Infertility is formally diagnosed after 12 months of regular unprotected intercourse without achieving pregnancy. That timeline shortens to 6 months for women over 35 and may prompt immediate evaluation for women over 40. But the diagnosis itself is really just a starting point. The real work is a series of tests designed to find out why pregnancy isn’t happening, and those tests evaluate both partners at the same time.
When Testing Should Start
The 12-month and 6-month timelines apply to couples with no known risk factors. Testing should begin right away, regardless of how long you’ve been trying, if you have irregular or absent periods, a known uterine or fallopian tube condition, endometriosis, a history of chemotherapy or radiation, or a suspected male factor like prior testicular injury or surgery. Sexual dysfunction that affects intercourse also warrants earlier evaluation.
The American Society for Reproductive Medicine recommends that evaluation proceed in a systematic, cost-effective way, starting with the least invasive tests that catch the most common problems. Both partners are evaluated simultaneously, since male factors contribute to a significant share of infertility cases.
The Initial Appointment
The first visit is longer than a typical checkup. Your provider will take a detailed medical, reproductive, and family history from both partners. For women, that includes menstrual cycle length and regularity, any prior pregnancies or miscarriages, pelvic surgeries, sexually transmitted infections, and medications. For men, the history covers testicular health, surgeries, medication use, and lifestyle factors like alcohol or tobacco.
A physical exam may follow, though a routine bimanual pelvic exam is no longer considered necessary for every infertility evaluation. The history alone often guides which tests to order first.
Semen Analysis for Male Partners
At least one semen analysis is recommended at the very start of any infertility workup when a male partner is involved. It’s one of the simplest and most informative tests available. The sample is collected (usually through masturbation) and analyzed in a lab, typically within an hour of production.
The lab measures three core parameters against reference values established by the World Health Organization. Sperm count should be at least 39 million per ejaculate. Progressive motility, meaning sperm that swim forward effectively, should be at least 30%. And normal sperm shape (morphology) should be at least 4%. These are lower-limit thresholds, meaning values below them suggest a contributing male factor.
If the first analysis is abnormal, a second one is usually ordered a few weeks later to confirm. A single bad result can reflect temporary illness, stress, or even recent heat exposure.
Male Hormonal Testing
When semen analysis reveals a low sperm count (below 15 million per milliliter, or severely low below 5 million), hormonal testing is the next step. Many fertility specialists now recommend hormonal screening for all men undergoing evaluation, not just those with abnormal semen results.
The blood panel typically measures FSH, testosterone, LH, prolactin, and estradiol. FSH and LH are produced by the pituitary gland and signal the testes to produce sperm and testosterone. High FSH with low sperm counts suggests the testes themselves aren’t responding properly. Low LH with low testosterone can point to a pituitary problem or, in men who appear unusually muscular, possible testosterone abuse. A scrotal ultrasound may also be ordered to check for varicoceles, which are enlarged veins in the scrotum that raise testicular temperature and impair sperm production.
Checking Ovulation
For women, confirming that ovulation is actually happening is one of the first diagnostic steps. Regular, predictable menstrual cycles (roughly every 25 to 35 days) are a good sign, but they don’t guarantee that an egg is being released or that hormone levels after ovulation are adequate.
The most common clinical test is a blood draw measuring progesterone about a week after expected ovulation. Progesterone rises sharply after an egg is released, so a single mid-luteal measurement can confirm that ovulation occurred. However, a single reading doesn’t tell the full story. Multiple progesterone measurements over several days, totaling at least 30 ng/mL combined, give a better picture of whether progesterone stays high long enough to support implantation. A luteal phase shorter than 10 days can signal a defect that raises the risk of early miscarriage even when ovulation does happen.
Home ovulation predictor kits detect the LH surge that triggers egg release, but they only predict ovulation. They can’t confirm it actually occurred or assess whether the hormonal environment afterward is healthy. That gap is why clinical testing remains important.
Ovarian Reserve Testing
Ovarian reserve refers to the quantity of eggs remaining in your ovaries. It naturally declines with age, and testing helps predict how your ovaries might respond to fertility treatment.
The key blood test is anti-Müllerian hormone (AMH), which is produced by developing follicles in the ovaries. Unlike most hormone tests, AMH can be drawn on any day of your cycle. Average levels fall between 1.0 and 3.0 ng/mL. Below 1.0 ng/mL is considered low, and below 0.4 ng/mL is severely low. To put the age-related decline in perspective: a typical 25-year-old might have an AMH around 3.0 ng/mL, while a 35-year-old might be closer to 1.5 ng/mL and a 40-year-old around 1.0 ng/mL.
FSH is also measured, usually on day 2 or 3 of your cycle. FSH works by stimulating egg growth. When fewer eggs remain, the pituitary gland has to produce more FSH to get a response, so elevated early-cycle FSH suggests diminished reserve. These two tests together, AMH and day-3 FSH, give your provider a clearer picture than either one alone.
Checking the Uterus and Fallopian Tubes
Structural problems in the uterus and fallopian tubes account for up to 60% of female infertility cases, so imaging is a core part of the workup. The primary test is a hysterosalpingogram, commonly called an HSG.
During an HSG, a thin catheter is placed through the cervix and a contrast dye is slowly injected into the uterine cavity. X-ray images are taken as the dye fills the uterus and travels through the fallopian tubes. If the tubes are open, the dye spills out the far ends near the ovaries. If it stops partway, that indicates a blockage. The test also reveals the shape of the uterine cavity, picking up fibroids, polyps, scar tissue (adhesions), and congenital abnormalities like a septum dividing the uterus.
The procedure takes about 15 to 30 minutes and is done in a radiology suite. Most women describe it as mildly to moderately uncomfortable, similar to strong menstrual cramps, particularly when the dye is injected. Over-the-counter pain relief beforehand can help. A pelvic ultrasound is often used alongside or instead of HSG to evaluate the ovaries and uterus, though ultrasound alone can’t assess tubal patency as effectively.
When Surgery Becomes Diagnostic
Laparoscopy, a minimally invasive surgery, is not part of a routine initial workup. It’s reserved for cases where less invasive tests suggest a problem that can’t be fully evaluated any other way. The most common reason is suspected endometriosis.
Endometriosis, where tissue similar to the uterine lining grows outside the uterus, often doesn’t show up on imaging. Surgery is the only way to confirm the diagnosis with certainty. During a laparoscopy, a small camera is inserted through a tiny incision near the navel, allowing the surgeon to directly see and assess the location, extent, and size of endometriosis tissue or pelvic adhesions. In many cases, the surgeon can treat what they find during the same procedure, removing adhesions or endometriosis growths, which may improve the chances of conception.
Tests No Longer Recommended
Two older tests have largely fallen out of routine use. Basal body temperature charting, which involves taking your temperature every morning to detect the small rise that follows ovulation, is considered too tedious and imprecise to be clinically useful when menstrual history already suggests regular cycles. Endometrial biopsy, once used to confirm ovulation by examining a tissue sample from the uterine lining, has been shown to lack the accuracy needed to distinguish fertile from infertile women. Neither is recommended as part of a standard evaluation today.
When No Cause Is Found
After a complete workup covering ovulation, ovarian reserve, tubal and uterine anatomy, and semen analysis, roughly 30% of couples worldwide receive a diagnosis of unexplained infertility. This doesn’t mean nothing is wrong. It means the standard tests didn’t identify a specific cause. Subtle issues with egg quality, sperm function, fertilization, or embryo implantation can all fall below the detection threshold of current testing.
Unexplained infertility is a real diagnosis, not a dead end. Treatment options still exist and are often effective. But the label reflects the limits of what diagnostic testing can currently measure, which is why fertility specialists sometimes proceed with treatment as a way of gathering additional information about what might be going wrong.