Testing should begin after 12 months of regular unprotected intercourse without a pregnancy, after 6 months if you are 35 or older, and without waiting at all where there is already a known reason to expect a problem: absent or irregular periods, a previous pelvic infection or pelvic surgery, a previous ectopic pregnancy, known tubal disease, or a male partner with a known problem. The same triggers apply to the male partner, and NG257 recommendation 1.16.5 asks for both partners to be assessed together rather than for his evaluation to follow hers.
Written by Dr. A. Ameer Jahan, Senior Consultant · Reproductive Medicine, Male Infertility & STD, Chairman, AJSMC, Egmore, Chennai (TNMC 28017). This page is about when the evaluation of female infertility should start and what each test in it can and cannot tell you. It follows NICE guideline NG257, "Fertility problems: assessment and treatment", published and last reviewed on 31 March 2026 by the National Institute for Health and Care Excellence, which partially updates and replaces the 2013 guideline CG156. Recommendations inside it carry their own evidence-review dates of 2004, 2013 or 2026, so a 2026 guideline number does not mean a 2026 evidence review. NG257 is a UK document, used where India has none of its own. Where it is silent or has removed a section, the WHO infertility guideline of 28 November 2025, the ASRM committee opinions and the ESHRE 2023 unexplained-infertility guideline are named individually.
Before any of it, the situations this page does not cover. Sudden severe one-sided pelvic pain with a missed period or a positive pregnancy test, especially with shoulder-tip pain, dizziness or fainting, may be a ruptured ectopic pregnancy and is a surgical emergency; so is sudden severe pelvic pain with vomiting in a woman with a known cyst or enlarged ovaries. Heavy bleeding that soaks a pad an hour needs a hospital with a 24-hour emergency department and a blood bank, and so does abdominal swelling, breathlessness, falling urine output or rapid weight gain after ovarian stimulation anywhere, which is ovarian hyperstimulation syndrome. Fever, worsening pain or offensive discharge in the days after hysterosalpingography, hysteroscopy or an endometrial biopsy needs same-day assessment. All of those mean 108, or the nearest hospital with a 24-hour emergency department. AJSMC is a multi-speciality centre with no casualty unit, no emergency department and no critical care: its ten beds take planned, stable admissions, with a nurse on site overnight and no doctor on the premises. Consultations run Monday to Saturday, 10am to 9pm, and it is closed all day Sunday. A fertility evaluation is never urgent. Those things are.
When should testing for infertility actually start?
At 12 months, at 6 months from age 35, or immediately where a cause is already known or suspected. The bodies differ by a year at the margins, and the difference is real rather than a rounding.
| Position | What it says | Source |
|---|---|---|
| Investigate both partners | After 1 year of unprotected vaginal intercourse, with no suspected or known clinical cause | NICE NG257, recommendation 1.16.5 [2013, amended 2026] |
| Refer at presentation, without waiting | Woman aged 36 or over, or either partner has a known or suspected cause or predisposing factors | NICE NG257, recommendation 1.16.8 [2013, amended 2026] |
| Begin evaluation | At 12 months under 35, and at 6 months at 35 or older | ASRM, "Definition of infertility" (2023) |
| Evaluate more immediately | Over 40; or at any age with irregular cycles, suspected uterine or tubal disease, male subfertility, sexual dysfunction, or a genetic condition affecting ovarian reserve | ASRM, "Fertility evaluation of infertile women" (2021) |
| Definition of infertility | Failure to achieve a pregnancy after 12 months of regular unprotected sexual intercourse | WHO infertility guideline (28 November 2025) |
| Statutory definition in India | "The inability to conceive after one year of unprotected coitus or other proven medical condition preventing a couple from conception." The Act sets no 6-month provision at any age. | ART (Regulation) Act, 2021, section 2(1)(j) |
Note where the age triggers sit. NICE uses 36 and over for referral at presentation, ASRM 35 and over for starting after six months. At 35, one document would have you begin and the other would not, which is reason enough to raise it yourself rather than wait to be offered. The 12-month rule is itself a convention, and the reason a shorter one is defensible with age is a modelling point ESHRE cites: after two years of trying, a false diagnosis of unexplained infertility occurs in about 10% of women under 35 and about 80% of women over 40. A longer wait stops being reassurance and becomes delay.
Two details are easy to miss. If you miscarry or have an ectopic pregnancy during that year the clock does not restart, under NG257 recommendation 1.16.7, new in 2026. And recommendation 1.5.1 states that intercourse every 2 to 3 days optimises the chance of pregnancy, which asks less of you than most ovulation-timing advice.
How is ovulation confirmed, and why is a "day 21 progesterone" so often wasted?
By a serum progesterone in the mid-luteal phase, timed to your own cycle length rather than to day 21. NG257 recommendation 1.18.6 says a woman with regular monthly cycles is likely to be ovulating and should be reassured of it; 1.18.7 offers the progesterone test even so; and 1.18.8 says that in prolonged irregular cycles the sample may need to go later, day 28 of a 35-day cycle for instance, repeated weekly until the next period starts. WHO 2025 states the rule independently as about 7 days before the expected next period (conditional recommendation, very low certainty of evidence).
Day 21 belongs to a 28-day cycle. NICE's own worked example moves it to day 28 on a 35-day cycle, and on a 45-day cycle the right day is later still, so a day-21 sample lands a week and a half or more before ovulation could have happened and returns a low result that means nothing. That result does not arrive flagged as unusable. It arrives looking like an answer. If your cycles are long or unpredictable, say so before the form is written rather than after the blood is drawn.
Two competent doctors may still order differently, because the guidelines disagree. ESHRE 2023 takes the opposite position for regularly cycling women: recommendation 1, a good practice point, says tests to confirm ovulation are not routinely recommended, and recommendation 3, a conditional one, suggests not routinely measuring mid-luteal progesterone. WHO sides with NICE. The dispute is whether the test is needed when cycles are regular, not the timing rule. ASRM 2021 puts a progesterone above 3 ng/mL as presumptive and sufficient evidence of recent ovulation, with two limits: ovulation in one cycle is not a surrogate for ovulating regularly, in ESHRE's words, and no blood test measures egg quality.
Three things are ruled out at this point and are still sold. NG257 1.18.9 says not to use basal body temperature charts, which do not reliably predict ovulation; NG257 1.18.1 and ESHRE recommendation 14, a strong one, say not to use the post-coital test of cervical mucus routinely, which has no predictive value on pregnancy rate; and ESHRE recommendation 4, also strong, says not to take an endometrial biopsy for histology without another indication. Where cycles are irregular, NG257 1.18.10 adds a blood test for serum gonadotrophins, FSH and LH.
What do AMH and antral follicle count actually predict?
How many eggs are likely to be retrieved if you undergo ovarian stimulation. Not whether you can conceive naturally, and not egg quality. ASRM's 2020 committee opinion on ovarian reserve testing says these markers are good predictors of oocyte yield but "poor independent predictors of reproductive potential", and "should not be used as a fertility test or to deny access to infertility treatment". That applies specifically to women who are not infertile or whose fertility is untested, and age, ASRM says, is a much stronger predictor of reproductive success than ovarian reserve, and age, ASRM says, is a much stronger predictor of reproductive success than ovarian reserve.
NICE reached the same place in 2026 in three recommendations: do not use AMH to predict clinical pregnancy through spontaneous conception (1.18.3); use AMH or antral follicle count as predictors of ovarian response, to inform counselling about assisted conception (1.18.4); and do not use FSH as a predictor of ovarian response or of the outcome of assisted conception at all (1.18.5), NICE noting that FSH is still offered in place of AMH despite predicting neither. WHO 2025 suggests diagnosing low ovarian reserve on age rather than on a test (conditional recommendation, very low certainty of evidence). ESHRE's recommendation 5, a strong one, is that in women with regular cycles ovarian reserve testing is not required to identify the cause of infertility or to predict spontaneous conception over 6 to 12 months.
The evidence is worth naming, because a low AMH frightens people out of proportion. ASRM cites two prospective cohorts. In the EAGER trial, 1,202 women aged 18 to 40, those with AMH below 1 ng/mL had cumulative pregnancy rates similar to those with AMH of 1.0 to 3.5 ng/mL. In the Time to Conceive study, 750 women aged 30 to 44 with no known infertility risk factors, those with AMH below 0.7 ng/mL or FSH above 10 IU/L had similar rates at 6 and 12 cycles to women with normal levels. Diminished ovarian reserve does not necessarily equate with an inability to conceive, and extremely low values should not be used to refuse IVF.
Two things to check on any report you are handed. AMH may be reduced by current hormonal contraception, and although the two markers usually agree they are discordant up to 30% of the time by at least one study ASRM cites. And if a report or a website quotes you a NICE ovarian-reserve threshold, it is quoting a guideline that has been superseded: the 2013 guideline carried numeric cut-offs for AMH, antral follicle count and FSH, and NG257 carries none at all.
How are the fallopian tubes checked, and which test should you have?
That depends on what else is in your history.
| Test | When it is the right first choice | What it does not do | Source |
|---|---|---|---|
| Hysterosalpingography (HSG) | Women with no known comorbidity such as pelvic inflammatory disease, previous ectopic pregnancy or endometriosis; reliable for ruling out tubal occlusion | Poor at the uterine cavity; cannot tell a septate uterus from a bicornuate one | NICE NG257 1.18.13 [2004]; ASRM 2021 |
| Hysterosalpingo-contrast-ultrasonography (HyCoSy) | Where the expertise is available; an effective alternative to HSG | Depends heavily on operator experience | NICE NG257 1.18.14; ESHRE 2023, recommendations 6 and 7 |
| Laparoscopy and dye | Where comorbidity is suspected, so tubal and other pelvic disease are assessed together, and where patency must be shown visually in a high-risk woman | Not recommended routinely for unexplained infertility | NICE NG257 1.18.15; ESHRE 2023, recommendations 9 and 13 |
| Hysteroscopy | Only when a uterine or endometrial abnormality is clinically suspected | Says nothing about the tubes | NICE NG257 1.18.16 [amended 2026] |
ESHRE grades the central finding at its highest certainty: HSG and HyCoSy are both valid tests of tubal patency compared with laparoscopy and chromopertubation, they are comparable in diagnostic capacity, and the choice turns on the preference of the clinician and the woman. WHO 2025 agrees (conditional recommendation, low certainty of evidence), adding that feasibility, trained providers and the possibility of contrast allergy should be weighed. Sensitivity and specificity figures for HSG as a test of tubal patency circulate widely online and are not printed here, because no primary source for the commonly copied pair could be traced.
One safety step comes first. NG257 recommendation 1.22.1 asks for screening for Chlamydia trachomatis before uterine instrumentation, and 1.22.3 covers what should be done where screening has not happened, which is a decision for the doctor arranging the test. That is what keeps a diagnostic test from causing a pelvic infection, which is why fever or offensive discharge afterwards sits on the emergency list at the top of this page.
Does genital tuberculosis need to be considered in India?
Yes. It is a cause of tubal damage that the Western guidelines on this page do not address at all. Female genital tuberculosis is chronic and low-grade, most women with it have no symptoms, and an ICMR-NIRT review in the Indian Journal of Medical Research (2017) records that it is usually found during an evaluation for infertility. The fallopian tubes are affected in almost all cases, the endometrium in 50 to 60% and the ovaries in 20 to 30%.
How common it is among women with infertility depends entirely on which women were counted, and the figures in circulation are hospital figures rather than population ones. A 2018 review in the same journal gives 1 to 19% across different areas of India, about 26% from tertiary centres because difficult cases are referred to them, and up to about 48% among women registering for assisted conception. The most quoted single figure, 48.5%, comes from a retrospective series at one North Indian tertiary centre and refers to 34 of the 70 women in it who had tubal-factor infertility. The only community-based Indian survey, Parvez R and colleagues in Public Health (2017), screened 13,300 women in the Andaman Islands and found 45.1 cases per 100,000 women (95% CI 16.6 to 98.1), an interval spanning a factor of six. None of these is a prevalence for India, and any page that hands you one is overstating what exists.
The 2017 ICMR-NIRT review states that conception rates among infertile women with genital tuberculosis remain low even after the infection has been fully treated, with a raised risk of ectopic pregnancy and miscarriage. Treating the infection treats the infection; it does not undo tubal damage already done. And a woman with infertility who also has a cough of more than two weeks, evening fever, night sweats or unexplained weight loss needs assessment for tuberculosis in its own right, through the National TB Elimination Programme.
Which uterine and pelvic findings matter for fertility, and which do not?
ASRM's 2021 committee opinion reports uterine abnormalities in 16.2% of infertile women, mostly polyps (13%) and submucous fibroids (2.8%). Whether a finding matters depends almost entirely on whether it distorts the cavity.
| Finding | What the evidence supports | Source |
|---|---|---|
| Submucosal fibroid | ASRM grades the evidence for hysteroscopic removal as fair (Grade B); it is the one fibroid category where removal has evidence behind it | ASRM myoma guideline (2017) |
| Fibroid not distorting the cavity | Insufficient evidence that myomas reduce the likelihood of pregnancy (Grade C); removal generally not advised in asymptomatic women | ASRM myoma guideline (2017) |
| Subserosal fibroid | Insufficient evidence that removal improves fertility (Grade C) | ASRM myoma guideline (2017) |
| Endometrial polyp found incidentally | Evidence insufficient; no major guideline recommends routine removal for subfertility alone | Cochrane reviews (2014, 2018) |
| Intrauterine adhesions with amenorrhoea | NICE recommends offering hysteroscopic adhesiolysis where intrauterine adhesions are causing amenorrhoea | NICE NG257 1.35.1 [2004] |
| Uterine septum, no history of recurrent pregnancy loss | WHO suggests not resecting it (conditional recommendation, low certainty) | WHO infertility guideline (2025) |
| Ovarian endometrioma before assisted reproduction | ESHRE strongly recommends against routine surgery: no benefit is shown, and surgery is likely to reduce ovarian reserve | ESHRE endometriosis guideline (2022) |
HSG misses about half the cavity lesions it is asked about. ASRM 2021 records a sensitivity of about 50% and a positive predictive value of about 30% for polyps and submucous fibroids in asymptomatic infertile women, whereas saline infusion sonohysterography has positive and negative predictive values above 90%, and hysteroscopy is the definitive method for diagnosing and treating intrauterine pathology. Those are cavity figures, not tubal ones. WHO 2025 ranks the cavity tests in that same order and puts HSG last (conditional recommendations throughout, low to very low certainty), permitting 2D ultrasound where resources are limited but requiring follow-up for a woman with a negative scan in whom a cavity disorder is still suspected.
Endometriosis is assessed differently now from what older pages suggest. ESHRE's 2022 guideline strongly recommends against blood, tissue and fluid biomarkers for diagnosis, states that a negative ultrasound or MRI does not exclude it, and reserves laparoscopy for women with negative imaging or where other management has not worked. NG257 1.36.1 then offers a choice between expectant management for up to two years, counting time already spent, and surgery.
Should thyroid and prolactin be checked?
Only if there is a reason, and trying to conceive is not by itself a reason. NG257 recommendation 1.18.11 says not to offer a prolactin test to women concerned about their fertility, and to offer it only to those with an ovulatory disorder, galactorrhoea or a pituitary tumour; ASRM 2021 agrees. Recommendation 1.18.12 restricts thyroid function testing to women with symptoms of thyroid disease, and when NICE reviewed subclinical hypothyroidism in 2026 it found no randomised evidence on treating it and concluded that the 2004 position not to screen asymptomatic women still stands. ASRM's 2024 guideline agrees: it does not recommend screening or treating asymptomatic subclinical hypothyroidism in infertility or pregnancy, finds insufficient evidence that it is associated with infertility (grade C, weak), and says a TSH between 2.5 and 4 mIU/L is not associated with an increased risk of miscarriage (grade B, moderate).
Keep one distinction straight, because it causes a great deal of confusion in India. TSH and prolactin are required exclusion tests in the diagnostic algorithm for PCOS, under the 2023 International Evidence-based PCOS Guideline. They are not routine tests in an asymptomatic woman being evaluated for infertility. The test is the same; the indication is not. Where hyperprolactinaemia does prove to be the cause of an ovulatory disorder, both NG257 and WHO carry recommendations on how it is managed, but that is a decision for the treating doctor once the tests are read.
How much does age really change the chance of conceiving?
Enough that NG257 recommendation 1.18.2 makes maternal age the initial predictor of the overall chance of pregnancy, spontaneously and with IVF, in preference to any test. The contemporary data NICE uses is a prospective cohort, and it should be read with its confidence intervals rather than as headline percentages.
| Age | Women in the band | Cumulative pregnancy by 6 cycles (95% CI) | Cumulative pregnancy by 12 cycles (95% CI) |
|---|---|---|---|
| 30–31 | 353 | 77% (72–81) | 87% (82–91) |
| 32–33 | 247 | 76% (70–81) | 88% (83–92) |
| 34–35 | 153 | 71% (63–78) | 82% (74–88) |
| 36–37 | 95 | 69% (59–79) | 76% (66–85) |
| 38–39 | 61 | 62% (49–76) | 71% (56–84) |
| 40–41 | 37 | 47% (31–66) | 54% (37–72) |
| 42–44 | 14 | 29% (10–65) | 48% (24–80) |
Source: Steiner AZ and Jukic AMZ, Fertility and Sterility 2016;105(6):1584–1588.e1, the Time to Conceive cohort, reproduced by NICE as Figure 1 of NG257. Four conditions travel with it and are usually dropped. It was a North American cohort, predominantly Caucasian, highly educated and of normal weight, enrolling only women trying for three months or less with no known infertility, PCOS or endometriosis, and it holds no women under 30, so 87% is its youngest band rather than a general baseline. Compared with ages 30 to 31, fecundability was lower by 14% at 34–35, 19% at 36–37 and 30% at 38–39, but those three confidence intervals all cross 1.0 and the reductions are not statistically significant; only 40–41 (FR 0.47, 95% CI 0.28–0.78) and 42–44 (FR 0.39, 95% CI 0.16–0.93) are. The oldest band rests on 14 women, which is why its interval runs from 24% to 80%. And the outcome counted is a positive pregnancy test, not a live birth, so the curves do not carry the rise in miscarriage with age. The authors put the meaningful decline in the late thirties, close to the position in ASRM Committee Opinion No. 589, "Female age-related fertility decline" (2014), that fecundity falls gradually from about age 32 and faster after 37.
The figure you are more likely to have met, that one in three women aged 35 to 39 will not conceive after a year, does not say what it is used to say. It is usually traced to a modelling paper, Leridon H, Human Reproduction 2004;19(7):1548–1553, though the sources that quote the figure never name that paper, and the phrasing was already in circulation before it was published. Leridon's Monte Carlo simulation reported that 75% of women starting to try at age 30 would have a conception ending in a live birth within one year, 66% at 35 and 44% at 40, rising to 91%, 84% and 64% within four years. The endpoint is live birth, not conception; the figures are for single exact ages; and the paper contains no 35-to-39 band and no "one in three" statement at all. Its conception and sterility inputs came from natural, non-contraceptive populations, largely historical, while its miscarriage risks came from contemporary data. An independent prospective study of contemporary couples, Dunson DB, Baird DD and Colombo B, Obstetrics and Gynecology 2004;103:51–56, estimated that 18% of women aged 35 to 39 fail to conceive within a year, closer to one in five. Neither settles it, and the popular phrasing should not be repeated as fact.
What does being referred onward for ART involve?
AJSMC does not perform ART. Nothing on this page is an offer of it, and if the evaluation points that way the next step is a separate, registered clinic. Under the ART (Regulation) Act, 2021, in force from 25 January 2022, only a registered clinic may provide ART, and section 21(g) places a duty on clinics to apply ART services to a woman above 21 and below 50, and to a man above 21 and below 55. How those limits apply to a married couple is unsettled: the High Courts have divided on it and the question is before the Supreme Court, so if you are near either threshold take current advice from a registered clinic rather than treating the figure as settled.
Before the word "unexplained" is used at all, WHO 2025 sets four conditions (conditional recommendation, very low certainty of evidence): 12 months of trying, a normal history and examination in both partners, presumptive confirmation of ovulation and of patent tubes in the woman, and, in the man, semen parameters within the WHO reference limits, 6th edition (2021), as carried in NG257 recommendation 1.17.1. Each element has to have been checked rather than assumed. NG257 1.38.1 then advises trying for a total of two years, including the year already spent, before treatment, and 1.38.2, new in 2026, says not to offer ovarian stimulation as a stand-alone treatment for it. Recommendation 1.39.2 keeps ovarian reserve in its place, taken into account when IVF is discussed, an input rather than a gate.
If a number is quoted to you anywhere, ask what its denominator was, which women were counted and over how many cycles, before you let it change a decision.
When should you see a doctor?
Book an outpatient appointment if you have been trying for 12 months without a pregnancy, or 6 months if you are 35 or older, or straight away at any duration if your periods are absent or very irregular, if you have had pelvic inflammatory disease, a previous ectopic pregnancy, pelvic or abdominal surgery, or tuberculosis or a household contact with it, or if your partner has a known problem. Say all of that when you call, because it is what decides whether you are booked routinely or sooner.
Bring the dates of your last three to six periods, or the longest and shortest cycle lengths you can recall. Bring previous scans and hormone reports with the dates they were done, since a result with no cycle day attached usually cannot be interpreted and will have to be repeated. Bring any record of past pelvic surgery or infection, and your partner's semen analysis if one has been done, since half of this evaluation is his and there is little sense in finishing yours before his has started. If you are on hormonal contraception say so before any test is booked, and do not stop a prescribed medicine on your own.
Ask to be seen sooner, and say why, if you have absent periods together with galactorrhoea, a new persistent headache or a change in your vision, which suggest a pituitary problem rather than a simple ovulatory one; if you have symptoms of thyroid disease in their own right; or if you have a cough of more than two weeks with fever, night sweats or weight loss. If the strain of all this has become severe distress or hopelessness, say that too. NG257 recommendation 1.2.3 requires that counselling be offered.
Do not come here, and do not wait for us to open, for the emergencies listed at the top of this page. Those go to 108 or to the nearest hospital with a 24-hour emergency department. AJSMC does not provide ART either, so if that is what you are looking for, a registered ART clinic is the right first call rather than this one. For the evaluation itself, outpatient consultations at AJSMC, Police Commissioner Office Road, Egmore, Chennai 600008, run Monday to Saturday, 10am to 9pm, on 044 2532 2021. If you are considering an appointment, ask on that number which of the tests named on this page are done in-house and which are sent to a referral laboratory, and which day of your cycle to come on.
