EXPLAINER: All to know about WHO’s infertility guideline, why it matters

The World Health Organisation has released its first-ever global guideline on infertility, calling on countries to make fertility care safer, fairer and more affordable.

It comes as infertility affects 1 in 6 people of reproductive age worldwide, while access to tests and treatments remains limited and, in many places, financially devastating.

Announcing the guideline, WHO Director-General, Dr Tedros Ghebreyesus, said, “Infertility is one of the most overlooked public health challenges of our time and a major equity issue globally.

“Millions face this journey alone – priced out of care, pushed toward cheaper but unproven treatments, or forced to choose between their hopes of having children and their financial security. We encourage more countries to adapt this guideline, giving more people the possibility to access affordable, respectful, and science-based care.”

WHO urges countries to integrate fertility care into national health systems rather than leave it to private or out-of-pocket payment, emphasising that infertility services must be accessible and clinically sound.

The organisation says care should begin with proper history-taking and physical examination, rely only on necessary and cost-effective tests, respect patient preferences, and include psychological support. It also stresses the need to weigh risks, benefits and costs before choosing treatments and to track outcomes after care.

These principles, WHO notes, apply across all stages of infertility management.

The guideline contains 40 recommendations covering prevention, diagnosis, treatment and system-wide implementation.

• Infertility in men. Image source WINFertility

Below is an harmonised explainer and summary of the WHO’s Guideline for the Prevention, Diagnosis and Treatment of Infertility – Summary of Recommendations.

1. General Principles for Infertility Care

WHO advises that care for individuals and couples should:

Be based on thorough history and physical examination.

Use only necessary, cost-effective diagnostic tests.

Respect patient preferences and offer psychological or peer support when needed.

Consider benefits, harms, costs and feasibility when choosing treatments.

Plan follow-up and manage treatment risks.

Document pregnancy outcomes after treatment.

2. Prevention of Infertility

Information & Lifestyle

Provide low-cost fertility and infertility information to all people of reproductive age (e.g., schools, primary care, reproductive health clinics).

Provide lifestyle advice (diet, alcohol, smoking, physical activity, weight management) to people with infertility before and during treatment.

Tobacco Smoking

Give brief cessation advice (30 seconds–3 minutes) to all tobacco users, including those trying to conceive.

Explain smoking’s link to infertility (especially for women).

Offer or refer for cessation support.

Sexually Transmitted Infections (STIs)

Inform all individuals/couples planning pregnancy about STIs and their infertility risks.

Encourage prompt care and treatment for STI symptoms.

3. Diagnosis of Female-Factor Infertility

A. Ovulatory Dysfunction

For women with regular cycles and normal exams:

Use mid-luteal serum progesterone to confirm ovulation; repeat if abnormal.

For suspected anovulation/oligo-ovulation:

Assess HPO-axis hormones (FSH, LH; sometimes estradiol/testosterone, TSH, prolactin).

Low ovarian reserve:

Base diagnosis mainly on age; if testing needed, use AFC, AMH, or day 2–3 FSH.

B. Tubal Disease

Use HSG or HyCoSy to assess tubal patency, depending on feasibility.

C. Uterine Cavity Disorders

Preferred assessment (where resources allow):

SIS over 3D ultrasound

3D ultrasound over 2D ultrasound

SIS over 2D ultrasound

SIS over HSG

4. Diagnosis of Male-Factor Infertility

If semen analysis is abnormal: repeat after ≥11 weeks.

If normal: do not repeat.

5. Diagnosis of Unexplained Infertility

Diagnose when ALL conditions are met:

No pregnancy after 12 months unprotected intercourse.

Normal history and physical exam (both partners).

Confirmed female ovulation and tubal patency.

Normal semen parameters.

6. Treatment of Female-Factor Infertility

A. Ovulatory Dysfunction (PCOS)

First-line: Letrozole over clomiphene citrate or metformin.

If letrozole use is restricted: clomiphene + metformin preferred.

Lifestyle advice (diet, exercise, weight management).

If oral therapy fails → gonadotrophins rather than ovarian drilling.

If gonadotrophins fail → IVF rather than expectant management.

Hyperprolactinaemia

Use cabergoline over bromocriptine.

B. Tubal Disease

<35 years, mild–moderate disease:

Surgery preferred over IVF; wait ~1 year post-surgery.

<35 years, severe disease: IVF preferred.

≥35 years: IVF preferred for any tubal disease.

Hydrosalpinx:

Salpingectomy or tubal occlusion before IVF.

Prefer these over transvaginal aspiration (unless other options unavailable).

C. Uterine Septum

If no history of recurrent pregnancy loss:

Do not perform septum resection.

7. Treatment of Male-Factor Infertility

Antioxidants

No recommendation for or against antioxidant supplements—evidence insufficient.

Varicocele

For men with infertility and clinical varicocele:

Treat (surgical or radiological) rather than observe.

Microscopic surgery preferred where possible.

If non-microscopic surgery: inguinal or retroperitoneal approaches acceptable.

Applies only when not undergoing ART.

8. Treatment of Unexplained Infertility

First-Line

Expectant management (3–6 months) preferred over:

Unstimulated IUI

Ovarian stimulation with timed intercourse

Second-Line

If no pregnancy after expectant management:

Stimulated IUI (S-IUI) using clomiphene or letrozole.

Prefer S-IUI with letrozole/clomiphene over S-IUI with gonadotrophins.

Third-Line

If S-IUI fails:

IVF rather than expectant management.

For IVF after S-IUI failure: use IVF alone; do not add ICSI.

9. Implementation & Adaptation

Countries should adapt these recommendations based on:

Local infertility epidemiology

Health system capacity and resources

Cultural and social context

Engagement with governments, clinicians, civil society, patient groups

Key needs include updating policies, essential medicine lists, health workforce training, and data systems.

10. Monitoring & Evaluation

Build monitoring into national programmes.

Strengthen health information systems, registries and data collection for infertility services.

Use indicators from existing HMIS/ART registries; use surveys where needed.

Ensure political support and a rights-based approach.

11. Future Guideline Updates

Future editions will cover:

Additional risk factors (obesity/underweight, alcohol, substances, vaping)

Environmental/workplace factors

Sexual dysfunction

Fertility preservation (e.g., cancer treatment)

Third-party reproduction (donor gametes, surrogacy)

Male infertility diagnostics & treatments

Emerging technologies (AI, new equipment, new therapeutics)

Why This Guideline Exists Now

The WHO emphasises that infertility has profound psychosocial impacts, noting distress, stigma, and financial hardship. The guideline calls for ongoing psychosocial support for people affected.

WHO’s Director of Sexual and Reproductive Health and HRP lead, Dr Pascale Allotey, said, “The prevention and treatment of infertility must be grounded in gender equality and reproductive rights. Empowering people to make informed choices about their reproductive lives is a health imperative and a matter of social justice.”