There are many things that can stand in the way of normal fertility [link to Conception]. Sometimes the causes are readily detectable. Other times more in-depth testing is required.   

How long should a couple try to conceive naturally before seeking medical help?

Couples should have sexual relations three to four times a week during the week before ovulation. The egg (oocyte) only survives for 24 hours after ovulation, so good timing is essential.

Women younger than 35 are usually advised to try to get pregnant naturally for 12 months before consulting a physician. A couple with prior knowledge of conditions such as irregular menstrual cycles or a history of tubal infections should consider basic examinations sooner.

Women older than 35 should request an initial examination after only six months of trying to get pregnant. Women older than 40 may begin fertility tests immediately.

Most gynecologists have ample training to handle the basic infertility workup for women, although some refer patients to a specialist immediately. Some OB/GYNs begin the testing process and appropriate treatments, then refer the couple to a fertility specialist if simple treatments are not successful.   

Diagnosis: The Female Infertility Workup

For the woman, basic testing begins with the medical interview and physical exam.

A complete related medical history interview will cover:

• Menstrual history
• Pregnancy history
• Birth control history
• History of sexually transmitted diseases
• Current sexual patterns
• Medications
• Surgical history
• Other significant health problems
• Lifestyle and work environment

A complete related physical examination will include:

• Thyroid exam - palpation of throat area
• Hair distribution- any unusual or excessive hair patterns on your face and body
• Breast examination- size, shape, and whether nipples leak
• Pelvic examination- signs of unusual growths, sores, discharge, or infection; PAP smear, cervical fluid sample
  

Additional testing -- via urine or blood tests and pelvic imaging --  may be performed to confirm if ovulation is occurring, predict upcoming ovulation cycles, evaluate ovarian reserve, and measure how ready the uterus is for a pregnancy during certain parts of the woman's cycle.

Home-Testing

If the woman has regular menstrual cycles, the couple can do the following tests at home to make sure they are having sex at the woman's most fertile time:

Basal Body Temperature Charts: Tracking BBT (basal body temperature) is a way to document whether ovulation has occurred.

Ovulation Predictor Kits: Measuring the LH level in urine can indicate that ovulation will likely occur within the next 36 hours.

Physician Testing

Testing performed in the fertility physician's office and lab will be conducted at different points in a woman's cycle.

Blood tests performed specifically on the third day of the woman's menstrual cycle will measure levels: follicle stimulating hormone (FSH) and estradiol (a type of estrogen.) These tests can give an indication of egg cell quality.

Blood tests can also measure the amount of prolactin, androgen and thyroid stimulating hormone.

A transvaginal ultrasound may be performed several days after the LH surge to determine if ovulation has occurred. A blood test in the last part of your cycle can measure progesterone to indicate that ovulation has occurred.

The following procedures are sometimes used to diagnose any structural problems [link to Female Structural Causes] with the reproductive system:

• Hysterosalpingogram (HSG)
• Hysteroscopy
• Laparoscopy
• Ultrasound
  

Diagnosis: The Male Infertility Workup

For men, basic testing begins with the medical interview and physical exam.

A complete related medical history interview will cover:

• History of undescended testicles or hernias
• Mumps after puberty
• Athletic injuries to the groin
• History of sexually transmitted diseases
• Current sexual patterns
• Medications
• Surgical history
• Urinary tract infections
• Prostatitis
• Impotence or ejaculatory problems
• Lifestyle and work environment
  

A complete related physical examination will include:

• Hair growth pattern
• Examination of the penis and scrotum for visible abnormalities
• Prostate examination
  

The Semen Analysis

The semen analysis is the single most important test of male fertility. It is also relatively inexpensive and non-invasive, especially compared to many of the female infertility diagnostic tests.

Sample collection may be performed at either a laboratory, a physician's office, or in some cases, the privacy of home. Ejaculate resulting from masturbation is collected into a special sterile cup. The semen will be examined within a few hours, to achieve the most accurate results.

Semen analysis evaluates the following:

Total Volume

Twenty -five milliliters is a normal volume. Very low volume indicates blocked or malfunctioning seminal vesicles, or a problem with the prostate gland.

Sperm Count

40 million to 300 million is a normal range for the number of sperm per milliliter. Counts below 10 million are considered poor; counts of 20 million or more may be fine if motility and morphology are normal.

Motility and Velocity

The number of active cells will be counted as a percentage of the total number of cells. From zero to 100 percent, at least 50 percent should be active.

On a scale of zero to four, a rating will be given as to how well the sperm move, whether in a straight path or in circles, and the amount of velocity. A satisfactory score is two or more.

Morphology

At least 30 percent of sperm cells should be normally shaped according to the World Health Organization (WHO).

Kruger (strict) morphology test

The shape and size of the sperm head are compared to what is considered normal by a standard referred to as Kruger test. Normal results are given when 14 percent or more of the sperm have normal shaped heads. Men with less than four percent of normal shaped sperm may have a significant infertility problem.

Liquefaction

Normal semen is liquid at ejaculation, immediately coagulates into a pearly gel, and again liquefies within 20 minutes. Failure to coagulate and liquefy may indicate a problem with the seminal vesicles, as would increased thickness or the presence of white blood cells.

Seminal Fructose

If no sperm are present, the semen will be tested for seminal fructose, normally produced by the seminal vesicles. If no fructose is present, congenital absence of the vas deferens or seminal vesicles or obstruction of the ejaculatory duct are possible causes.

Other Tests

• Semen and/or the urethra may be tested for the presence of any sexually transmitted infection or other bacteria.

• Blood tests may be performed to evaluate the levels of reproductive hormones.