Fertility Tests: What Your Doctor Will Actually Order

The honest picture, with numbers

A fertility work-up is a short, defined list of tests. It is not open-ended, and it is not the panel of thirty markers you will be offered by a direct-to-consumer service. NICE guideline NG257 sets out both what to do and — just as usefully — what not to do, which is the part that saves you money and false alarms.

The work-up exists to sort your situation into one of a small number of categories. NICE's Clinical Knowledge Summary gives the UK distribution: male factors in about 30% of couples, ovulatory disorders in about 25%, tubal damage in about 20%, uterine or peritoneal disorders in about 10%, and no identifiable cause in about 25%. Disorders in both partners are found in about 40%. Nearly every test below maps onto one of those categories.

What you will actually be offered

For the partner with male reproductive organs: semen analysis

One test, compared against the WHO reference values NICE reproduces: volume 1.4 ml or more, concentration 16 million per ml or more, total sperm number 39 million or more, total motility 42% or more, progressive motility 30% or more, vitality 54% or more, and 4% or more normal forms. If the first result is abnormal, a repeat is offered — ideally at 3 months, to allow a full cycle of sperm formation, unless azoospermia or severe oligozoospermia is found, in which case it is repeated as soon as possible.

For the partner with female reproductive organs: confirming ovulation

NICE recommends a serum progesterone blood test in the mid-luteal phase — day 21 of a 28-day cycle — to confirm ovulation even if your cycles are regular. With prolonged irregular cycles the timing changes: the test may need to be taken later (for example day 28 of a 35-day cycle) and repeated weekly until the next period starts. A single badly timed day-21 test on a long cycle is one of the most common reasons people are wrongly reassured.

With irregular cycles you should also be offered serum gonadotrophins — FSH and luteinising hormone.

Checking the tubes

If you have no known comorbidities, NICE recommends hysterosalpingography (HSG) to screen for tubal occlusion, because it is reliable for ruling out blockage and is less invasive than laparoscopy. Hysterosalpingo-contrast-ultrasonography is an effective alternative where the expertise exists. If you are thought to have comorbidities — pelvic inflammatory disease, previous ectopic pregnancy, endometriosis — you should be offered laparoscopy and dye instead, so that other pelvic pathology can be assessed at the same time.

Before any uterine instrumentation you should be offered chlamydia screening; if it is positive, you and your sexual partners are referred for treatment and contact tracing. Where screening has not been done, prophylactic antibiotics are considered.

The newer additions

NG257 added a recommendation in 2026 to consider serological testing for coeliac disease in people with unexplained subfertility. That is a cheap blood test for a treatable condition that is easy to miss.

Rubella and cervical screening

NICE recommends offering rubella testing to anyone concerned about their fertility who has not been vaccinated or is unsure, with vaccination for those susceptible and advice not to conceive for at least a month afterwards. You will also be asked about the timing and result of your most recent cervical screening, so that treatment is not delayed later.

Viral status

Testing for HIV, hepatitis B and hepatitis C is offered to people undergoing IVF, with specialist advice and management for anyone who tests positive.

What NICE says not to do

This list is worth reading twice, because most of these tests are still sold privately:

• Do not use anti-Müllerian hormone (AMH) as a predictor of pregnancy through spontaneous conception. AMH and antral follicle count are used to predict ovarian response to stimulation, which informs counselling about assisted conception. A low AMH does not tell you your chance of conceiving naturally this year, and it is the single most over-interpreted result in fertility medicine.
• Do not use FSH as a predictor of ovarian response or outcome of assisted conception.
• Do not use basal body temperature charts to confirm ovulation — NICE's stated reason is that they do not reliably predict ovulation.
• Do not routinely use post-coital testing of cervical mucus, because it has no predictive value on pregnancy rate.
• Do not carry out sperm DNA integrity (fragmentation) testing.
• Do not offer routine antisperm antibody testing.
• Do not offer a prolactin blood test unless there is an ovulatory disorder, galactorrhoea or a pituitary tumour.
• Only test thyroid function if there are symptoms of thyroid disease.
• Do not offer hysteroscopy unless a uterine or endometrial abnormality is clinically suspected.

NICE's instruction on what to use instead of AMH for the first question is blunt: use maternal age as the initial predictor of the overall chance of becoming pregnant, whether spontaneously or through IVF.

What to do next

1. Have both partners tested in parallel, not in sequence. Given that both partners have a problem in about 40% of couples, sequential testing routinely costs months.
2. Take your cycle dates to the appointment. Length, regularity, when you started trying, any positive tests or losses. The timing of the progesterone test depends on your actual cycle length, not a default day 21.
3. Ask which tubal test you are getting and why. HSG if no comorbidities, laparoscopy and dye if there are — that choice should be explained to you.
4. List every medication, including over-the-counter. NICE specifically flags GLP-1 agonists, testosterone-replacement therapy, finasteride, NSAIDs, vaginal lubricants, anabolic steroids and cannabis.
5. If a test on the "do not" list is proposed, ask what it will change. A test that cannot alter the plan is not worth the money or the anxiety.

When to seek help

NICE recommends offering both partners further clinical assessment and investigation after 1 year of unprotected vaginal intercourse with no conception and no known cause. Referral is offered at first presentation if the woman, trans man or non-binary person with female reproductive organs trying to conceive is 36 or over, or if either partner has a suspected or known clinical cause of infertility or a history of predisposing factors. If you are using artificial insemination, the trigger is 6 cycles rather than a year.

Referral should be expedited where planned treatment may cause infertility, such as cancer treatment. ACOG's thresholds are similar — evaluation after 12 months, after 6 months if you are older than 35, and a conversation now if you are older than 40.

The practical point: the thresholds are about when investigation is justified, not when a problem becomes real. Irregular or absent periods, known PCOS or endometriosis, previous pelvic infection, previous pelvic or testicular surgery, or previous cancer treatment are all reasons to go now.