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.
Key red flags
Amenorrhoea, galactorrhoea, low libido or visual symptoms may reflect prolactin-mediated gonadotrophin suppression; medicine causes and macroprolactin complicate interpretation.
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.
Key medicines
CabergolineUse the specialist-titrated oral regimen to normalise prolactin and restore ovulation under the 2026 NICE pathway.
Letrozole or clomifene ovulation inductionUse only the fertility service's cycle-specific oral regimen with the required response monitoring.