Infertility Evaluation Guide

This guide from Param Maternity & Surgical Nursing Home explains the infertility evaluation process, covering definitions, causes, symptoms, risk factors, and the diagnostic steps for both partners. Learn when to seek help, what tests to expect, and how to prepare for your fertility journey.

Published: July 29, 2024•Updated: July 29, 2024

Understanding Infertility Evaluation

If you're trying to conceive and finding it challenging, you're not alone. Infertility affects many couples, and understanding the evaluation process is the first step towards finding answers and solutions. This guide from Param Maternity & Surgical Nursing Home is designed to help you navigate the journey of infertility evaluation, explaining what to expect, why certain tests are done, and when to seek specialist care.

What is Infertility?

Infertility is defined as the inability to achieve a clinical pregnancy after 12 months or more of regular, unprotected sexual intercourse. For women over 35, this timeframe is often shortened to 6 months before evaluation and treatment may begin. Immediate evaluation is also recommended if you have known conditions that affect fertility, such as irregular periods, a history of certain medical treatments, or known male fertility issues. (Source: WHO, ACOG, ASRM)

Primary Infertility: This means a couple has never achieved a pregnancy.
Secondary Infertility: This applies to couples who have had at least one prior pregnancy but are now struggling to conceive again.

Sometimes, you might hear the term "subfertility," which generally refers to any reduced fertility that leads to a longer time to conceive. These terms are often used interchangeably in some guidelines. (Source: NICE)

When Should You Seek Medical Help?

The general recommendation is to consult a doctor if you haven't conceived after:

12 months of regular, unprotected intercourse if the woman is under 35 years old.
6 months of regular, unprotected intercourse if the woman is 35 years or older.

You should also seek immediate evaluation if you have conditions known to affect fertility, such as very irregular or absent periods, a history of chemotherapy or radiation, severe endometriosis, or if your partner has known fertility issues. (Source: ACOG, ASRM)

What Causes Infertility?

Infertility can stem from factors affecting either partner, or a combination of both. It's important to remember that it's rarely "one person's fault."

Female Factors (approximately 30-40% of cases)

Ovulation Problems: Issues with releasing an egg regularly. This can be due to conditions like Polycystic Ovary Syndrome (PCOS), problems with ovarian reserve (the number and quality of eggs), or thyroid disorders. (Source: ACOG)
Tubal Factors: Blocked or damaged fallopian tubes, which prevent the egg and sperm from meeting. This can result from infections (like Pelvic Inflammatory Disease), previous surgeries, or endometriosis. (Source: ACOG)
Uterine or Cervical Factors: Problems with the uterus (womb) or cervix. These might include fibroids, polyps, or structural abnormalities of the uterus. (Source: ASRM)
Endometriosis: A condition where tissue similar to the lining of the uterus grows outside it, which can cause inflammation and scarring. (Source: RCOG)

Male Factors (approximately 30-40% of cases)

Sperm Production or Function Issues: Problems with the number, movement (motility), or shape (morphology) of sperm. Causes can include varicoceles (enlarged veins in the scrotum), hormonal imbalances, genetic conditions, or testicular damage. (Source: ASRM)
Sperm Transport Issues: Blockages in the tubes that carry sperm, often due to infections, previous surgeries (like vasectomy), or congenital conditions. (Source: ASRM)

Combined Factors (10-20% of cases)

Sometimes, both partners have factors contributing to infertility. (Source: NICE)

Unexplained Infertility (10-20% of cases)

In some cases, despite a thorough evaluation, no specific cause for infertility is found. This is known as unexplained infertility. (Source: ACOG, NICE)

What are the Symptoms of Infertility?

The main symptom of infertility is simply not being able to get pregnant after the recommended time frame. Often, there are no other obvious signs.

Symptoms in Women that Might Suggest an Underlying Cause:

Irregular, infrequent, or absent periods: This is a strong indicator of ovulation problems, such as PCOS. (Source: ACOG)
Painful periods, pelvic pain, or pain during intercourse: These can be signs of conditions like endometriosis or uterine fibroids. (Source: RCOG)
Excessive hair growth (hirsutism) or severe acne: May suggest hormonal imbalances, often seen with PCOS. (Source: ASRM)
Milky nipple discharge (galactorrhea): Could indicate high prolactin levels. (Source: ASRM)

Symptoms in Men that Might Suggest an Underlying Cause:

Often, men have no noticeable symptoms other than the inability to conceive. However, some signs might include:

Pain, swelling, or a lump in the testicle area: Could indicate a varicocele or infection. (Source: Mayo Clinic)
Problems with sexual function: Such as erectile dysfunction, difficulty with ejaculation, or low sex drive. (Source: ASRM)
Recurrent respiratory infections: In rare cases, this can be linked to certain genetic conditions affecting sperm transport. (Source: ASRM)

Red Flag Symptoms: Seek immediate medical attention for sudden, severe testicular pain (which could be testicular torsion), severe debilitating pelvic pain, or headaches and visual disturbances combined with absent periods and milky nipple discharge (which might suggest a pituitary issue).

Risk Factors for Infertility

Several factors can increase the risk of infertility. Some you can change, and some you cannot.

Modifiable Risk Factors (Things you can change)

Weight: Being significantly underweight (BMI <19) or overweight/obese (BMI >30) can affect fertility in both men and women. (Source: ASRM, NICE)
Smoking: Tobacco use by either partner significantly harms fertility. (Source: ASRM, NICE)
Alcohol: Excessive alcohol intake (more than 1 drink/day for women, more than 2 drinks/day for men) can negatively impact fertility. (Source: ASRM)
Substance Use: Illicit drugs, including marijuana and anabolic steroids, can impair sperm production and ovulation. (Source: ASRM)
Environmental/Occupational Exposures: Contact with certain pesticides, solvents, heavy metals, or excessive heat (for men) can be harmful. (Source: CDC)

Non-Modifiable Risk Factors (Things you cannot change)

Female Age: This is the most significant factor. Ovarian function and egg quality naturally decline after age 35. (Source: ACOG, RCOG)
Medical History (Female): Conditions like PCOS, endometriosis, pelvic inflammatory disease, uterine fibroids, premature ovarian insufficiency, and thyroid disorders. (Source: ACOG)
Medical History (Male): History of testicular trauma, undescended testicles, varicocele, mumps after puberty, or cancer treatments (chemotherapy, radiation). (Source: ASRM)
Genetic Factors: Certain chromosomal abnormalities or gene mutations. (Source: ASRM)

Areas of Uncertainty: While severe stress can affect hormones, the direct link between common life stress and infertility is not well-established. Similarly, no specific diet has been conclusively proven to improve fertility, though a balanced, healthy diet is always recommended. (Source: ASRM)

The Infertility Evaluation Process

A comprehensive evaluation involves both partners and aims to identify any factors contributing to difficulty conceiving. The process is systematic, concurrent, and designed to be as efficient as possible. (Source: ACOG, ASRM)

Initial Assessment for Both Partners

Detailed History: Your doctor will ask about your medical, surgical, sexual, and family history, including menstrual cycles (for women), coital frequency and timing, lifestyle habits (smoking, alcohol), and how long you've been trying to conceive. (Source: ACOG, NICE)
Physical Examination: A general physical exam for both partners, including a pelvic exam for women and a genital exam for men. (Source: ACOG, ASRM)

Female Evaluation

For women, the evaluation focuses on three key areas:

1. Assessment of Ovulation

This determines if you are regularly releasing an egg.

Menstrual Cycle History: Regular periods are a good sign of ovulation.
Blood Tests: A mid-luteal phase serum progesterone level can confirm ovulation.
At-Home Tests: Urinary luteinizing hormone (LH) detection kits can help predict ovulation. (Source: ACOG)

2. Assessment of Ovarian Reserve

This helps estimate the number and quality of eggs remaining in your ovaries.

Blood Tests: Basal (early cycle) Follicle-Stimulating Hormone (FSH) and estradiol levels, and Anti-Müllerian Hormone (AMH) levels are commonly checked.
Ultrasound: A transvaginal ultrasound can count the number of small follicles (antral follicle count or AFC) in your ovaries.

It's important to know that no single test perfectly predicts your ability to conceive naturally. Ovarian reserve tests primarily indicate how your ovaries might respond to fertility medications. (Source: ASRM)

3. Assessment of Pelvic Anatomy

This checks for any structural issues in your uterus or fallopian tubes.

Hysterosalpingography (HSG): An X-ray procedure where dye is injected into the uterus to see if the fallopian tubes are open and to check the shape of the uterine cavity.
Saline Infusion Sonohysterography (SIS or SHG): An ultrasound procedure where saline is infused into the uterus to get a clearer view of the uterine lining for polyps or fibroids.
Hysterosalpingo-contrast-sonography (HyCoSy): An ultrasound alternative to HSG using a contrast agent.
Laparoscopy: A surgical procedure (keyhole surgery) that is considered the most accurate way to assess tubal and pelvic problems like endometriosis or adhesions. However, it is invasive and usually not the first test performed. (Source: RCOG)

Other Female Laboratory Tests

These may include thyroid-stimulating hormone (TSH) and prolactin levels, and screening for infectious diseases like chlamydia. (Source: ACOG)

Male Evaluation

The male evaluation is crucial and typically starts with a semen analysis.

Semen Analysis: This is the most important test for men. It measures the volume of semen, the number of sperm (concentration/count), how well they move (motility), and their shape (morphology). If the first analysis is abnormal, at least one more is usually recommended. (Source: ASRM, WHO)
Hormonal Evaluation: If semen analysis results are abnormal, or if there are other clinical concerns, blood tests for total testosterone, FSH, and LH may be done. (Source: ASRM)
Scrotal Ultrasound: May be used if a physical abnormality, such as a varicocele, is suspected. (Source: ASRM)
Genetic Testing: For men with very low sperm counts or no sperm, genetic tests like karyotyping or Y-chromosome microdeletion analysis might be recommended. (Source: ASRM)

Differences in Guidelines

It's worth noting that different national guidelines may have slightly different recommendations. For example, UK guidelines (NICE) generally recommend against routine use of basal FSH for predicting conception and against routine hysteroscopy unless there's a specific clinical reason. In contrast, US guidelines (ACOG/ASRM) often include ovarian reserve testing (AMH, AFC, FSH) as part of the initial workup, especially for women over 35 or with other risk factors. (Source: NICE, ACOG, ASRM)

What Happens After Evaluation? (Brief Overview of Treatment)

While this guide focuses on evaluation, it's helpful to know what comes next. Based on the evaluation results, your doctor will discuss potential treatment options. Referral to a reproductive endocrinologist or fertility specialist is often recommended in specific situations, such as for women over 40, or after 6-12 months of trying to conceive depending on age and identified factors. (Source: ACOG, NICE)

Treatment modalities can include:

Lifestyle Modifications: Optimizing weight, quitting smoking, reducing alcohol.
Medical Treatments: Medications to induce ovulation.
Surgical Treatments: Procedures to correct issues like endometriosis, fibroids, or varicoceles.
Assisted Reproductive Technology (ART): Such as Intrauterine Insemination (IUI) or In Vitro Fertilization (IVF). (Source: NICE, ACOG)

Potential Complications and Emotional Impact

The journey through infertility evaluation and treatment can be emotionally challenging.

Emotional and Social Impact

Infertility can lead to significant emotional distress, including anxiety, depression, grief, and feelings of guilt. It can also strain relationships and lead to social isolation. Support and counseling are often beneficial. (Source: ASRM)

Complications of Evaluation and Treatment

During Evaluation: Procedures like HSG can cause pelvic cramping, and there's a small risk of infection or allergic reaction.
From Medications: Ovulation induction medications carry a risk of Ovarian Hyperstimulation Syndrome (OHSS), which can range from mild bloating to more severe, though rare, complications. (Source: RCOG)
Surgical Risks: Any surgery carries standard risks like bleeding, infection, and anesthesia complications.
Long-Term Risks: Fertility treatments, especially ovulation induction and IVF, increase the risk of multiple pregnancies (twins, triplets), which carry higher risks for both mother and babies (e.g., preterm birth). There's also a slightly increased risk of ectopic pregnancy after ART. (Source: ACOG)

The long-term risk of certain cancers after fertility drug use is an area of ongoing research, but most large studies have not shown a significant independent risk after accounting for underlying conditions. (Source: ASRM)

Preventing Infertility

While not all causes of infertility are preventable, some steps can help protect your reproductive health.

Primary Prevention (Before trying to conceive)

Healthy Lifestyle: Maintain a healthy weight, avoid smoking, and limit alcohol and illicit drug use. (Source: ASRM)
Sexual Health: Practice safe sex to prevent sexually transmitted infections (STIs) like chlamydia and gonorrhea, which can damage fallopian tubes. (Source: CDC)
Vaccination: Ensure you are vaccinated against mumps, as mumps after puberty can impair male fertility. (Source: CDC)

Secondary Prevention (Early action)

Early Evaluation: Seek timely medical advice for conditions that might affect fertility, such as irregular periods, persistent pelvic pain, or testicular concerns. (Source: ACOG)
Fertility Preservation: If you are facing medical treatments (like chemotherapy) that could harm your fertility, discuss options like egg, sperm, or embryo freezing with your doctor beforehand. (Source: ASRM)

Prognosis and Success Rates

The likelihood of achieving pregnancy depends on many factors, including the specific cause of infertility, the woman's age, ovarian reserve, and the chosen treatment.

Natural Conception: For couples with unexplained infertility, there's still a chance of spontaneous conception, though this decreases with age and duration of infertility. (Source: NICE)
Treatment Success: Success rates for treatments like IVF vary significantly based on age and diagnosis. For example, live birth rates per IVF cycle are generally higher for women under 35 (often over 40-50%) and decrease with age (less than 5-10% for women over 42). Your fertility specialist can provide specific success rates relevant to your situation. (Source: SART)

It's important to have realistic expectations and discuss your individual prognosis with your healthcare team.

Frequently Asked Questions

When should we seek medical help for not being able to conceive?

If the woman is under 35, seek help after 12 months of regular, unprotected intercourse. If the woman is 35 or older, seek help after 6 months. Immediate evaluation is also recommended if you have known conditions affecting fertility, such as very irregular periods, a history of chemotherapy, severe endometriosis, or known male factor infertility. (Source: ACOG, ASRM)

What are the first steps in an infertility evaluation?

The first steps involve a comprehensive medical, surgical, sexual, and family history for both partners, along with physical examinations. Initial tests typically include semen analysis for men and assessment of ovulation, ovarian reserve, and pelvic anatomy for women. (Source: ACOG, ASRM, NICE)

Do both my partner and I need to be tested?

Yes, a comprehensive infertility evaluation should involve both partners concurrently, as factors contributing to infertility can affect either or both individuals. (Source: ACOG, ASRM)

What does a semen analysis measure and what is considered normal?

A semen analysis measures the volume of semen, the concentration (count) of sperm, their motility (movement), and their morphology (shape). Normal values are based on established criteria, such as those from the WHO, and your doctor will interpret your specific results. (Source: ASRM, WHO)

How do you check if my fallopian tubes are open and is the test painful?

Fallopian tube patency is typically checked using procedures like Hysterosalpingography (HSG), Saline Infusion Sonohysterography (SIS), or Hysterosalpingo-contrast-sonography (HyCoSy). These tests involve injecting a dye or saline into the uterus to visualize the tubes. They can cause pelvic cramping, which some women find uncomfortable or painful, but it is usually brief. (Source: ACOG, RCOG)

What is 'ovarian reserve' and how is it measured?

Ovarian reserve refers to the number and quality of eggs remaining in a woman's ovaries. It is measured through blood tests for hormones like Basal FSH, estradiol, and Anti-Müllerian Hormone (AMH), as well as by a transvaginal ultrasound to count antral follicles (AFC). (Source: ASRM)

How much does female age impact the chances of getting pregnant?

Female age is the single most important factor affecting fertility. Ovarian function and egg quality naturally decline significantly after age 35, making it more challenging to conceive and increasing the risk of miscarriage. (Source: ACOG, RCOG)

Can my weight or my partner's weight affect our fertility?

Yes, being significantly underweight (BMI <19) or overweight/obese (BMI >30) can negatively impact fertility in both men and women. This can affect hormone balance, ovulation in women, and sperm production in men. (Source: ASRM, NICE)

What specific lifestyle changes can we make to improve our chances?

Key lifestyle changes include maintaining a healthy Body Mass Index (BMI), quitting smoking, reducing excessive alcohol consumption, and avoiding illicit drug use. Practicing safe sex to prevent STIs and ensuring vaccinations like MMR are up-to-date can also protect fertility. (Source: ASRM, NICE, CDC)

Is infertility more often a female problem or a male problem?

Infertility is equally common in men and women. Female factors contribute to approximately 30-40% of cases, and male factors contribute to another 30-40%. In 10-20% of cases, both partners have contributing factors, and in 10-20%, no cause is identified (unexplained infertility). (Source: ACOG, ASRM, NICE)

What does it mean if we are diagnosed with 'unexplained infertility'?

Unexplained infertility means that after a comprehensive standard evaluation, no specific cause for the difficulty in conceiving has been identified in either partner. While frustrating, many couples with unexplained infertility can still achieve pregnancy, sometimes with treatment or even spontaneously. (Source: ACOG, NICE)

What are the main differences between IUI and IVF?

Intrauterine Insemination (IUI) involves placing specially prepared sperm directly into the woman's uterus around the time of ovulation. In Vitro Fertilization (IVF) is a more complex process where eggs are retrieved from the woman, fertilized with sperm in a laboratory, and then the resulting embryo(s) are transferred into the uterus. (Source: ACOG)

What are the success rates for different fertility treatments?

Success rates for fertility treatments vary significantly based on the specific treatment, the underlying cause of infertility, and most importantly, the woman's age. For example, IVF success rates are generally higher for younger women and decrease with age. Your fertility specialist can provide personalized success rates relevant to your situation. (Source: SART)

How long does the entire evaluation process typically take?

The initial infertility evaluation for both partners can often be completed within one to two menstrual cycles for women, alongside male testing. However, if further specialized tests, procedures, or referrals to specialists are required, the entire process can extend over several months. (Source: ACOG, ASRM)

Can stress cause infertility?

While severe psychological stress can affect hormone levels and ovulation, the direct link between common life stress and infertility is not well-established. However, managing stress is beneficial for overall health and well-being during the fertility journey. (Source: ASRM)

I have very irregular periods. Does this automatically mean I am infertile?

Very irregular, infrequent, or absent menstrual periods strongly suggest an ovulatory disorder, which is a common cause of infertility. While it doesn't automatically mean you are infertile, it does warrant an early medical evaluation to identify the cause and discuss potential treatments. (Source: ACOG)

Did my past use of hormonal birth control cause my current fertility issues?

No, hormonal birth control does not cause long-term infertility. Once you stop using it, your natural fertility typically returns. Any difficulty conceiving after discontinuing birth control is usually due to underlying fertility factors that were present before or developed independently. (Source: ASRM)

What are the risks and side effects of fertility medications like Clomid?

Fertility medications used for ovulation induction, such as clomiphene citrate, carry risks including an increased chance of multiple pregnancies (twins, triplets) and a potential for Ovarian Hyperstimulation Syndrome (OHSS), which can range from mild to severe. Your doctor will discuss these and other potential side effects with you. (Source: RCOG)

What is PCOS and how does it affect my ability to get pregnant?

Polycystic Ovary Syndrome (PCOS) is a common hormonal disorder that is a leading cause of ovulatory infertility. It often leads to irregular or absent ovulation, making it difficult to conceive naturally. PCOS can also be associated with symptoms like irregular periods, excess hair growth, and acne. (Source: ACOG, ASRM)

Are there any non-medical or alternative therapies that can help with fertility?

While maintaining a balanced, healthy diet and adopting positive lifestyle modifications (like healthy weight, avoiding smoking and excessive alcohol) are recommended, no specific non-medical or alternative therapies have been conclusively proven to improve fertility in the general population. Always discuss any alternative therapies with your doctor. (Source: ASRM)

If we need IVF, how many cycles does it usually take to be successful?

The number of IVF cycles required for success varies significantly among individuals. Success rates are reported per cycle and are influenced by factors such as the woman's age, the cause of infertility, and the specific clinic. Many couples may require more than one cycle to achieve a successful pregnancy. Your fertility specialist can provide personalized information based on national data and your unique situation. (Source: SART)