pathways of REI are long-term and, like much of medicine, begin with diagnosis.


The unique clinical work-up of REI often involves two people, not just one. Male factor infertility is a common contributor and must be evaluated alongside the female pelvic anatomy and reproductive physiology. The many possible diagnoses from the work-up have a commensurate spectrum of management options, including education, timed intercourse with ovarian stimulation, correction of structural abnormalities, intrauterine insemination (IUI), IVF, and using a “third party” which may include donor eggs, donor sperm or a gestational carrier (commonly referred to as a surrogate).


Beyond that, the least invasive technique is appropriately timed intercourse. This method may be done by the couple alone with tracking and timing of the menstrual cycle, possibly the use of apps and/or commercially available urine ovulation monitors. The next step with an REI is using serial ultrasounds, ovulation-stimulants (e.g., Clomid or Letrozole), and/or a trigger shot, an injection of hCG to mimic the luteinizing hormone surge that naturally occurs before and causes ovulation. For the male partner, a semen analysis can demonstrate sperm quantity, quality and motility but there is no test for the ability to fertilize an egg. While there is a litany of possibilities that may improve sperm parameters, this is multifactorial with variable success. When infertility is caused by something more complex beyond these basic steps, investigating structures may be the next step.


The IR role To detect structural abnormalities, an REI specialist may perform a sonohysterogram or consult an IR to perform a hysterosalpingogram (HSG). HSG can be therapeutic with tubal flushing or recanalization. Other abnormalities detected at this stage, such as uterine adhesions or septum, may require hysteroscopic surgery. Fibroids, particularly submucosal or large intramural types which may prevent fertility by disrupting endometrial receptivity, have been shown to be successfully treated with uterine fibroid embolization (UFE).3


With that said, the impact of UFE on fertility remains debated and requires thoughtful patient selection and interdisciplinary alignment.


From a structural standpoint, the other role IR may take is performing ovarian vein embolization in the setting of pelvic venous congestion. While more commonly seen in multiparous patients and treated for lifestyle reasons (chronic pain, dysmenorrhea), the alteration of hemodynamics and associated dyspareunia from ovarian varices may contribute to infertility. One small case series (n=12) found 67% of women that underwent ovarian vein embolization due to infertility had a subsequent pregnancy.4


Overall, pelvic


venous congestion in the setting of infertility is not well studied, likely due to its rarity as a possible contributing cause of infertility.


The most common structural abnormality in men are varicoceles. A gonadal vein embolization, as performed by an IR, has a clear benefit in semen parameters of select patients.5–7


If sperm parameters are


adequate, the semen specimen may be acceptable for IUI (as described below).


Other less common structural abnormalities exist, such as the absence of vas deferens. In the absence of sperm delivery from lack of structural transport,


sperm can be retrieved (i.e., aspirated) from the testicles or epididymis. This sperm can only be used for IVF given its low numbers and often poor motility. In the case of aspirated sperm or poor ejaculated semen quality, fertilization may be completed by intracytoplasmic sperm injection (ICSI) into a non- fertilized egg that was retrieved from the intended biological mother or egg donor. The embryo is then transferred to the uterus.


These scenarios highlight the key distinction between IUI and IVF: unlike IVF, IUI does not involve retrieving (i.e., aspirating) eggs from the biological mother or egg donor. In IUI, a concentrated sample of sperm is injected into the uterus, timed to ovulation and performed with or without ovarian- stimulating medications and/or a trigger shot. Generally, IUI is used for mild male factors or first-line treatment of unexplained infertility (along with ovarian stimulation medications). It is also used in cases of female same-sex relationships or a single woman seeking pregnancy.


Understanding where IUI fits within the broader reproductive algorithm allows IRs to interface more effectively with REI specialists, particularly in managing coexistent pathologies such as fibroids


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