The Infertility Evaluation:  What ANPs Can Do Before a Referral to a Specialist

The below was written by Jordan Moore Vaughan. MSN, APRN, WHNP-BC

Infertility doesn’t discriminate. It affects all races, religions, and all socioeconomic backgrounds. This complex diagnosis can affect physical, mental, and financial well-being. It is often overlooked or misunderstood. During this Infertility Awareness Week, I hope to shed some light on this condition as well as some tools we have as providers prior to referring a patient to a specialist.

Infertility 101

The definition of infertility is the inability conceive after one year of regular, unprotected intercourse, or six months if a woman is over the age of 35.  According to the CDC, as many as 10% of women struggle to become pregnant or continue a pregnancy in the United States.

As an advanced practice nurse (APN), you may be the first point of contact for patients in the fertility journey. Before referring them to an infertility specialist, you can provide them with education and guidance on how to maximize fertility.

Guidance for Women

All women of childbearing age should be on a prenatal vitamin with folic acid. They should not be smoking, and should limit their alcohol and caffeine consumption. Women should also maintain a healthy body weight to promote efficient ovulation and optimal health for continuing pregnancy.

Guidance for Men

The guidance for men is similar. They should also be taking a multivitamin. They should not be smoking, and should limit alcohol consumption. Men also need to maintain a healthy body weight.

In addition, men should not be taking any anabolic steroids, as it affects the hormonal balance between the brain and testes, which impacts sperm production.

Guidance for Couples

Education on the timing of intercourse is very important. To increase the chances of pregnancy, couples should have intercourse during the “ fertile window” which is the  5 days leading up to and the day of ovulation.  You should educate your patients on how to monitor ovulation, whether by menstrual calendar, ovulation predictor kits, or evaluation of cervical mucus.

What APNs Can Do

In order for a woman to conceive three components are necessary: Ovulation, a suitable uterine environment, and motile sperm capable of fertilization. Here are three things you can do before initiating a referral:

Ovarian Reserve Testing

Determine if a woman is ovulating either by a detailed history or by testing. Although there is no perfect test, and generally a combination of testing is used to predict chances of pregnancy, AMH (Antimullerian Hormone) is a promising screening tool to predict ovarian reserve. This may be obtained by blood sample at any day of a women’s cycle, whereas a basal FSH (Follicle stimulating hormone) is only reliable on menstrual days 2-4.  In the literature, a level of > 1 ng/ml is generally considered to be normal.


Tubal disease is a common cause of infertility. You can rule this out prior to referral.  Screening for a history of Chlamydia is particularly important as it is the primary modifiable cause of tubal factor infertility.  Doing an HSG (hysterosalpingogram) is an inexpensive way to determine tubal status. This is done after a woman stops bleeding and prior to ovulation. This can document tubal patency, uterine anomalies, such as a fibroid or polyp, and uterine malformations, such as a septum.

Semen Analysis 

For the male partner, a semen analysis should be considered early in the evaluation. This analysis is the most accurate evaluation of male fertility and can be used as a cost-effective way to quickly exclude male factors as the cause of a couple’s infertility. Collections should be made with 2-5 days of abstinence for optimal results.  Contact your local fertility practice or lab for specific instructions as all centers are different.

The diagnosis of infertility is life altering for many couples, with lasting psychological impact as well.  As an APN you are in a unique position to guide your patients through the fertility journey providing holistic care and addressing both the physical and emotional well-being aspects.  Because of the length and intimacy of the evaluation, patients may feel more comfortable working with you because of the already established a trusting relationship you have before referral to a specialist.  These are some components of the evaluation that you can do in your practice prior that are helpful in the referral process.

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