# Infertility (Primary Assessment and Referral) - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: NICE Guideline CG156: Fertility problems - assessment and treatment 2017 · Egyptian National Drug Formulary - Blood Disorder Medications 2025 (folic acid monograph) · Female Infertility - StatPearls NBK556033, disease-level clinical article (infertility-referral-full.txt). StatPearls splits infertility by sex; the male side is covered here only through semen analysis - Verified date: 2026-08 ## Verified against - NICE Guideline CG156: Fertility problems - assessment and treatment 2017 - Egyptian National Drug Formulary - Blood Disorder Medications 2025 (folic acid monograph) ## Treatment metadata - Primary assessment, lifestyle advice, and specialist referral - Folic acid — 0.4 mg — oral.solid ## Complete treatment card ```text INFERTILITY (PRIMARY ASSESSMENT AND REFERRAL) Sources: NICE Guideline CG156: Fertility problems - assessment and treatment 2017 · Egyptian National Drug Formulary - Blood Disorder Medications 2025 (folic acid monograph) · Female Infertility - StatPearls NBK556033, disease-level clinical article (infertility-referral- full.txt). StatPearls splits infertility by sex; the male side is covered here only through semen analysis Review status: REVIEWED against 2 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (10) - Cycles varying by more than a week point to a problem with ovulation; no periods at all point to the hypothalamus or to ovaries that have failed early [absent periods] - Infrequent periods are present in about eight of every ten women with polycystic ovary syndrome - Take the obstetric history: earlier pregnancies, miscarriages or an ectopic can expose disease of the womb or the tubes - Diabetes, thyroid disease and any past pelvic operation all reduce fertility - Smoking cuts fertility by about a third, and more than fourteen units of alcohol a week doubles the risk - Weight and what she is exposed to at work also count - Pelvic pain, or pain during intercourse, suggests endometriosis or a past pelvic infection [abdominal pain · pelvic pain] - Milk from the breasts outside pregnancy means a raised prolactin until proved otherwise - Coarse hair in a male pattern, on the face included, points at polycystic ovaries - Ask whether the mother or sisters stopped their periods early, and about any known genetic disorder SIGNS - what you find (6) - Look for too much androgen: coarse body hair, acne, obesity, and dark velvety skin in the folds [acne · obesity] - A body mass index below 18.5 points the opposite way, to periods switched off by low weight - Pelvic examination may turn up fibroids, or a cyst of endometriosis on the ovary [cyst] - Breasts that never developed properly point to ovaries that never made enough oestrogen - Feel the thyroid - thyroid disease is present in roughly one infertile woman in ten - Short stature, a low hairline, a webbed neck, widely spaced nipples or a wide carrying angle suggest Turner syndrome [short stature] TESTS (12) - Semen analysis belongs in the first round - the male side accounts for four cases in ten, and a normal result lets you stop investigating him - Progesterone taken in the middle of the second half of the cycle, above 3 ng/mL, confirms she ovulated - Home ovulation kits find the LH surge about 97 percent of the time, but their specificity is only 25 percent, so a negative tells you more than a positive - AMH measures the ovarian reserve: below 1 is low, 1 to 3.5 is normal, above 4 suggests polycystic ovaries - Counting the small follicles on transvaginal scan says the same thing: under 5 is low, 5 to 20 normal, over 20 suggests polycystic ovaries - FSH on day 3 usually sits between 3 and 9; higher means the reserve is falling, lower points at the pituitary - The dye test of the tubes finds 85 to 90 percent of blockages - It is not only a test - pregnancy and live birth rates rise after it, most of all with oil- based contrast - The ultrasound version agrees with the dye test 80 percent of the time and is less invasive - Only laparoscopy settles endometriosis - Transvaginal ultrasound is the first look at the womb and finds about 90 percent of fibroids - TSH over 4 means an underactive thyroid, and that alone doubles the risk of infertility IF NOT THIS - what else fits (8) - Polycystic ovary syndrome, behind about seven in ten cases where ovulation fails - Endometriosis - pelvic pain, painful periods, pain with sex, or a cyst on the scan - Ovaries failing before 40, with periods stopped, FSH above 25 and menopausal symptoms - Blocked tubes, most often after pelvic infection or endometriosis - A womb of abnormal shape, adenomyosis, fibroids, or scarring inside the cavity that stops implantation - A male factor, which is the answer when her workup is normal and his semen analysis is not - Unexplained infertility, which is where 15 to 30 percent of couples end after everything comes back normal - A hormone-producing tumour of ovary or adrenal, late-onset adrenal hyperplasia, Cushing syndrome, a prolactinoma, or thyroid disease Source StatPearls "Female Infertility" - disease-level clinical article Status traced to the source above 1. PRIMARY ASSESSMENT, LIFESTYLE ADVICE, AND SPECIALIST REFERRAL[1st line] Adult Refer couple for specialist fertility assessment after 12 months of unprotected intercourse (or after 6 months if female age >= 35 or known risk factors). Initiate baseline primary care tests: male semen analysis, female mid-luteal progesterone (day 21 of a 28-day cycle; adjust later for longer cycles per NICE CG156), pelvic US, and Rubella immunity verification (reserve FSH/LH/TSH for irregular cycles per NICE CG156). - Initial 3-6 months evaluation and referral Peds Adult-only condition - paediatric section not applicable Source NICE Guideline CG156: Fertility problems - assessment and treatment 2017 Why Empiric drug therapy (e.g., clomifene or gonadotropins) should NOT be initiated in primary care without specialist diagnosis and monitoring Caution Do not prescribe empiric ovulation induction agents in primary care due to risk of multiple pregnancy and ovarian hyperstimulation syndrome (OHSS). Advise intercourse every 2-3 days throughout menstrual cycle rather than timing strictly to ovulation predictors to reduce stress. Screen both partners for smoking, obesity (BMI > 30), excessive alcohol, and occupational toxin exposure. Verify Rubella immunity status prior to pregnancy (offer MMR vaccination if non-immune, avoiding pregnancy for 1 month post-vaccination) and perform Chlamydia screening prior to uterine assessment or specialist referral (NICE CG156). 2. FOLIC ACID [add-on - not a substitute] Adult 0.4 mg (400 mcg) once daily for female partner before conception and until 12 weeks of pregnancy (use 5 mg once daily if high risk: diabetes, BMI > 30, anti-epileptic drug, or prior NTD) - Pre-conception until 12 weeks gestation Peds Adult-only condition - paediatric section not applicable Source Egyptian National Drug Formulary - Blood Disorder Medications 2025 (folic acid monograph) Why Vitamin supplement added during infertility assessment to reduce the risk of neural tube defects if conception occurs; it is preconception care, not a treatment for the underlying cause of infertility, and the dose is increased for higher-risk women. Caution High-dose 5 mg daily is required for women with BMI > 30 kg/m², diabetes mellitus, anti- epileptic therapy, or personal/family history of neural tube defects. Folic acid does not treat underlying infertility but is essential pre-conception care to prevent neural tube defects. May mask hematological symptoms of vitamin B12 deficiency in rare cases. Egypt FOLICUREX 400 MCG 30 TABS. MULTICARE 96.00 EGP (3.20/unit) FOLIRAQ 400 MCG TABS HP PHARMA 42.00 EGP FOLIC ACID 400 MCG 250 TABLETS (ILLEGAL IMPORT) PURITANS PRIDE 26.00 EGP (0.10/unit) FOLIDDOX 400 MCG / 5 ML LIQUID 150 ML MADDOX PHARMA 150.00 EGP -> ? strength differs, ? different route - not oral solid Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)