Causes and diagnosis of infertility: what an evaluation looks for
Infertility: the short answer
Infertility can involve ovulation, the fallopian tubes, the uterus, sperm, both partners or a mechanism that the first tests do not identify. The World Health Organization estimates that about one in six people experience infertility at some point in life, but an individual evaluation still needs to start with that person’s history rather than a population average.
Without a known risk factor, evaluation may begin after 12 months of regular unprotected intercourse when the woman is under 35, after 6 months from age 35, and more promptly after 40. Evaluation should also begin sooner when there are irregular or absent cycles, suspected tubal or uterine disease, endometriosis, known male-factor concerns or another relevant risk factor. These time points come from the ASRM fertility evaluation guidance.
Common female factors
The most useful starting point is usually the menstrual and reproductive history. Possible factors include:
- Ovulation problems: irregular or absent cycles, PCOS, thyroid disease and other hormonal causes.
- Tubal or pelvic factors: blocked or damaged tubes, adhesions, previous pelvic infection or a previous ectopic pregnancy.
- Endometriosis: its effect depends on location, extent, pain, ovarian involvement and the wider clinical picture.
- Uterine-cavity factors: some polyps, fibroids or congenital differences may affect the cavity or the transfer plan.
- Age and ovarian reserve: egg number and egg competence change with age. AMH and antral follicle count can help anticipate response to stimulation, but neither is a stand-alone fertility test.
One abnormal result rarely explains the entire situation. It should be interpreted alongside age, cycles, symptoms, imaging and the reproductive history.
Common male factors
Male factors may involve sperm production, sperm movement or shape, the passage of sperm, ejaculation, hormones, genetics, medication, testosterone use or a testicular condition. A varicocele or a previous infection may be relevant in some people, but no single finding should be treated as the explanation without context.
The initial assessment usually includes a reproductive and medical history and a semen analysis. If the result is abnormal, it may need confirmation and interpretation by a clinician familiar with male fertility. The AUA/ASRM guideline describes the male evaluation and the importance of looking for associated health conditions as well as fertility factors.
Male and female evaluation should begin together when both partners contribute to the pregnancy. Infertility is not a problem that can be assigned to one partner by default.
How does a fertility evaluation work?
ASRM recommends a systematic and proportionate evaluation that starts with the least invasive methods likely to answer the common questions:
- A detailed medical, reproductive, menstrual and family history for both partners.
- A targeted physical examination when it can add useful information.
- Semen analysis and assessment of ovulation when indicated by the history.
- Transvaginal ultrasound to assess the uterus and ovaries.
- Assessment of tubal patency or the uterine cavity when the history and treatment plan make it relevant.
- Additional hormone, genetic or imaging tests only when the first findings create a specific reason.
Not every couple needs every test. In the absence of a clear indication, routine laparoscopy, postcoital testing, immunological testing, endometrial biopsy and advanced sperm-function tests are not usually the first step. A test should answer a clinical question rather than simply add another line to the file.
What is unexplained infertility?
Sometimes the standard evaluation is reassuring but pregnancy does not occur. This is called unexplained infertility. It does not mean that the problem is imaginary. It means that current tests have not identified a single mechanism that explains the delay.
The next discussion depends on age, duration of attempts, prior pregnancies, symptoms, test results and preferences. Depending on the situation, options may include a defined period of trying, ovulation treatment, intrauterine insemination or IVF. No single pathway is right for everyone.
Dr. Aksoy’s approach
I prefer a map with a purpose. Before ordering a test, I ask what decision its result would change. A semen analysis, a cycle history and a focused ultrasound may answer more useful questions than a long list of tests ordered in parallel.
The aim is not to prove that one partner is responsible. It is to understand which finding matters now, which can wait, and which result would change the next step.
Frequently asked questions
What are common causes of infertility?
Causes may involve ovulation, the fallopian tubes or uterus, sperm production or delivery, both partners, or no mechanism identified by the initial tests. The pattern differs between people.
When should infertility be evaluated?
Without a known risk factor, evaluation may begin after 12 months of regular unprotected intercourse when the woman is under 35, after 6 months from age 35, and more promptly after 40 or when a relevant risk factor is already known.
Does AMH diagnose infertility?
No. AMH and antral follicle count can help estimate ovarian response to stimulation, but neither result alone diagnoses infertility or predicts a spontaneous pregnancy.
Do both partners need an evaluation?
Yes, when both partners contribute to the pregnancy, evaluation should begin for both at the same time. A semen analysis is usually part of the initial male assessment.
What if standard tests find no cause?
This is called unexplained infertility. It does not mean the problem is imaginary; it means the available tests have not identified a specific mechanism. The next step depends on age, duration, history and preferences.
Important information
This page provides general education and does not replace an individual assessment. Tests should be selected and interpreted by a qualified clinician who knows the medical history of the people involved.
Sources
- World Health Organization: Infertility prevalence estimates, 1990–2021
- ASRM: Fertility evaluation of infertile women
- AUA/ASRM: Diagnosis and treatment of infertility in men, Part I
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