GA31 - Female Infertility: Complete ICD-11 Coding Guide

1. Introduction

Female infertility represents one of the most challenging conditions in the field of reproductive medicine, affecting millions of women of reproductive age worldwide. According to the World Health Organization, infertility is recognized as a disease of the reproductive system, defined by the inability to achieve clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.

The clinical importance of this condition transcends purely medical aspects, profoundly impacting the mental, emotional, and social health of affected women and couples. It is estimated that infertility affects a significant proportion of couples of reproductive age globally, making it a relevant public health issue that demands specialized attention and adequate resources.

The impact on public health is considerable, not only due to the costs associated with assisted reproduction treatments, but also due to the psychological and social consequences that accompany the diagnosis. Women with infertility frequently experience elevated levels of stress, anxiety, and depression, in addition to facing social and family pressures in diverse cultures.

The correct coding of female infertility in the ICD-11 system is critical for multiple reasons: it enables appropriate epidemiological tracking of the condition, facilitates proper allocation of health resources, ensures correct reimbursement of diagnostic and therapeutic procedures, and enables robust clinical research. Furthermore, accurate documentation is essential for planning public policies aimed at reproductive health and for justifying the need for specialized treatments before health systems and insurance companies.

2. Correct ICD-11 Code

Code: GA31

Description: Female infertility

Parent category: Diseases of the female genital system

Official definition: Disease of the reproductive system defined by failure to achieve clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.

Important note: In clinical practice, the duration of infertility, the age of the female partner, and other medical conditions are important factors that should be specified and may affect clinical management.

The code GA31 represents a broad category that encompasses all forms of female infertility, regardless of the underlying cause. This code should be used when clinical evaluation confirms that factors related to the woman are the primary contributors to the inability to conceive. It is fundamental to understand that this code does not specify the etiology of infertility, but rather establishes the functional diagnosis of reproductive incapacity.

The ICD-11 classification allows greater granularity through subcategories that specify different types of female infertility, enabling more precise coding when the specific cause is identified. However, the code GA31 serves as the primary code when female infertility is established as a diagnosis, and may be complemented with additional codes that describe associated conditions or specific causes.

3. When to Use This Code

The code GA31 should be applied in specific clinical situations where diagnostic criteria are clearly met:

Scenario 1: Documented primary infertility A 28-year-old woman seeks care after 14 months of unsuccessful conception attempts. The couple maintains regular sexual relations (2-3 times per week) without use of contraceptive methods. Initial evaluation reveals regular menstrual cycles, but complementary investigation identifies alterations in ovarian reserve. In this case, GA31 is appropriate as it meets temporal and functional criteria.

Scenario 2: Secondary infertility after previous delivery A 35-year-old patient with a history of successful pregnancy 4 years ago seeks evaluation after 18 months attempting a second pregnancy. Despite previously proven fertility, current inability to conceive after an adequate period of attempts characterizes secondary infertility, justifying the use of GA31.

Scenario 3: Infertility with multiple female factors A 32-year-old woman presents with polycystic ovary syndrome, menstrual irregularity, and difficulty conceiving for 15 months. Although specific conditions are identified, the functional diagnosis of infertility is established by the period of unsuccessful attempts, making GA31 the appropriate primary code.

Scenario 4: Initial evaluation of infertility A 38-year-old patient seeks specialized care after 12 months of unsuccessful pregnancy attempts. Even before completion of all etiological investigation, the diagnosis of infertility can already be established based on temporal criteria and the patient's age, which justifies earlier investigation.

Scenario 5: Infertility in women of advanced maternal age A 41-year-old woman reports 8 months of conception attempts. Considering advanced maternal age as a risk factor, investigation is initiated early. After confirmation that no pregnancy occurred after the period of attempts and considering the age factor, GA31 is appropriate even before 12 complete months.

Scenario 6: Infertility after treatment of gynecological condition A 30-year-old patient who underwent surgery for removal of uterine fibroid 2 years ago, without success in conceiving during the last 13 months of regular attempts. Infertility is established regardless of surgical history, justifying GA31.

4. When NOT to Use This Code

It is fundamental to understand the situations where GA31 is not the appropriate code, avoiding coding errors:

Male infertility as primary factor: When the couple's investigation reveals that male factors (severe oligospermia, azoospermia, erectile dysfunction) are the main or only ones responsible for the inability to conceive, the appropriate code is not GA31, but rather the specific codes for male infertility. This distinction is crucial for epidemiological statistics and treatment direction.

Relative infertility or subfertility: In cases where there is reduced fertility but not complete infertility, or when temporal criteria are not fully met, alternative codes may be more appropriate. Relative infertility implies diminished but not absent reproductive capacity.

Insufficient period of attempts: Couples seeking evaluation after only 6-8 months of attempts, without specific risk factors such as advanced age, do not meet diagnostic criteria. In these cases, guidance and follow-up are more appropriate than formal diagnosis of infertility.

Inconsistent use of contraceptive methods: When there is a report of conception attempts, but investigation reveals intermittent use of contraceptive methods or very sporadic sexual relations, the criteria for "regular attempts" are not met, invalidating the diagnosis of infertility.

Gynecological conditions without proven reproductive impact: The presence of conditions such as small functional ovarian cysts or asymptomatic fibroids, without documentation of conception attempts for an adequate period, does not justify the infertility code. Coding should reflect the specific condition identified.

Personal choice not to conceive: Women who are not actively trying to become pregnant, even with conditions that may affect fertility, should not receive code GA31, as the diagnosis requires documented active attempts.

5. Coding Step by Step

Step 1: Assess Diagnostic Criteria

The first fundamental step is to confirm that the diagnostic criteria established by the World Health Organization are met. This requires clear documentation of:

Detailed reproductive history: Investigate the exact timing of conception attempts, frequency of sexual intercourse (ideally 2-3 times per week), absence of contraceptive use, and history of previous pregnancies. Question about menstrual regularity, cycle duration, and associated symptoms.

Complete clinical evaluation: Gynecological physical examination, body mass index assessment, signs of hyperandrogenism, and investigation of medical conditions that may affect fertility such as thyroid disorders, diabetes, or hyperprolactinemia.

Basic laboratory investigation: Hormonal dosages including follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, prolactin, thyroid hormones, and when indicated, anti-müllerian hormone for assessment of ovarian reserve. These evaluations should be performed at specific times of the menstrual cycle.

Imaging evaluation: Transvaginal ultrasound to assess uterine morphology, presence of fibroids, polyps, endometrial thickness, and antral follicle count. When indicated, hysterosalpingography to assess tubal patency.

Step 2: Verify Specifiers

After confirming the diagnosis, it is essential to document specifiers that influence management:

Duration of infertility: Specify whether infertility has persisted for 12-24 months, 24-36 months, or more than 36 months, as this impacts the urgency and aggressiveness of treatment.

Type of infertility: Classify as primary (no previous pregnancy) or secondary (infertility after previous successful pregnancy), as prognosis and approach may differ.

Patient age: Document age precisely, especially if over 35 years, as this is a crucial prognostic factor that affects therapeutic options and success rates.

Identified causal factors: When possible, specify whether there is ovulatory, tubal, uterine, cervical, or unexplained factor, using complementary codes when appropriate.

Step 3: Differentiate from Other Codes

Inflammatory disorders of the female genital tract: These conditions, such as pelvic inflammatory disease, salpingitis, or endometritis, are acute or chronic infectious or inflammatory processes. The key difference is that they represent specific pathological processes that may cause infertility, but are not synonymous with it. If a patient has active pelvic inflammatory disease, this specific code should be used, with GA31 being added if infertility is documented.

GA10 - Endometriosis: Endometriosis is a specific condition characterized by the presence of endometrial tissue outside the uterine cavity. Although frequently associated with infertility, endometriosis is a specific anatomical and histological diagnosis. A patient may have endometriosis without infertility (if not attempting to conceive or conceives despite the condition) or have infertility without endometriosis. When both are present and documented, both codes should be used.

GA11 - Adenomyosis: Similar to endometriosis, adenomyosis is a specific structural condition where the endometrium invades the myometrium. It is an anatomopathological diagnosis that may or may not be associated with infertility. The GA11 code should be used when adenomyosis is diagnosed (usually by specialized ultrasound or magnetic resonance imaging), while GA31 is added if infertility criteria are met.

Step 4: Necessary Documentation

Checklist of mandatory information:

Date of onset of conception attempts
Frequency of sexual intercourse
Confirmation of absence of contraception
Detailed menstrual history
Results of complementary examinations
Partner evaluation (even if summarized)
Patient's precise age
Previous reproductive history
Associated medical conditions
Previous infertility treatments, if any

Adequate medical record documentation: Documentation should include clear narrative establishing the diagnosis of infertility, explicitly mentioning the period of attempts, criteria met, and clinical reasoning. Also include the plan for additional investigation and therapeutic options discussed with the patient.

6. Complete Practical Example

Clinical Case

Initial presentation: A 33-year-old female patient seeks consultation at a human reproduction service with a complaint of inability to become pregnant. She reports being in a stable relationship for 5 years and that 16 months ago the couple decided to have children, discontinuing oral contraceptive use that she had been using for 10 years. Since then, she maintains regular sexual relations, approximately 3 times per week, without use of any contraceptive method.

The patient reports menstrual cycles that regularized 3 months after contraceptive discontinuation, currently with intervals of 28-32 days, duration of 4-5 days, moderate flow without clots. She denies severe dysmenorrhea, dyspareunia, or intermenstrual bleeding. She has no history of previous pregnancies, miscarriages, or sexually transmitted diseases. She denies previous pelvic surgeries.

Evaluation performed: On physical examination, the patient presents with a body mass index of 24 kg/m², without signs of hyperandrogenism. Gynecological examination reveals external genitalia without alterations, speculum examination shows a cervix of normal appearance, and bimanual examination does not identify masses or increased sensitivity.

Initial complementary investigation was requested including hormonal dosages on the third day of the cycle: FSH 8.2 mIU/mL (normal), LH 5.1 mIU/mL (normal), estradiol 45 pg/mL (normal), prolactin 18 ng/mL (normal), TSH 2.1 mIU/L (normal). Anti-müllerian hormone measured at 1.8 ng/mL, indicating adequate ovarian reserve for her age.

Transvaginal ultrasound demonstrates a uterus of normal dimensions, regular contours, without fibroids or polyps. Endometrium 8 mm in thickness (proliferative phase). Ovaries of normal appearance, with antral follicle count of 12 on the right and 10 on the left. Absence of cysts or adnexal masses.

Hysterosalpingography performed showed a uterine cavity with regular contours, without filling defects, with bilateral tubal patency, although with discrete delay in filling of the left fallopian tube.

Semen analysis of the partner revealed volume of 3.2 mL, concentration of 18 million/mL, progressive motility of 38%, normal forms of 5% (strict criteria), compatible with borderline parameters but within values that permit natural conception.

Diagnostic reasoning: The patient clearly meets the diagnostic criteria for infertility: a period of 16 months of conception attempts with regular sexual relations without contraception, exceeding the 12-month limit established. The age of 33 years falls within a range where fertility already shows decline, although still with reasonable prognosis.

Initial investigation revealed no obvious causes of infertility. Ovarian reserve is adequate, ovulatory function apparently preserved by regular cycles, uterine anatomy is normal, and there is bilateral tubal patency. The partner's semen analysis, although borderline, would not contraindicate natural conception.

The discrete delay in filling of the left fallopian tube may suggest some tubal functional compromise, possibly related to mild adhesions or alteration in tubal motility, but without complete obstruction. This could be a contributing factor, but would not completely explain bilateral infertility.

This case represents what we frequently call "infertility of unknown cause" or "unexplained infertility," where despite adequate investigation, no obvious cause is identified. It represents approximately 15-30% of infertility cases.

Coding Step by Step

Criteria analysis:

Period of attempts: 16 months - ✓ Meets criteria (>12 months)
Regular sexual relations: 3x/week - ✓ Meets criteria
Absence of contraception: Confirmed - ✓ Meets criteria
Failure to achieve clinical pregnancy: Confirmed - ✓ Meets criteria
Documented female factor: Complete investigation - ✓ Meets criteria

Code chosen: GA31 - Female infertility

Complete justification: The code GA31 is appropriate because all diagnostic criteria established by the ICD-11 definition are met. The patient presents with failure to achieve clinical pregnancy after a period exceeding 12 months of regular unprotected sexual relations. The investigation performed rules out severe male factors as the sole factor, and identifies infertility as primarily related to female factors, although the specific cause is not completely elucidated.

The patient's age (33 years) and duration of infertility (16 months) are important specifiers that should be documented in the medical record, as they influence therapeutic decisions. The possible discrete tubal compromise identified on hysterosalpingography does not justify an additional specific code, as there is no documented complete tubal obstruction.

Complementary codes: In this specific case, there is no need for additional mandatory codes, as no comorbid conditions requiring separate coding were identified. If during follow-up a specific tubal factor or other condition is confirmed, additional codes may be added.

7. Related Codes and Differentiation

Within the Same Category

Inflammatory disorders of the female genital tract: These codes should be used when there is evidence of active or chronic inflammatory or infectious process affecting the uterus, fallopian tubes, ovaries, or pelvic structures. The main difference in relation to GA31 is that inflammatory disorders represent specific pathological processes with their own clinical, laboratory, and imaging characteristics, while GA31 is a functional diagnosis of reproductive incapacity. A patient may have a history of previous pelvic inflammatory disease that resulted in infertility; in this case, if the inflammatory process is inactive, only GA31 would be coded at the present time.

GA10 - Endometriosis: Endometriosis should be coded when there is diagnostic confirmation of this specific condition, whether by direct visualization (laparoscopy), characteristic imaging findings, or strongly suggestive clinical markers. The main difference is that endometriosis is a specific anatomopathological diagnosis, while infertility is functional. Approximately 25-50% of women with infertility have endometriosis, and 30-50% of women with endometriosis experience infertility. When both conditions are present and documented, both codes should be used, with GA10 specifying the probable cause of infertility coded as GA31.

GA11 - Adenomyosis: Adenomyosis is diagnosed when there is evidence of endometrial invasion into the myometrium, usually identified by specialized ultrasound, magnetic resonance imaging, or histopathological examination post-hysterectomy. The essential difference is that adenomyosis is a specific structural alteration of the uterus, while infertility is the functional consequence. Women with adenomyosis may or may not have infertility, depending on the severity of the condition and other factors. When adenomyosis is diagnosed in a patient who also meets criteria for infertility, both codes are appropriate.

Differential Diagnoses

Subfertility versus infertility: Subfertility implies reduced but not absent fertility, often used when there are factors that decrease the chances of conception but do not prevent it completely. The distinction may be subtle, but generally infertility (GA31) is reserved for cases where there is complete failure to conceive after an adequate period.

Sterility: A historical term that implies permanent and irreversible inability to conceive, different from infertility which may be temporary or treatable. ICD-11 prefers the term infertility, being more clinically appropriate.

Delay in conceiving: Couples who take longer than average to conceive (usually 6-12 months) but still within the period considered normal should not receive the infertility code until the temporal criteria are met.

8. Differences with ICD-10

In ICD-10, female infertility was coded primarily as N97, with subcategories specifying the type: N97.0 for female infertility associated with anovulation, N97.1 for female infertility of tubal origin, N97.2 for female infertility of uterine origin, N97.3 for female infertility of cervical origin, N97.4 for female infertility associated with male factors, N97.8 for other forms of female infertility, and N97.9 for unspecified female infertility.

The main change in ICD-11 with code GA31 is the more integrated and hierarchical approach to classification. While ICD-10 fragmented infertility into multiple codes based on etiology, ICD-11 offers a primary code (GA31) with the possibility of specification through subcategories and complementary codes, allowing greater flexibility and precision.

Another significant difference is the clearer definition aligned with World Health Organization criteria, explicitly specifying the 12-month period of attempts and emphasizing the importance of documenting factors such as age and associated medical conditions. ICD-10 was less specific in these aspects.

The practical impact of these changes includes greater uniformity in coding across different services and countries, improved epidemiological tracking, and facilitation of international comparative research. For healthcare professionals, the transition requires familiarity with the new hierarchical structure and understanding of when to use the primary code versus more specific codes.

ICD-11 also allows better integration with electronic health record systems, facilitating structured documentation and information retrieval for clinical and research purposes.

9. Frequently Asked Questions

How is female infertility diagnosed? The diagnosis of female infertility is established primarily by clinical history, confirming that conception attempts have occurred for at least 12 months (or 6 months in women over 35 years of age) with regular sexual intercourse without contraceptive use, without success in achieving pregnancy. After establishing this temporal criterion, investigation proceeds to identify possible causes, including evaluation of ovulation through hormonal assays, evaluation of uterine anatomy and tubal patency through ultrasound and hysterosalpingography, and evaluation of ovarian reserve. The investigation should also include evaluation of the male partner through semen analysis. It is important to understand that the diagnosis of infertility is clinical and temporal, while subsequent investigation seeks to identify treatable causes.

Is infertility treatment available in public health systems? The availability of infertility treatments in public health systems varies considerably among different regions and countries. Many public systems offer basic infertility investigation, including laboratory tests, ultrasound, and guidance on optimizing natural fertility. Lower complexity treatments, such as ovulation induction with oral medications, are often available. However, higher complexity treatments such as in vitro fertilization may have limited availability, long waiting lists, or specific eligibility criteria. Some systems offer partial coverage or a limited number of treatment cycles. It is recommended that patients specifically investigate the resources available in their local health systems.

How long does infertility treatment last? The duration of infertility treatment is highly variable and depends on multiple factors, including the identified cause, the woman's age, the severity of the condition, and the response to initial treatments. Simpler treatments, such as ovulation induction, may be attempted for 3-6 menstrual cycles (3-6 months). If unsuccessful, progression to more complex treatments may occur. Intrauterine insemination is generally attempted for 3-4 cycles before considering in vitro fertilization. Each in vitro fertilization cycle takes approximately 4-6 weeks from the start of stimulation to the pregnancy test. Many couples require multiple treatment cycles. Overall, the complete process from diagnosis to achieving pregnancy can take from several months to several years, depending on the complexity of the case and response to treatments.

Can this code be used in medical certificates and work documentation? Yes, the code GA31 can and should be used in official medical documentation, including certificates when appropriate. Infertility is recognized as a legitimate medical condition that may require time off work for diagnostic or therapeutic procedures. Many assisted reproduction treatments require frequent visits for monitoring, egg retrieval, embryo transfer, and surgical procedures that justify medical certificates. Proper documentation with the correct ICD-11 code strengthens the legitimacy of the certificate and may be necessary to justify absences to employers. Furthermore, in many jurisdictions, infertility is recognized as a condition that may justify medical leave or workplace accommodations during treatment.

What is the difference between primary and secondary infertility? Primary infertility refers to a situation where a woman has never been able to achieve pregnancy, despite adequate attempts. Secondary infertility occurs when a woman who has had one or more successful pregnancies in the past now faces difficulty conceiving again. Although both are coded as GA31, the distinction is clinically important and should be documented. Secondary infertility may be caused by age-related factors (decline in ovarian reserve over the years), complications from previous pregnancies or deliveries, development of new medical conditions, or change of partner with different male factors. The prognosis may differ between the two types, with primary infertility sometimes indicating more complex conditions, although this is not an absolute rule.

Is female infertility always permanent? No, female infertility is frequently not permanent and may be treatable or even resolve spontaneously in some cases. Many causes of infertility are reversible with appropriate treatment: ovulatory disorders may respond to medications, tubal obstructions may be corrected surgically, conditions such as endometriosis may be treated, and even when conventional treatments are not effective, assisted reproduction technologies offer possibilities for pregnancy. There is also the phenomenon of spontaneous pregnancies after an infertility diagnosis, even in cases classified as unexplained. However, some conditions such as premature ovarian failure or anatomical absence of reproductive structures may represent permanent infertility. Individual prognosis depends on the specific cause, patient's age, duration of infertility, and response to treatments.

How does age affect female infertility? Age is one of the most significant factors affecting female fertility. A woman's natural fertility begins to decline gradually after age 30, with more pronounced decline after age 35 and dramatic decline after age 40. This occurs primarily due to the decrease in quantity and quality of eggs with aging. Younger women have a higher probability of conceiving naturally and respond better to fertility treatments. For this reason, diagnostic criteria for infertility are more flexible for women over 35 years of age, recommending investigation after only 6 months of attempts rather than 12 months. Age also affects success rates of assisted reproduction treatments and the risk of gestational complications. Therefore, the patient's age should always be documented when coding infertility, as it significantly influences management and prognosis.

Is it necessary to investigate the male partner before coding female infertility? Ideally, yes. Infertility is a condition of the couple, not just the woman, and approximately one-third of cases have contribution from male factors. The initial evaluation of the infertile couple should include semen analysis of the male partner, which is a non-invasive and relatively simple examination. Identifying significant male factors is important because it can completely alter the therapeutic approach. However, the code GA31 is appropriate when female factors are identified as primary or when there is mixed contribution, but with significant female component. If investigation reveals that male factors are the sole or primary cause of infertility, specific codes for male infertility would be more appropriate. In clinical practice, investigation of both partners should occur simultaneously to optimize time and direct treatment appropriately.

Conclusion:

Proper coding of female infertility using the ICD-11 code GA31 is fundamental for appropriate clinical management, accurate documentation, and epidemiological tracking of this condition that affects millions of women globally. Understanding the diagnostic criteria, appropriate situations for use, and necessary differentiations in relation to other codes enables healthcare professionals to correctly document this complex condition, facilitating access to appropriate treatments and contributing to research and public policies aimed at reproductive health.

External References

This article was prepared based on reliable scientific sources:

References verified on 2026-02-03

Female Infertility

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