WHO Infertility Workup: Tests and Thresholds for Couples

The WHO infertility workup tests both partners in a fixed order: confirm ovulation with a mid-luteal progesterone level, assess hormones where ovulation is in doubt, consider ovarian reserve, test whether the fallopian tubes are open, examine the uterine cavity and analyse the semen. If all are normal, the couple has unexplained infertility. Dr. Hrishikesh Pai adds two steps the guideline omits: diagnostic laparoscopy and a deliberate search for genital tuberculosis.

Dr. Hrishikesh Pai, Director of Fortis Bloom IVF Centre, set out the thresholds he applies at each step, test by test. This article follows the same order. The guideline's wider principles and his critique of it are in the complete guide to the WHO infertility guidelines; what happens once a cause is found is covered in the stepped treatment article.

The WHO infertility workup covers both partners, starting with the man

The guideline makes the workup mandatory for both partners. Dr. Pai's emphasis is practical: many husbands resist testing, yet in his experience the male partner accounts for about half of infertility, so a semen analysis belongs at the start, not after months of tests on the woman.

Timing matters too. Infertility is defined as no pregnancy after 12 months of regular, unprotected intercourse; standard practice is to start investigating after 12 months, or after six months when the woman is 35 or older.

Confirming ovulation with a mid-luteal progesterone test

For a woman with infertility whose history and examination are normal, WHO suggests presumptive confirmation of ovulation with a mid-luteal progesterone test. Dr. Pai takes the test on day 21 of a regular cycle. A level above 10 nanograms per millilitre (ng/mL) confirms that ovulation has occurred.

Hormone profile when ovulation is in doubt

Where anovulation is suspected, the guideline describes assessing the hormones of the hypothalamic-pituitary-ovarian axis: follicle-stimulating hormone (FSH), luteinising hormone (LH), oestradiol and testosterone. In Dr. Pai's practice anti-Müllerian hormone (AMH) has largely replaced that panel for assessing the ovaries, but two other tests stay in every workup:

• Thyroid-stimulating hormone (TSH). The usual normal limit is below 5, but in infertility Dr. Pai wants TSH below 2.5. A woman whose TSH is within the normal range but above 2.5 can be given thyroxine as part of treatment.
• Prolactin. He wants prolactin below 20 ng/mL. Above that, bromocriptine or cabergoline can be added.

Ovarian reserve: age first, then AMH and antral follicle count

Ovarian reserve is the number of eggs a woman has left. For women in whom other causes of anovulation have been excluded, WHO suggests diagnosing low ovarian reserve on the basis of age rather than a diagnostic test. Dr. Pai agreed that age matters, but in his practice two measurements carry the classification.

Antral follicle count (AFC) is measured by transvaginal ultrasound on the second or third day of the cycle, counting the small resting (antral) follicles in both ovaries together. AMH is a blood test that reflects the size of the remaining follicle pool, and it is Dr. Pai's main test of reserve; in predicting how the ovaries will respond, it performs about as well as the follicle count. It is widely available through large laboratory networks, and participating doctors confirmed that it is available in Ethiopia.

Dr. Pai classifies women into three groups:

In Dr. Pai's practice, polycystic ovary syndrome (PCOS) is now diagnosed largely on these two markers: on ultrasound the ovaries show many small follicles arranged like a necklace around the edge, and an AMH above 3.5 ng/mL confirms the picture. The 2023 international PCOS guideline requires two of three features for diagnosis: irregular or absent ovulation, androgen excess, and polycystic ovaries on ultrasound or a raised AMH. The classification also decides the stimulation drug, as described in the PCOS and ovulation induction article. At the other end, Dr. Pai sees many women with AMH values of 0.3 or 0.4 ng/mL, where the realistic options narrow quickly.

Testing tubal patency: HSG or HyCoSy

There are two practical ways to establish whether the fallopian tubes are open:

1. Hysterosalpingography (HSG). A radio-opaque dye, about 5 to 8 mL, is injected through the cervix and X-rays are taken. The images show whether the tubes are open or blocked and whether they look diseased.
2. Hysterosalpingo-contrast sonography (HyCoSy). Saline is pushed through the cervix during a transvaginal ultrasound scan, and the sonographer watches it spill from the tubes into the pouch of Douglas behind the uterus. A dedicated contrast agent gives clearer images but is expensive.

In Dr. Pai's view either a saline test with a good ultrasound machine or a conventional HSG is entirely adequate. The guideline asks that the choice take account of feasibility, the availability of trained providers and the risk of allergy to the contrast medium.

Assessing the uterine cavity: SIS and 3D ultrasound

For a woman suspected of a uterine cavity disorder (a septum, polyp or fibroid distorting the cavity), WHO suggests saline infusion sonohysterography (SIS): saline is instilled into the uterus during an ultrasound so that the cavity outline can be seen. The guideline prefers SIS to HSG for the cavity, and to two-dimensional ultrasound alone where resources are limited. All of these recommendations are conditional.

Dr. Pai's practice is to use three-dimensional ultrasound wherever it is available, as it now is in most Indian cities. Where it is not, saline infusion with a 2D scan gives comparable information. Disposable balloon catheters can be used in place of the older reusable cannulas; Dr. Pai put their cost at about 1,500 rupees (roughly $15 to $20) each.

Semen analysis

Every couple needs a semen analysis. When the result is abnormal, Dr. Pai repeats the test after about 11 weeks before drawing conclusions. His centres use automated semen analysers, which he considers much more reliable than manual counting: a badly performed manual test can produce a misleading report and send treatment in the wrong direction. He put the cost of an analyser at about $1,500, with each test costing roughly $5 to $7; a single drop of semen is placed on a carrier slide and the machine reads it.

The guideline also covers treatment of varicocele (dilated veins around the testis), which is addressed in the treatment pathway article.

When every test is normal: unexplained infertility

The guideline defines unexplained infertility as failure to conceive after 12 months of regular unprotected intercourse with a normal physical examination, ovulation confirmed by mid-luteal progesterone, patent tubes and semen parameters within WHO reference ranges. Dr. Pai noted that most couples fall into this group once tests are complete. The exception he sees repeatedly in women from Africa is uterine disease, adenomyosis and fibroids, which is then the explanation rather than unexplained infertility.

The step the guideline omits: diagnostic laparoscopy and hysteroscopy

Laparoscopy (a camera passed into the abdomen) and hysteroscopy (a camera passed into the uterus) are absent from the guideline. Dr. Pai considers that a serious omission. Without them, mild endometriosis, pelvic adhesions, infection and tuberculosis are missed, and IVF is then attempted against an uncorrected problem.

His sequence for a couple with normal first-line tests:

1. HSG and ultrasound to confirm open tubes and a normal uterus.
2. Timed intercourse for two cycles.
3. Two or three IUI cycles.
4. If those fail, laparoscopy and hysteroscopy before any IVF.

At laparoscopy, adhesions can be divided and endometriosis treated, and many women then conceive without further treatment. Although laparoscopy is invasive, he regards it as a very good procedure, and he regrets that younger clinicians often avoid it. For an international patient the stay is short: about five to seven days in total, with most able to fly home three to four days after surgery. Indicative prices are on the hysteroscopy cost page.

Genital tuberculosis and infertility: the diagnosis WHO leaves out

Genital tuberculosis (TB) is not mentioned in the guideline. Dr. Pai described it as very common in India and present in many African countries. Because it is uncommon in Europe and the United States, clinicians trained there tend not to consider it; they move from IUI straight to IVF, and if the infection is missed, IVF does not produce a pregnancy. Genital TB can also lower ovarian reserve.

Clinical picture

Infertility is the commonest presentation of genital TB. Where periods are affected, very scanty periods or amenorrhoea (absent periods) are more usual than heavy bleeding.

Diagnosis

Dr. Pai's first choice is laparoscopy, because a visual diagnosis is more reliable than laboratory tests: polymerase chain reaction (PCR) testing for TB often gives false-negative results. Where a patient will not accept laparoscopy, he combines several tests:

• Hysteroscopy with dilatation and curettage (D&C), sending the endometrium for histopathology and TB PCR.
• A chest X-ray to look for a lung lesion.
• Examination of the neck and groin for enlarged lymph nodes.
• A personal and family history of TB.
• Sputum examination for acid-fast bacilli on three consecutive days.
• An interferon-gamma release assay and a Mantoux (tuberculin skin) test, although neither can confirm or exclude active genital TB.

When suspicion is strong but the tests are inconclusive, Dr. Pai will start anti-tuberculosis treatment empirically. Standard guidance favours confirming the diagnosis wherever possible before committing a patient to months of treatment, so empirical therapy remains a clinical judgement made case by case.

Treatment

Anti-tuberculosis treatment, in Dr. Pai's regimen, begins with an intensive phase of four drugs for two months, followed by a continuation phase with two drugs to a total of nine months; standard courses for most tuberculosis run six months. Dr. Pai's rule is absolute: once anti-tuberculosis treatment has started, it must be completed. Stopping after one or two months breeds drug resistance, and multidrug-resistant TB is a serious global problem that kills patients.

Many women conceive spontaneously once treatment is complete. For those who do not, he repeats laparoscopy and hysteroscopy to confirm the pelvis is healthy, then moves to IUI and, if that fails, IVF. Questions from participating doctors on genital tuberculosis are answered in the masterclass Live Discussion, and related infections are covered under infectious diseases.

For the treatment steps that follow a diagnosis, see the PCOS and ovulation induction article and the treatment pathway from IUI to IVF. For a different specialist's view of testing before assisted reproduction, Dr. Shelly Singh's guide to pre-IVF workups and corrective surgery covers the same ground from the surgical side.