WHO Infertility Guidelines

The 2025 WHO infertility guidelines, covering the prevention, diagnosis and treatment of infertility, treat infertility as a disease that needs integrated care, not a private misfortune. They ask clinicians to work up both partners, test ovulation, the tubes, the uterine cavity and the semen in a fixed sequence, offer the least expensive effective treatment first, and fast-track couples who have not conceived within six months to a year.

Dr. Hrishikesh Pai, Director of Fortis Bloom IVF Centre, has practised in vitro fertilisation (IVF) for 35 years, since an IVF fellowship in Melbourne in 1989 and 1990, and served as a regional trustee of FIGO, the global federation of obstetrics and gynaecology societies, from 2023 to 2025. Addressing doctors from Ethiopia, Uganda, Nigeria, Zimbabwe, Zambia and Kenya, he walked through the guideline recommendation by recommendation, then set out where, in his view, it falls short for clinicians in Africa, Asia and Latin America. This guide covers the guideline's evidence base, its principles and its prevention advice, then his critique. Three companion articles go deeper: the WHO diagnostic workup for both partners, including genital tuberculosis, PCOS, weight loss and ovulation induction, and stepped treatment from IUI to IVF by cause.

Why the WHO issued a new infertility guideline

The guideline follows a 2023 WHO analysis that changed the size of the problem. WHO reviewed research published between 1990 and 2021 and drew on 133 studies to estimate how common infertility is. Clinicians had long worked with a prevalence of about 5%, Dr. Pai noted; the analysis put lifetime prevalence at 17.5%, or roughly one in six people of reproductive age.

The burden is not only clinical. Dr. Pascale Allotey, WHO's Director of Sexual and Reproductive Health and Research, said at the time that millions of people face catastrophic healthcare costs after seeking infertility treatment, making it a major equity issue and, too often, a medical poverty trap. Dr. Pai pointed to the consequences the guideline lists: anxiety, depression, strain in relationships, social stigma and, in a figure he presented, intimate partner violence affecting 36% of women because of infertility.

Since the analysis, he said, health ministries and non-governmental organisations have begun to finance treatment. Several European countries already fund IVF publicly. India's national Ayushman Bharat scheme does not yet cover it, but a number of Indian state governments run schemes that provide IVF at lower cost, and he expects African governments to follow.

How the WHO defines infertility

WHO defines infertility as a disease of the male or female reproductive system: the failure to achieve a pregnancy after 12 months or more of regular, unprotected sexual intercourse. Infertility can stem from the female partner, the male partner or causes that remain unexplained. The guideline notes that women are more often blamed and male factors are neglected.

Dr. Pai was blunt on this point. Many husbands decline testing, yet in his experience the problem lies with the male partner in about half of cases. A semen test therefore comes first, not last.

Key points of the WHO infertility guidelines

Dr. Pai summarised the guideline in eight commitments:

1. Infertility is a disease and requires integrated care.
2. Timely evaluation. Standard practice is to begin investigation after 12 months of trying, or after six months when the woman is 35 or older.
3. A mandatory couple-based workup that includes semen analysis.
4. Standard diagnostic pathways: ovulation, tubal patency, the uterine cavity and the endocrine profile.
5. Lifestyle optimisation: healthy weight, no smoking, little or no alcohol, and prevention and treatment of infections.
6. Treatment stratified by cause and age, with a fast track to assisted reproductive technology (ART) when pregnancy has not occurred within six months to a year.
7. Equity, with infertility care integrated into universal health coverage so that people with low incomes can reach it.
8. Regulation, quality assurance and data systems for the services that provide care.

The intended users are deliberately broad: policymakers at national and sub-national level; physicians, nurses, embryologists and midwives; professional societies such as FIGO, the African federations and national societies; patient support and advocacy groups; and funders and philanthropic agencies.

Six WHO principles for managing infertility

The guideline's general approach rests on six principles, which Dr. Pai summarised as Select, Listen, Base, Consider, Discuss and Document:

• Select diagnostic tests on the basis of clinical findings, so that evaluation is systematic and cost-effective.
• Listen to individuals and couples, respect their preferences and provide psychosocial support where needed.
• Base treatment decisions on benefits, harms, patient values, feasibility, cost and the resources available.
• Consider cost-effectiveness: offer the least expensive treatment that works first.
• Discuss follow-up plans and the management of potential risks.
• Document the outcomes of pregnancies that result from infertility treatment.

The fourth principle shapes the whole pathway. It is why the guideline moves through expectant management and stimulated intrauterine insemination (IUI), in which prepared sperm are placed in the uterus after ovarian stimulation, before IVF in unexplained infertility, and why Dr. Pai argues that most couples can be treated close to home.

Prevention: information, lifestyle, tobacco and infections

Information for the general population

WHO suggests giving people of reproductive age information on fertility and infertility through low-cost strategies whenever the opportunity arises: digital or printed material in schools, primary healthcare centres and reproductive health clinics. The content should be adapted to local context and cover age-related fertility decline, lifestyle change and the value of consulting a doctor early. Dr. Pai linked this to the wider awareness effort, including the More Joy campaign run by the International Federation of Fertility Societies.

Lifestyle advice before and during treatment

For people with infertility, WHO suggests low-cost lifestyle advice before and during treatment, covering diet, alcohol, smoking, physical activity and weight. Obesity reduces fertility and lowers the chance of pregnancy even with IUI or IVF, which is why Dr. Pai urged clinicians to use weight-loss medicines such as semaglutide and tirzepatide where they are available. His approach to weight is covered in the PCOS and ovulation induction article.

Tobacco: brief advice at every encounter

The guideline asks clinicians to assess tobacco use as part of the history and to give brief advice of about three minutes per encounter to anyone planning a pregnancy, trying to conceive or living with infertility. That advice should explain that tobacco use, particularly smoking, raises the risk of infertility, that the risk is higher among women, and that help to stop exists. It follows the five As: ask, advise, assess, assist and arrange follow-up.

Sexually transmitted infections

Couples should be told routinely about sexually transmitted infections (STIs), including the risk that untreated infection leads to infertility, and encouraged to seek care promptly if they have symptoms. Where symptoms are present or infection is confirmed, WHO's separate STI management guidelines apply, and Dr. Pai encouraged clinicians to adopt them locally.

The stepwise diagnostic and treatment pathway

The core of the guideline is a sequence. Confirm ovulation with a mid-luteal progesterone test, with a reproductive hormone profile where ovulation is in doubt; judge ovarian reserve, which WHO bases on age rather than tests; test tubal patency; examine the uterine cavity; and analyse the semen. Couples in whom every test is normal have unexplained infertility. The thresholds Dr. Pai applies at each step, and the tests he adds, are set out in the diagnostic workup article.

Treatment then follows the cause. Ovulatory disorders, most often polycystic ovary syndrome (PCOS), start with oral ovulation induction and weight reduction, then gonadotropins or laparoscopic ovarian drilling, then IVF. Severe tubal disease goes to IVF after the damaged tube is dealt with. Clinical varicocele in a man with abnormal semen parameters is treated surgically or radiologically. Unexplained infertility moves from expectant management to stimulated IUI to IVF. Each of these steps is covered in the treatment pathway article.

What the WHO infertility guidelines leave out

Dr. Pai called the guideline a landmark, rights-based global document, and noted that it acknowledges its own limits: several clinically important causes and strategies are omitted, and expert bodies will need to complement it. His own critique was sharper. The committee, he argued, was drawn largely from Europe and North America and did not reflect the problems clinicians face in Asia, Africa and Latin America. He identified seven gaps.

Diagnostic laparoscopy and hysteroscopy

The guideline does not include diagnostic laparoscopy and hysteroscopy (camera examinations of the abdomen and of the uterine cavity), procedures gynaecologists have used for decades. Without them, mild endometriosis, pelvic infection and tuberculosis can be missed. Dr. Pai's practice is to perform laparoscopy and hysteroscopy after two or three unsuccessful IUI cycles and before IVF, because minor corrections at surgery allow many women to conceive without further treatment.

Genital tuberculosis

The guideline makes no mention of genital tuberculosis, which Dr. Pai described as very common in India and present in many African countries. Because it is rarely seen in Europe and the United States, he argued, clinicians there do not think of it, and a missed diagnosis means IVF fails. How he diagnoses and treats it is set out in the diagnostic workup article.

Endometriosis and fibroids

Endometriosis receives no specific coverage, and fibroid management, which Dr. Pai considers a major problem in African women, is not mentioned at all. He wants both in a future edition.

Fertility preservation

Many women are postponing pregnancy, and IVF success falls after 35. Dr. Pai's centres freeze eggs and sperm before cancer treatment and for women who have not yet found a partner. He advises an anti-Müllerian hormone (AMH) test for daughters before 30 to gauge ovarian reserve, and egg freezing before 35 for women who are not yet married; women who try at 37 or 39 can still conceive, he said, but egg quality is then lower and the rate of genetic abnormality higher. He freezes eggs for five to ten women a month. Egg freezing is currently used mostly by affluent families, and he wants it within reach of the middle class; in India, instalment financing now makes that easier.

Azoospermia

There is no discussion of azoospermia, the absence of sperm in the ejaculate. Men with azoospermia can now have sperm retrieved surgically under an operating microscope (microsurgical testicular sperm extraction) for intracytoplasmic sperm injection (ICSI), and Dr. Pai noted new reports of hormonal injections inducing sperm production in some men. He described an African couple who had been through eight failed cycles in four European countries over many years; donor sperm was not acceptable to them on religious grounds, and they had a baby after surgical sperm retrieval at his Gurugram centre.

The ART laboratory and emerging technology

The guideline does not address how to set up and run an ART laboratory. Dr. Pai also showed a fully automated, AI-controlled ICSI system, supervised by humans, in which machines handle the sperm, operate the laser and inject the egg; the first baby conceived this way was born in 2025. He expects automation to define the future of ART, much as robotic surgery has changed operating theatres, and he expects eggs and sperm derived from skin cells and stem cells to reach clinical use within about five years.

Third-party reproduction and the rest of the future agenda

His list for the next edition: fertility preservation, endometriosis management, fibroid management, third-party reproduction (donor eggs, donor sperm and surrogacy), male infertility and artificial intelligence.

Equity: the same standard of care for every patient

Dr. Pai closed on equity, the guideline's own central theme. In his view international agencies too often speak to clinicians in low- and middle-income countries only about postpartum haemorrhage and sexually transmitted infections, or propose a lower-cost, compromised form of IVF. He rejects that. Every patient, he argued, should receive the treatment a doctor would give his own daughter, and the way to make that affordable is to reduce charges, not to compromise care.

His practical answer is a division of labour. Most couples, in his estimate, can be treated in their own country with good ultrasound, an IUI laboratory and access to laparoscopy and hysteroscopy, and only a minority need IVF. Indicative prices for those who do are on the IVF and fertility treatment cost page. Questions from the participating doctors, on weight-loss drugs, IUI stimulation, genital tuberculosis and IVF success, are answered in the masterclass Live Discussion.