Infertility: When to Get Checked, What the Tests Show and Which Treatments Work
About one couple in seven has difficulty conceiving. The word "infertility" sounds final, which is part of why it hurts so much to hear. In practice it is a starting point for investigation, and most couples who seek help end up with a pregnancy, either naturally or with treatment.
Two facts tend to get lost. First, roughly half of cases involve a male factor, yet testing often focuses on the woman for months before anyone asks for a semen analysis. Second, time matters, particularly after 35, so waiting to see what happens is not a neutral choice.
This guide covers when to seek help, what the first tests are, what causes what, and which treatments do what, including the ones sold online that should never be taken unsupervised.
⏰ When to seek help
| Situation | When to be assessed |
|---|---|
| Woman under 35 | After 12 months of regular unprotected sex |
| Woman 35 to 39 | After 6 months |
| Woman 40 or over | Straight away |
| Irregular or absent periods | Straight away |
| Known problem: endometriosis, pelvic infection, previous surgery, chemotherapy, undescended testicle | Straight away |
| Two or more miscarriages | Straight away |
"Regular unprotected sex" means every two to three days across the cycle. That is more effective than trying to pinpoint ovulation, and far less stressful. How ovulation tests fit in is covered in our guide to ovulation tests.
🧪 The first tests
The initial workup is simple and should include both partners from the start.
- Semen analysis
- Counts sperm number, movement and shape. Cheap, quick, and decisive. If abnormal, it is repeated after about three months, since sperm take that long to develop and a recent illness can distort the result.
- Confirming ovulation
- A progesterone blood test about seven days before the expected period. Regular monthly periods usually mean ovulation is happening.
- Hormone tests
- Thyroid, prolactin, and tests of ovarian reserve such as AMH and an antral follicle count on ultrasound.
- Checking the tubes and womb
- An X-ray or ultrasound dye test shows whether the fallopian tubes are open and the cavity of the womb is normal.
- Infection screening
- Chlamydia in particular, because it silently damages tubes.
🧬 What causes it
| Group | Main causes |
|---|---|
| Ovulation problems (about a quarter) | Polycystic ovary syndrome, thyroid disorders, raised prolactin, very low or very high body weight, heavy exercise, stress |
| Tubal damage | Past chlamydia or pelvic infection, endometriosis, previous surgery or ectopic pregnancy |
| Womb and cervix | Fibroids distorting the cavity, polyps, scarring, congenital differences |
| Male factor (about 30 to 50 percent, alone or combined) | Low sperm count or movement, blockage, varicocele, hormonal problems, previous infection or surgery, genetic causes |
| Age | Egg number and quality fall steadily from the mid-thirties, faster after 40 |
| Unexplained (about a quarter) | All tests normal, which is frustrating but not hopeless |
Polycystic ovary syndrome is the single most common cause of ovulation problems and is covered in our PCOS guide.
👨 The male half
Male fertility is more changeable than most people assume, and several factors can be improved within a few months:
- 🚬 Smoking, heavy drinking and cannabis all lower sperm quality
- ⚖️ Obesity reduces testosterone and sperm quality
- 🌡️ Heat — hot tubs, saunas and a laptop on the lap
- 💪 Anabolic steroids and testosterone — testosterone supplements shut down sperm production, sometimes for many months. This is a common and reversible cause
- 💊 Some medicines, including certain antidepressants, sulfasalazine and chemotherapy
- 🩸 Varicocele, enlarged veins in the scrotum, which can sometimes be treated surgically
💊 Treatment 1: making ovulation happen
When the problem is not ovulating, medicines that trigger ovulation work well.
| Medicine | Role |
|---|---|
| Letrozole | Now first choice in polycystic ovary syndrome, with higher live birth rates than clomiphene in trials |
| Clomiphene | Long-established, widely used, taken for five days early in the cycle |
| Metformin | An addition in PCOS, especially with insulin resistance |
| Gonadotrophin injections | When tablets fail; requires close ultrasound monitoring |
| Cabergoline or bromocriptine | When raised prolactin is stopping ovulation |
In our women's health category these include Clomid (Clomiphene), Fertomid (Clomifene IP), Femara (Letrozole), Dostinex (Cabergoline) and Parlodel (Bromocriptine).
🔴 These are not medicines to take on your own. Ovulation induction needs a diagnosis first, because it is useless if the tubes are blocked or the semen analysis is abnormal, and it needs monitoring. Without supervision the risks are real: multiple pregnancy, which carries higher risks for mother and babies, and ovarian hyperstimulation, which can cause severe abdominal swelling, breathlessness and clots. Treatment is also usually limited to about six cycles, after which other options work better.
🏥 Treatment 2: procedures
- Intrauterine insemination — washed sperm placed in the womb around ovulation; used for mild male factor, unexplained infertility or with a donor
- IVF — eggs collected, fertilised in the laboratory, and an embryo transferred; used for tubal problems, severe male factor, endometriosis, age-related infertility and when other treatments fail
- ICSI — a single sperm injected into an egg, for severe male factor
- Surgery — to remove fibroids or polyps, treat endometriosis, or repair a varicocele
- Donor eggs or sperm — where own gametes cannot be used
🌱 What helps regardless of the cause
- Weight
- Both high and very low body weight reduce fertility. Even modest weight loss can restore ovulation in PCOS.
- Stopping smoking
- Smoking reduces fertility in both partners and lowers IVF success.
- Alcohol and caffeine
- Keep alcohol low, and caffeine moderate.
- Folic acid
- Start before conception to protect the baby from neural tube defects.
- Timing without obsession
- Sex every two to three days beats calendar-driven pressure, which strains relationships and rarely improves the odds.
Fertility supplements are heavily marketed. Apart from folic acid, and vitamin D if deficient, the evidence for them is weak.
💛 The part nobody prepares you for
Infertility is one of the most stressful experiences people go through, and it tends to be private. Cycles of hope and disappointment, invasive tests, financial pressure and other people's pregnancy announcements all take a toll. Anxiety and depression are common, and so is strain between partners who grieve differently.
Counselling helps, and many clinics offer it. So does deciding together, in advance, how many cycles to attempt and when to pause. It is not giving up to set limits; it is protecting yourselves while you try.
📞 When to see a doctor
- Trying for 12 months, or 6 months if over 35, or straight away if over 40
- Irregular or absent periods
- Painful periods or pain during sex — possible endometriosis
- Two or more miscarriages
- Known past chlamydia or pelvic infection
- Testicular problems, past surgery or steroid use in the male partner
- Severe abdominal swelling, breathlessness or leg pain during fertility treatment — urgent
❓ Frequently asked questions
How long should we try before seeking help?
Twelve months of regular unprotected sex if the woman is under 35, six months between 35 and 39, and straight away at 40 or over, or if periods are irregular or there is a known problem such as endometriosis or previous pelvic infection.
Is infertility usually the woman's problem?
No. A male factor is involved in roughly 30 to 50 percent of cases, alone or combined with a female factor. A semen analysis is simple and should be one of the first tests, not the last.
What are the first tests for infertility?
A semen analysis for the man, and for the woman a progesterone test to confirm ovulation, thyroid and prolactin tests, ovarian reserve testing, a check that the fallopian tubes are open, and chlamydia screening.
Is letrozole better than clomiphene?
In polycystic ovary syndrome, letrozole produces higher live birth rates than clomiphene in trials and is now the usual first choice. Clomiphene remains widely used and effective.
Can I take clomiphene without a doctor?
No. It only helps if you are not ovulating, and it is useless if the tubes are blocked or the semen analysis is abnormal. Without monitoring it risks multiple pregnancy and ovarian hyperstimulation, which can be serious.
Does testosterone affect male fertility?
Yes, and strongly. Testosterone supplements and anabolic steroids shut down the body's own sperm production, sometimes for many months after stopping. It is a common and often reversible cause of male infertility.
How often should we have sex when trying?
Every two to three days throughout the cycle. That works as well as trying to time ovulation precisely and puts far less strain on the relationship.
What does unexplained infertility mean?
All standard tests are normal, which happens in about a quarter of couples. Many still conceive naturally, and treatments such as insemination or IVF improve the chances.
Do fertility supplements work?
Evidence for most of them is weak. Folic acid before conception is recommended for everyone trying, and vitamin D if a test shows deficiency. Stopping smoking and managing weight do more than any supplement.
How does age affect fertility?
Egg number and quality decline steadily from the mid-thirties and faster after 40, which lowers the chance of pregnancy per cycle and raises miscarriage risk. This is why assessment is recommended sooner at older ages.
📑 Sources and editorial
- Clinical guidelines on the assessment and treatment of infertility
- Trials comparing letrozole and clomiphene for ovulation induction in polycystic ovary syndrome
- Guidance on semen analysis and male factor investigation
- Reviews of ovarian hyperstimulation syndrome and multiple pregnancy risk
- Evidence on lifestyle factors, weight and smoking in fertility
- Related reading: PCOS, ovulation tests
- Related products: Clomid (Clomiphene), Femara (Letrozole), women's health category
- RXshop Editorial Team — reviewed by Anita Sharma, MD, OB-GYN
Medical Disclaimer: The information in this article is for educational and informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. Always seek guidance from a qualified healthcare provider with any questions you may have regarding a medical condition, and before starting, stopping or changing any medication.