.” Evaluation of infertility should be performed for all persons attempting to conceive through penis-in-vagina sex with sperm after 12 months if younger than age 35 years and at 6 months if age 35 years or older. For people older than age 40 years or those with a medical history associated with infertility, consider immediate evaluation or referral for MAR.
For persons AFAB, a physical examination that includes vital signs; thyroid examination to identify any enlargement, nodule, or tenderness; and integumentary examination for signs of androgen excess should be performed. Genital exams, including pelvic exam, are not required for basic infertility evaluation. Assessment of ovulatory function for people AFAB is often best determined by a thorough menstrual history, and in many cases, this is all that is required. Menstrual cycles should be 21−35 days, regular, predictable, and consistent in terms of symptoms and flow. If a patient has a history of oligomenorrhea or amenorrhea, this is sufficient to establish anovulation and warrants further investigation to identify underlying etiology.137
For individuals AMAB, the semen analysis is the first and most simple screen for infertility. Abnormal results should be followed up with a physical exam to assess for infection, varicocele, or other causes of impaired sperm production.
Few laboratory tests are needed in the initial infertility evaluation and should be limited to findings of the history and physical exam. The following tests should not be ordered routinely unless specifically indicated: prolactin (galactorrhea), estradiol, follicle-stimulating hormone (FSH), luteinizing hormone (LH), progesterone, endometrial biopsy, thrombophilia testing, karyotype, immunologic testing, advance sperm function testing, and laparoscopy for unexplained fertility.137