First fertility visit: which tests you need
The first visit to a fertility specialist often brings anxiety and many questions: which tests will be needed, which are genuinely necessary and which are superfluous. The good news is that the basic infertility work-up is simple, focused and, to a large extent, standardized internationally.
The aim of the first assessment is to answer four key questions: is there ovulation? is the semen normal? are the tubes patent? and what is the ovarian reserve? The work-up always concerns both partners together.
When does the infertility work-up begin?
The work-up is indicated when a couple has been trying without success for twelve months, or for six months if the woman is 35 or older. Earlier investigation is justified when there is a known problem — for example irregular periods, a history of pelvic infection or surgery, or a known male disorder.
The reason for the different thresholds is the woman’s age: after 35, fertility declines more quickly and time carries greater weight.
How is ovulation confirmed?
The first step is the menstrual history. A stable, regular period is strong evidence that ovulation is occurring. Confirmation is usually obtained by measuring progesterone in the mid-luteal phase — about day 21 of a 28-day cycle.
If the period is irregular or absent, further hormonal testing is needed to look for the cause (e.g. polycystic ovary syndrome, thyroid disorder or raised prolactin).
Why is the semen analysis essential from the start?
A male factor is involved in about half of infertility cases, so the semen analysis is a core test from the very first visit. It is simple, painless and provides decisive information for the strategy to follow.
The results are interpreted against the World Health Organization reference values. A single abnormal value is not a diagnosis and is usually repeated after a few weeks.
How is ovarian reserve assessed?
Ovarian reserve is assessed mainly in two ways: measuring anti-Müllerian hormone (AMH) in the blood and counting the antral follicles (AFC) by transvaginal ultrasound at the start of the cycle. FSH on day 2–3 was used more in the past.
These tests predict how many eggs are expected to respond to a possible stimulation. However, they do not predict egg quality, nor do they guarantee or exclude natural conception — the woman’s age remains the strongest indicator.
Are tubal testing and ultrasound always needed?
Transvaginal ultrasound is almost always part of the first work-up: it shows the uterus, the ovaries, any fibroids, polyps or cysts and helps count the antral follicles.
Tubal patency testing (with hysterosalpingography, HSG, or ultrasound-based HyCoSy/HyFoSy) is advised when natural conception or insemination is planned, to confirm that the tubes are open. When IVF is planned from the outset, tubal patency is no longer a prerequisite.
Which tests are usually unnecessary at the start?
Many expensive or invasive tests do not belong in the basic routine work-up. Laparoscopy, extensive immunological or thrombophilia panels, testing for “NK cells” and specialized genetic tests are not recommended for every couple, only when the history justifies them.
A good basic work-up is lean and targeted. Additional tests are added only when they genuinely change the treatment decision.
Summary
The basic infertility work-up answers four questions: is there ovulation (menstrual history, progesterone), is the semen normal (WHO-based analysis), what is the ovarian reserve (AMH, antral follicle count), and are the tubes patent (HSG/HyCoSy, when needed). It begins at 12 months of trying — or 6 months if the woman is 35 or older — and always concerns both partners. Expensive or invasive tests are reserved for those who genuinely need them.
⚕ Medically reviewed by Prof. Stratis Kolibianakis · Thessaloniki Medical Association Reg. No. 16340
ARTICLE 15 · INFERTILITY & DIAGNOSIS
