The World Health Organization's first comprehensive infertility guideline represents a landmark in global reproductive health. To help healthcare professionals, policy-makers, and individuals understand the key recommendations, we've compiled 10 essential questions and answers covering the guideline's core elements from diagnostic protocols and treatment strategies to prevention measures and implementation challenges. These Q&As distill the evidence-based recommendations into accessible insights for better fertility care worldwide.

Q1. What is the WHO definition of infertility, and what is its estimated global prevalence?

A.     Infertility is defined as the failure to achieve a pregnancy after 12 months of regular unprotected sexual intercourse. Globally, approximately one in six people of reproductive age experience infertility at some stage in their lives, with a lifetime prevalence estimated at 17.5%. This prevalence does not differ significantly between high-income countries (HICs) and low- and middle-income countries (LMICs).

Q2. Who is the primary target audience for the new WHO Infertility Guideline?

A.     The guideline is primarily intended for use by health care professionals (including physicians, embryologists, nurses, midwives, laboratory specialists, and other health care providers) involved in the provision of fertility care. It is also relevant to policy-makers responsible for developing national health policies, services, and financing, as the recommendations adopt a public health perspective that considers resource constraints and equity.

Q3. What specific public health measure does the WHO strongly recommend regarding tobacco use for people attempting to achieve pregnancy?

A.     WHO strongly recommends that brief advice against tobacco use be routinely provided to all tobacco users accessing any health care setting, including individuals and couples who are planning a pregnancy, attempting to achieve a pregnancy, or dealing with infertility. This is a "strong recommendation" given the association between smoking (especially among women) and a higher risk of infertility. This brief advice should follow the 

Q4. In the initial diagnosis of female infertility, how should ovulation typically be confirmed in regularly menstruating women?

A.     For females with infertility but normal findings on history-taking (including regular menstrual cycles) and physical examination, WHO suggests presumptive confirmation of ovulation by measuring the level of mid-luteal serum progesterone rather than performing an ultrasound scan. If the initial measurement indicates no ovulation, a repeat measurement is suggested to minimize the risk of an inaccurate diagnosis of anovulation.

Q5. What guidance is provided regarding the need to repeat semen analysis for males in infertile couples?

A.     For males (in couples with infertility) with one or more semen parameters outside the WHO reference ranges, WHO suggests repeating the semen analysis after a minimum of 11 weeks. Conversely, for males whose semen parameters are all within the WHO reference ranges, WHO suggests not repeating the semen analysis. The recommendation for waiting 11 weeks aligns with the minimum duration estimated for spermatogenesis to occur.

Q6. What fundamental principle is noted as "good practice" regarding the selection and conduct of diagnostic evaluations for infertility?

A.     It is good practice that diagnostic tests should be selected based on the clinical findings derived from a comprehensive medical history and physical examination to ensure that the evaluation is systematic and cost-effective. It is also considered good practice to listen to individuals and couples, respect their preferences, and discuss if psychological or peer support is needed.

Q7. What is the suggested initial management strategy for couples diagnosed with unexplained infertility?

A.     WHO suggests expectant management rather than ovarian stimulation with timed intercourse. Expectant management involves monitoring the couple, providing advice on lifestyle and fertile days, and expecting pregnancy to occur without medical intervention. In studies informing this recommendation, the duration of expectant management was typically 3–6 months.

Q8. How does the guideline recommend assessing tubal patency in females suspected of tubal disease?

A.     WHO suggests using either hysterosalpingogram (HSG) or hysterosalpingo contrast sonography (HyCoSy) to assess tubal patency. The choice between the two methods should consider factors such as feasibility, the availability of trained health care providers, and the potential for allergy.

Q9. When couples with unexplained infertility require IVF, what is the recommendation regarding the use of Intracytoplasmic Sperm Injection (ICSI)?

A.     For couples undergoing IVF for unexplained infertility, WHO strongly recommends using IVF alone rather than IVF with ICSI. This strong recommendation is based on the finding that IVF and ICSI result in similar clinical pregnancy and live birth rates, but ICSI involves significantly higher costs and resource requirements.

Q10. What are some significant research gaps identified by the Guideline Development Group (GDG) that need to be addressed in future editions?

A.     Key research gaps noted include relatively few studies identified from LMICs, a deficit of studies on patient values, preferences, and acceptability of different interventions, suboptimal data on costs and cost-effectiveness, and a lack of emphasis on reporting the effect of interventions on live birth rate (rather than just clinical pregnancy rate). Future guidelines are also anticipated to expand coverage to topics currently excluded, such as third-party reproduction (donor gametes and surrogacy), advanced male infertility treatments, and psychosocial support.