The first step of infertility investigation is a semen assessment and this has to be repeated at least twice with two months between each analysis. Investigation of the male is simple and has to be undertaken prior to administration of and form of treatment to the female partner. Unexpected finding of severe seminal defects will change the form of the treatment. If the semen analysis results are normal, there is no need to do a physical examination in the male. Varicocele which is the dilation of testicular veins when associated with a normal semen analysis is not regarded as a cause of infertility. Idealy semen analysis should be performed after a period of 2-4 days of sexual abstinence.

While the semen analysis is done the woman should be checked for ovulation. 95% of women with regular menstrual cycles ovulate normally. Simple hormone test (progesterone) performed between the 19th and 21st days of the menstrual period will give a reliable estimation fort he occurrence of ovulation. Alternative tests are ultrasound monitoring of the follicular growth or qualitative measurement of LH activity in the urine could be checked. The later can be performed at home by the woman herself.

One of the most important tests in women is the determination of the capacity of the ovaries. Primordial follicules (tiny cysts which carry eggs inside) within the ovaries is counted using a vaginal ultrasound during menstruation for this purpose. If there are less than a total of 6 primordial follicules in both ovaries, it is regarded as the capacity of the ovaries is decreased. The capacity of the ovaries start dropping after the age of 37 and getting pregnant after the age of 44 becomes very difficult. Sometimes the capacity drops at earlier ages. The capacity of the ovaries has to be very carefully evaluated especially in women with a family history of early menapause, who previously had a cyst removed from thier ovaries, women with one ovary, women with history of endometriosis, young infertile couples with no obvious cause for their infertility and in couples with repeated miscariages.
In couples with normal semen analysis, ovulation and ovarian capacity, the woman is checked to see whether there is any obstruction in her fallopian tubes. Histerosalpingography (HSG) is done for this purpose. Although HSG is simple and does not cause pain, pressured administration of the radiocontrast material may be mildly painful. The patient is advised to take one tablet of Naproxen 1 hour prior to the procedure. HSG should be done right after the completion of menstrual bleeding. With HSG, the uterus and the fallopian tubes are evaluated. If the fallopian tubes are blocked the degree of blockage could be determined. Although HSG will give information regarding the fallopian tubes, it will not give any idea about their function.

For women with no findings in their history and examination, laparascopy can be done to see the abdominal cavity. Although this was a widely used procedure in the past, today its use is very limited especially for diagnostic purposes. We only recommend laparascopy for treatment purposes.

There are also some tests which have no proven value used in infertility diagnosis. Immunological tests (antisperm antibodies) and postcoital tests are some of them. I recommend a minimalistic approach for investigastion of infertility. Conducting unnecessary tests is both a waste of time and financial resources.