Concerns regarding the WHO guideline on infertility: implications for contemporary reproductive medicine

Dear Editors, We read the World Health Organization (WHO) guideline on the prevention, diagnosis, and treatment of infertility with increasing concern (World Health Organisation Guideline Development Group for Infertility, 2026). While the need for globally oriented guidance in infertility care is undeniable, several recommendations within this document appear disconnected from established principles of reproductive endocrinology and contemporary clinical practice. Given the potential impact of WHO guidelines on policy-making and clinical standards worldwide, these issues warrant careful scrutiny. A first major concern relates to the diagnostic approach to women with infertility and oligo- or anovulation. The guideline suggests that hormonal investigations should be performed ‘only in selected clinical presentations’. However, oligo- or anovulation is, by definition, the clinical scenario in which a comprehensive endocrine evaluation is mandatory. In particular, androgen assessment is presented as optional, despite being a cornerstone of diagnosis in the most common cause of anovulation, polycystic ovary syndrome (PCOS). The 2023 International Evidence-based Guideline for PCOS clearly states that when clinical hyperandrogenism is absent, biochemical hyperandrogenism must be assessed, and that androgen measurement is essential for diagnosis (Teede et al., 2023). Vagueness in this area risks systematic underdiagnosis and inappropriate management. Similar concerns apply to prolactin and thyroid function testing. The guideline implies that prolactin assessment may be reserved for selected cases, yet asymptomatic hyperprolactinemia is well described and clinically relevant (Melmed et al., 2011). Galactorrhea is neither necessary nor sufficient for diagnosis. Likewise, thyroid dysfunction is a recognized contributor to menstrual irregularities and infertility, and thyroid-stimulating hormone should be routinely assessed in women with ovulatory disorders (Poppe and Velkeniers, 2003). Waiting for overt clinical symptoms before testing reflects an outdated approach that contradicts decades of endocrine practice.