This module is for general information purpose only and should not be taken as medical advice. Consult a qualified gynecologist or reproductive specialist, for personalized treatment recommendations and dosages.
Definition: Infertility is defined as failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse (ASRM/ESHRE/WHO). Reduced to 6 months for women ≥35 years, and immediate evaluation for known risk factors (ASRM 2023).
Couple Identification
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Female Partner
Male Partner
Infertility History & Chief Complaint
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Lifestyle & Environmental Factors
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Menstrual & Cycle History
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Obstetric History
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PCOS & Ovulatory Disorders (Rotterdam Criteria)
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Rotterdam Criteria 2003 (Revised ESHRE/ASRM): PCOS diagnosis requires ≥2 of 3: (1) Oligo/anovulation, (2) Clinical/biochemical hyperandrogenism, (3) Polycystic ovarian morphology on ultrasound (≥20 follicles 2–9mm per ovary OR ovarian volume >10 mL).
Endometriosis Assessment (rASRM Staging)
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0 (None)010 (Severe)
Uterine & Tubal Factor
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Past Medical & Family History
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Semen Analysis (WHO 2021 5th Edition)
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WHO 2021 Lower Reference Limits (5th centile): Volume ≥1.4 mL, Total sperm ≥39×10⁶, Concentration ≥16×10⁶/mL, Total motility (PR+NP) ≥42%, Progressive motility ≥30%, Vitality ≥54%, Normal morphology ≥4% (strict Kruger). Abstinence: 2–7 days.
Andrological & Clinical Examination
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Ovarian Reserve Assessment
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Key Markers: AMH (age-independent, reflects primordial follicle pool) + AFC Day 2–5 ultrasound (most predictive). FSH/LH Day 2–3 (less sensitive). POSEIDON classification for poor responders (Bologna criteria updated 2019).
Female Hormonal & Biochemical Profile
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Male Hormonal Profile
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Genetic, Immunological & Infectious Workup
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BMI & Weight Management Calculator
Female Partner
Male Partner
IVF / ICSI Success Predictor (Lass / HFEA-based model)
Important: This is an estimated probability based on published population data. Individual outcomes vary. For validated centre-specific prediction, use centre's own outcomes data.
OHSS Risk Assessment (ESHRE Stratification)
Semen Parameter Grading & ART Pathway
Auto-populates from Male Assessment tab. Adjust values or re-enter for independent calculation.
Ovarian Age Estimation & Reserve Interpretation
Stepped-Care Treatment Algorithm
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1
Lifestyle
2
OI/TI
3
IUI
4
IVF/ICSI
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Advanced ART
6
Alternatives
🌿 Step 1 — Lifestyle Optimisation (All Couples)
- Target BMI 18.5–24.9 (Asian: 18.5–22.9) — weight loss ≥5–10% if overweight/obese improves ovulation and IVF outcomes (ESHRE 2023)
- Folic acid 400–800 μg/day (female) — 3 months pre-conception; 5 mg if high risk (epilepsy, BMI >30)
- Cessation of smoking (both partners) — reduces live birth rates by 40%
- Reduce alcohol — abstinence recommended during ART cycles
- Optimise coital timing — 2–3 times/week, including periovulatory window
- Vitamin D supplementation if deficient (<20 ng/mL) — 2000 IU/day
- Treat hypothyroidism — target TSH <2.5 mIU/L before ART (ATA/FOGSI)
- Control diabetes — target HbA1c <6.5% pre-conception (ADA 2023)
- Mental health support and stress reduction counselling
💊 Step 2 — Ovulation Induction / Timed Intercourse
- PCOS / Anovulation (WHO Group II): First-line: Letrozole 2.5–7.5 mg Day 2–6 (superior to CC; NEJM 2014, ESHRE 2023). Second-line: CC 50–150 mg + Metformin. Third-line: Gonadotrophins (FSH/hMG) starting 37.5–75 IU/day with TVS monitoring
- Hypogonadotrophic hypogonadism (WHO Group I): Pulsatile GnRH or low-dose gonadotrophins (FSH + LH)
- PCOS with CC resistance: Laparoscopic ovarian drilling (LOD) — equivalent to gonadotrophins, no OHSS/multiple pregnancy
- Metformin: 500–2000 mg/day for PCOS with insulin resistance (HOMA-IR >2.5) — reduces androgens, improves ovulation rate
- Monitor with TVS for follicular development (target 18–22 mm), trigger with hCG 5000–10000 IU or GnRH agonist when eligible
- Luteal phase support: Progesterone 200–400 mg micronized vaginal/oral if using gonadotrophins
🧬 Step 3 — Intrauterine Insemination (IUI)
- Indications: Unexplained infertility (duration <3 yrs, age <38), mild male factor (TMSC ≥5×10⁶ post-wash), cervical factor, mild endometriosis (Stage I/II)
- Pre-requisites: At least one patent tube (confirmed), TMSC ≥5×10⁶ post-wash, no bilateral tubal block
- Protocol: Natural cycle IUI (preferred) OR mild stimulation (Letrozole ± FSH 50–75 IU), trigger hCG/agonist at 17–18mm follicle, inseminate 36–40 hours later
- Success: Cumulative pregnancy rate per cycle ≈ 8–18%. Recommend maximum 3–6 cycles before IVF (NICE 2013, ESHRE 2023)
- Under Indian ART Act 2021 — IUI requires registered ART bank for donor sperm; strict consent protocol
- If no success after 3 IUI cycles in women ≥35 years — direct to IVF/ICSI
🧪 Step 4 — IVF / ICSI
- Absolute IVF Indications: Bilateral tubal block, severe endometriosis (Stage III/IV), severe male factor (TMSC <5×10⁶), failed 3 IUI, unexplained infertility with age ≥38, POSEIDON poor reserve, genetic testing (PGT-A/M required)
- ICSI Indications: Severe oligozoospermia (<5×10⁶/mL), azoospermia (surgical sperm retrieval — PESA/TESA/microTESE), high DFI (>25%), previous fertilization failure, freeze-all cycles, PGT
- Stimulation Protocols:
— GnRH antagonist protocol (preferred, OHSS risk reduction) — flexible or fixed day 6
— GnRH agonist long protocol (PCO patients, poor responders)
— POSEIDON Group 3/4: Dual stimulation (DuoStim) or Progestin-primed OI (PPOS)
— Mild/mini IVF (BMI consideration, oncofertility) - OHSS Prevention: AMH >3.5 or AFC >15 → GnRH agonist trigger + freeze-all strategy (ESHRE 2023 )
- Endometrial preparation (FET): Artificial cycle (estradiol + progesterone) or natural cycle — comparable success rates. ERA (Endometrial Receptivity Array) for recurrent implantation failure
- Indian ART Act 2021 Compliance: Registration of ART clinic with National ART Registry; written informed consent; PGT requires Ethics Committee approval; age limit female donor 23–35 years; one embryo rule for good-prognosis patients ≤35 years (eSET)
- Luteal phase support: Micronized progesterone 600 mg/day (vaginal) until 10–12 weeks gestation
🔬 Step 5 — Advanced ART / Special Situations
- Donor Oocyte IVF: Indicated for POI/POF (FSH >40, AMH undetectable), advanced maternal age ≥43, repeated poor response, genetic conditions, recurrent implantation failure with own eggs
- Surgical Sperm Retrieval: PESA/TESA for obstructive azoospermia; microTESE for NOA (Klinefelter, AZFc deletion, testicular failure). Cryopreserve sperm for subsequent ICSI cycles
- PGT-A (Preimplantation Genetic Testing for Aneuploidies): Indicated: RPL (≥3 losses), advanced maternal age ≥38, repeated IVF failure (≥3 failed), severe male factor. Consider single euploid blastocyst transfer
- PGT-M (Monogenic): For known genetic conditions (CF, SMA, thalassaemia, BRCA). Ethics Committee clearance under Indian Law
- Fertility Preservation: Oocyte vitrification for oncology patients, elective egg freezing, sperm banking; ovarian tissue cryopreservation (experimental)
- Gestational Surrogacy: Under Surrogacy (Regulation) Act 2021 — altruistic surrogacy only for married Indian couples with proven infertility; regulated by National Surrogacy Board
🤝 Step 6 — Non-ART Alternatives & Support
- Adoption — under CARA (Central Adoption Resource Authority), Ministry of Women & Child Development, India
- Child-free living counselling — psychological support and couple counselling
- Referral to integrated fertility psychology / support groups (Indian Fertility Society)
- Complementary therapies (acupuncture, yoga) — evidence limited but low harm if not replacing standard care
Key Drug Reference — Doses & Monitoring
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| Drug | Indication | Dose | Monitoring | Key Notes |
|---|---|---|---|---|
| Letrozole | OI (PCOS) | 2.5–7.5 mg Day 2–6 | TVS Day 10–12 | First-line OI; off-label but ESHRE 2023 endorsed |
| Clomiphene Citrate | OI (anovulation) | 50–150 mg Day 2–6 | TVS +/- LH surge | Anti-estrogenic endometrium effect; max 6 cycles |
| Metformin | PCOS + IR | 500–2000 mg/day | RFT, LFT | Reduces OHSS, improves response in PCOS |
| rFSH / uFSH | Gonadotrophin OI / IVF stimulation | 37.5–300 IU/day SC | Daily/alt day TVS + E2 | Titrate by response; cap ≤300 IU/day |
| hMG (LH+FSH) | Hypogonadotrophic, poor LH | 75–225 IU/day SC | TVS + E2 | Beneficial in WHO Group I, thin endometrium |
| GnRH antagonist (Cetrorelix/Ganirelix) | Prevent premature LH surge | 0.25 mg/day SC from day 5–6 | TVS | Flexible protocol; preferred to reduce OHSS |
| GnRH agonist (Buserelin/Triptorelin) | Down-regulation (long protocol) / trigger | Long: 0.5 mg/day from luteal phase. Trigger: 0.2 mg stat | E2 suppression check | Agonist trigger → freeze-all to prevent OHSS |
| hCG (urinary/recombinant) | Final follicular maturation trigger | uCG: 5000–10000 IU IM. rhCG: 250 μg SC | TV-USG 34–36h later | Avoid if OHSS risk — use GnRH agonist trigger instead |
| Progesterone | Luteal phase support | Micronized vaginal 200–400 mg BD-TDS | βhCG + USG | Continue until 10–12 weeks of pregnancy |
| Levothyroxine | Hypothyroidism / elevated TSH | 25–150 μg/day (titrate) | TSH 4-weekly | Target TSH <2.5 before ART; <2.0 in first trimester |
| Cabergoline | Hyperprolactinaemia | 0.25–2 mg twice weekly | Prolactin levels monthly | Preferred over bromocriptine for compliance |
| Estradiol valerate | FET endometrial prep | 2–8 mg/day oral + vaginal | TVS endometrial thickness | Target ≥7 mm trilaminar; add progesterone at ≥8 mm |
Instructions: Fill in the assessment tabs, then click "Generate / Refresh Summary" to produce the clinical report.