We Can’t Get Pregnant: How Does an Infertility Assessment Begin?

When pregnancy does not happen in the expected time, the first question that comes to mind is usually “Is something wrong with us?” Medicine approaches this question not with blame, but with order and method. Infertility (in everyday Turkish, “kısırlık”) is a defined health condition, and its assessment follows a set order: when to start, who should be assessed together and which basic tests are done at the first examination are clearly set out in international guidelines ^1,2. This article aims to explain that roadmap step by step, without causing alarm.

When should you start an assessment rather than waiting?

Infertility is defined as pregnancy not occurring despite regular, unprotected intercourse for 12 months in women under 35, or for 6 months in women aged 35 and over; this definition covers up to 15% of couples ^1,2. The reason for the waiting period is simple: the chance of pregnancy is higher in the first months, and about 80% of couples conceive within the first 6 months ³. So for most couples, not conceiving in the first few months is not a sign of illness; once the period has passed, however, moving on to assessment rather than continuing to wait is recommended ¹.

In some situations, you do not wait for this period. A woman with a known cause of infertility should be offered assessment without delay; over the age of 40, more prompt assessment and treatment are also needed ¹. Irregular periods, cycles shorter than 25 days, infrequent or absent periods, and a known or suspected fertility problem in the male partner are also reasons to seek care without waiting ². The 2026 guideline from NICE, the UK’s national guideline body, recommends that women aged 36 and over be referred to a specialist at their first visit ⁴. The reason is the effect of age: at 40, fertility falls to about half of what it is in the late 20s and early 30s ³.

The first consultation is for two

An infertility assessment is not a process that the woman goes through alone. In 40–50% of couples experiencing infertility, a male factor, alone or together with a female factor, is among the causes; this is why the male partner’s basic medical history and assessment should be carried out from the very start ¹. The American Society for Reproductive Medicine (ASRM) calls for the assessment of both partners to begin at the same time ². It is not necessary to go to an assisted reproduction (IVF) centre for the initial assessment; an obstetrics and gynaecology specialist can take the male partner’s history and request a semen analysis (commonly called a sperm test), and, if needed, refer him to a doctor experienced in male reproductive health ¹.

The first appointment is largely spent talking. Medical history and physical examination are essential parts of the initial assessment; tests are planned based on this information ¹. Your menstrual pattern, previous pregnancies, past operations, medicines you take, smoking and how often you have sex are natural parts of this conversation ². In a woman with regular periods, a detailed menstrual history can provide much of the information needed about ovulation ². The history is also the basis for later decisions: according to the guideline of the European Society of Human Reproduction and Embryology (ESHRE), age, duration of infertility, previous treatments and previous pregnancies are among the most important factors that determine the chance of pregnancy ⁵.

Three basic questions: ovulation, tubes, sperm

The basic assessment looks for answers to three questions ¹: is an egg being released (ovulation), are the tubes (fallopian tubes) open, and is the semen analysis normal? Reliable and objective evidence of ovulation is the hormone progesterone, measured about one week before the expected period; a value above 3 ng/mL is accepted as sufficient evidence ². In women with regular periods, ASRM and ESHRE do not consider this measurement routinely necessary ^2,5; NICE, however, recommends it even when periods are regular and advises against using basal body temperature charts ⁴. Which route is followed is decided based on the history.

To check whether the tubes are open, in women with no history of pelvic infection, ectopic pregnancy or endometriosis, hysterosalpingography (HSG, an X-ray of the womb) is a reliable test for ruling out blockage and is less invasive than laparoscopy (keyhole surgery) ⁴; in women with such a history, the tubes and pelvis can be assessed by laparoscopy in the same session ^4,5. HyCoSy (hysterosalpingo-contrast sonography), which is done with ultrasound, is also a valid option compared with laparoscopy ⁵. The cavity of the womb (uterus) is assessed by transvaginal ultrasound or saline infusion sonography; hysteroscopy shows the inside of the womb directly ². Semen analysis should be carried out according to World Health Organization criteria and in a laboratory that takes part in an external quality control programme ⁵.

What do ovarian reserve tests tell you, and what do they not?

Ovarian reserve (egg reserve) tests are part of the initial assessment: basal FSH (follicle-stimulating hormone) and oestradiol, anti-Müllerian hormone (AMH), antral follicle count on ultrasound, and ovarian volume ². These markers decrease with age, but they are poor at predicting fertility in women who are not infertile ³. NICE recommends that AMH should not be used to predict the chance of natural pregnancy, and that AMH or antral follicle count should be used to predict ovarian response in assisted reproduction techniques ⁴. A low AMH value does not mean that you cannot get pregnant ²; in a woman with regular periods, these tests are also not needed to predict the chance of natural pregnancy over 6–12 months ⁵. Their main role is to guide the treatment plan ².

Not every test is needed for everyone. ASRM recommends that the post-coital test (examination of mucus after intercourse), endometrial biopsy (taking a sample from the lining of the womb), laparoscopy in unexplained infertility, thrombophilia (tendency to clot) tests and karyotype (chromosome) analysis should not be requested routinely, and that hormone measurements such as prolactin should be done only if there is a specific reason ². This list matters; ASRM calls for the assessment to be carried out in a systematic, timely and cost-effective way, looking for the most common causes with the least invasive methods ². When the results come back, either a cause is identified or all the basic tests are normal; the second situation has its own name in medicine.

If the tests are normal: unexplained infertility

When there is evidence of ovulation, the tubes are open and the semen analysis is normal, but pregnancy still does not occur, this is called unexplained infertility; this diagnosis is made in up to 30% of infertile couples ^1,5. The word “unexplained” does not mean “hopeless”; it means that no obstacle that standard tests can detect has been found. ESHRE recommends that in this group the decision to start active treatment be based on the prognosis (the expected chance of pregnancy); age, duration of infertility, previous treatment and previous pregnancies are the main criteria for this decision ⁵. So different timings may be recommended for two couples with the same diagnosis.

The guidelines do not fully agree on treatment either. ESHRE 2023 recommends insemination (intrauterine insemination, IUI) together with ovarian stimulation as the first step; it probably does not recommend choosing in vitro fertilisation (IVF) directly over this approach (conditional recommendation) ⁵. NICE 2026, by contrast, recommends trying for a total of 2 years before moving on to treatment, and then, before IVF, considering up to 4 cycles of IUI with stimulation by gonadotrophins (hormones given by injection to stimulate ovulation), or offering IVF; it does not recommend ovarian stimulation without insemination ⁴. These differences mean that the decision needs to be made individually, according to age, duration and the couple’s preference.

What can you do before your appointment?

While you wait for the assessment, there is some simple information that affects the chance of pregnancy. The fertile window (fertile days) is the 6-day interval that ends on the day of ovulation ³. Intercourse every 1–2 days in this interval increases the chance of pregnancy the most; intercourse 2–3 times a week gives a similar result, so couples are not advised to limit how often they have sex ³. Methods such as ovulation kits and tracking cervical mucus can increase the chance of conceiving in a given cycle; however, a strict schedule can turn sex into a chore and create unnecessary stress ³. There is no scientific basis for lying on your back after intercourse; sperm reach the tubes within 15 minutes ³.

Lifestyle areas where the evidence is clear: women and men planning a pregnancy should stop smoking and recreational drugs, and keep alcohol and caffeine to a minimum or a moderate level ³. Both being very underweight and obesity reduce fertility in women ³. Women are also advised to take at least 400 micrograms of folic acid a day to reduce the risk of neural tube defects (defects in the development of the brain and spinal cord) in the baby ³. Some lubricants reduce sperm movement in the laboratory, but their use by couples has been shown not to affect the chance of pregnancy per cycle ³. None of these replaces an assessment; if the time has passed or there is a risk factor, seeking care should not be delayed.

If you have symptoms, please see an obstetrics and gynaecology specialist.