Synopsis
Investigate both gamete contributors in parallel, identify treatable ovulatory and gonadal endocrine disorders, and refer promptly for monitored fertility treatment without offering hormones that impair sperm or create avoidable multiple pregnancy.
- NICE NG257 replaced CG156 in March 2026; use the new guideline and current local commissioning rules rather than an inherited fertility checklist.
- Assess both partners or gamete sources at the same time where relevant; finding an ovulation disorder does not remove the need for semen and tubal or uterine assessment.
- Offer earlier specialist referral when age, amenorrhoea, previous gonadotoxic treatment, known tubal or male-factor disease, cancer or another clear risk makes waiting inappropriate.
- Confirm ovulation with cycle history and correctly timed progesterone when needed; a fixed day-21 sample is wrong for every cycle that is not 28 days.
- Measure FSH and LH in irregular or absent cycles, and add prolactin, thyroid and androgen assessment when symptoms or an ovulatory disorder justify them rather than screening indiscriminately.
- Use anti-Müllerian hormone or antral follicle count to predict ovarian response to stimulation in the indicated setting, not as a stand-alone test of natural fertility or egg quality.
- Semen analysis is the first male test. Severe oligozoospermia or azoospermia needs repeat confirmation, endocrine localisation and genetic or obstructive assessment through andrology.
- Do not give exogenous testosterone or anabolic androgens to improve male fertility; they suppress gonadotrophins and intratesticular testosterone and can cause azoospermia.
- Ovulation induction, gonadotrophins and assisted conception require monitored specialist protocols with cancellation rules to limit multiple pregnancy and ovarian hyperstimulation.
- NHS treatment access differs across nations and commissioners; explain clinical recommendations separately from funding eligibility and direct people to an HFEA-licensed service.
Key red flags
Amenorrhoea, galactorrhoea, low libido or visual symptoms may reflect prolactin-mediated gonadotrophin suppression; medicine causes and macroprolactin complicate interpretation.
Post-stimulation pain, distension, breathlessness, oliguria, syncope or rapid weight gain suggests OHSS, torsion, bleeding or ectopic pregnancy and needs urgent specialist assessment.
Investigation priorities
Assess sperm concentration, motility and morphology early in every pathway using sperm relevant to conception.
Management branches
Pregnancy has not occurred within the current NICE timeframe or earlier risk factors justify review.
- Clarify duration, frequency and method of conception attempts, age, previous pregnancies, cycles, pelvic and sexual symptoms, medicines, hormones, gonadotoxic exposure, lifestyle and each person's goals.
- Arrange semen analysis and assess ovulation in parallel, adding pelvic or tubal evaluation according to history rather than completing one partner's tests before starting the other's.
- Use targeted endocrine tests for irregular cycles, galactorrhoea, thyroid symptoms, androgen excess or male hypogonadism and avoid AMH as a general natural-fertility screen.
- Refer earlier for amenorrhoea, severe semen abnormality, older reproductive age, prior cancer therapy or known disease, and explain current local NHS access separately from medical need.
Key medicines
CabergolineUse the specialist-titrated oral regimen to normalise prolactin and restore ovulation under the 2026 NICE pathway.Review nausea, postural hypotension, impulse-control symptoms, cardiac valve risk and pregnancy plan. Pituitary mass symptoms require urgent assessment; coordinate interacting psychiatric medicines.
Letrozole or clomifene ovulation inductionUse only the fertility service's cycle-specific oral regimen with the required response monitoring.Letrozole use for ovulation induction may be off-label; explain this. Multiple pregnancy, cysts and visual or other adverse effects require monitoring and cycle-stopping rules.