Couple infertility: which tests after a year of trying to conceive?
In brief
Couple infertility (subfertility) means no pregnancy after 12 months of regular sex without contraception. Tests are recommended after one year of trying if the woman is under 35, and after six months from the age of 35. Both partners are always assessed: ovulation, ovarian reserve, uterus and fallopian tubes for the woman, and a semen analysis for the man.
What is the difference between infertility and sterility?
The two words are often confused, but they do not mean the same thing:
- infertility (or subfertility) is difficulty conceiving: pregnancy is still possible, sometimes naturally, sometimes with treatment. The World Health Organization (WHO) defines it as no pregnancy after 12 months or more of regular unprotected sex;
- sterility is a permanent inability to conceive, which can only be confirmed after full testing and in specific situations (no fallopian tubes, menopause, a total absence of sperm that cannot be treated, etc.).
The vast majority of couples who seek help have infertility, not sterility. In women, endometriosis is one of the causes to look for, especially with painful periods or pain during sex.
How long should we try before seeing a doctor?
Even in couples with no fertility problem, pregnancy does not always happen in the first few months: the chance of conceiving in each cycle is limited. The guidelines of the French College of Gynaecologists and Obstetricians (CNGOF, 2022) suggest starting tests:
| Situation | When to get tested? |
|---|---|
| Woman under 35 | After 12 months of regular sex without contraception |
| Woman aged 35 or over | After 6 months |
| Very irregular cycles or no periods, known endometriosis, history of pelvic infection or pelvic surgery, known problem in the male partner | Straight away |
The timing of sex matters. The Wilcox study (NEJM, 1995) showed that conceptions occur after intercourse within a six-day window ending on the day of ovulation. Having sex every two or three days covers this window well, with no need to schedule every encounter.
What are the main causes of couple infertility?
Causes can be female, male, combined, or remain unexplained despite full testing.
In women
- age, the most important factor: fertility falls markedly from 35, because the number and quality of eggs decline (see ovarian reserve);
- ovulation disorders: polycystic ovary syndrome, high prolactin, thyroid disorders, premature ovarian insufficiency, major weight loss or excess weight;
- the fallopian tubes: blockage or damage after an infection (chlamydia in particular), an ectopic pregnancy, surgery or endometriosis;
- the uterus: polyp, fibroid distorting the cavity, synechiae (adhesions), malformation;
- endometriosis.
In men
- abnormal sperm count, motility or shape;
- azoospermia (no sperm), due to a production problem or a blockage in the sperm ducts;
- aggravating factors: tobacco, cannabis, alcohol, heat, some medicines and cancer treatments, varicocele.
Which lifestyle factors affect fertility?
Several lifestyle habits, in both women and men, affect the chances of pregnancy. The CNGOF guidelines (2022) advise infertile couples to:
- stop smoking tobacco and cannabis, both partners;
- limit alcohol to fewer than five drinks a week;
- follow a Mediterranean-style diet, rich in vegetables, fruit, pulses, fish and olive oil;
- take regular physical activity, adapted to each person.
Weight matters too: being very underweight or obese can disrupt ovulation in women and sperm production in men. However, the CNGOF does not set a body mass index threshold above which medical infertility care would be refused.
Other points should be checked before any pregnancy, whatever the timeframe: folic acid, up-to-date vaccinations (rubella in particular), current medicines compatible with pregnancy, and good control of any chronic condition (thyroid, diabetes).
What happens at the first fertility consultation?
Infertility tests concern the couple. It is preferable to come together to the first consultation. The doctor reviews:
- how long you have been trying, how often you have sex, any sexual difficulties;
- the menstrual cycle (regularity, pain) and any previous pregnancies for each partner;
- medical and surgical history, genital infections, current treatments;
- lifestyle: tobacco, alcohol, cannabis, weight, physical activity, occupational exposure.
A gynaecological examination is carried out, and a cervical screening test is done if it is not up to date. Any further tests needed are prescribed at this consultation; the average wait for an appointment is one week to 10 days, except during holiday periods.
Which fertility tests are done for women and men?
According to the CNGOF 2022 guidelines, first-line tests include:
| Test | For whom? | What it looks for |
|---|---|---|
| 3D pelvic ultrasound with antral follicle count | Woman | Uterus, ovaries, signs of endometriosis, estimate of ovarian reserve |
| Hormone tests | Woman | Ovulation, prolactin, thyroid depending on the situation; AMH before assisted reproduction |
| Hysterosalpingography or HyFoSy (foam ultrasound) | Woman | Whether the tubes are open, shape of the uterine cavity |
| Vaginal swab | Woman | Bacterial vaginosis |
| Semen analysis, sperm morphology and semen culture | Man | Sperm count, motility and shape, infection |
If the semen analysis is abnormal, an examination by an andrologist, a testicular ultrasound and hormone tests are recommended; if it is normal, it does not need to be repeated. Find out more: semen analysis and hysterosalpingography.
Some tests that used to be routine are no longer recommended as first-line: the post-coital test (Hühner test), chlamydia serology to assess the tubes, and hysterosonography and diagnostic hysteroscopy when the 3D ultrasound is normal.
What fertility treatments are available after the tests?
Treatment depends on the cause, the woman's age and how long the infertility has lasted:
- lifestyle measures for both partners: stopping tobacco and cannabis, a Mediterranean-style diet, physical activity, alcohol limited to fewer than five drinks a week (CNGOF 2022);
- ovulation induction for ovulation disorders, with monitoring to avoid multiple pregnancies; it is not recommended for a woman who ovulates normally and whose tests are normal;
- surgery when needed: before assisted reproduction, removal of a polyp larger than 10 mm or a fibroid distorting the cavity (types 0, 1 and 2), treatment of synechiae, management of a swollen tube (hydrosalpinx), endometriosis surgery in some situations;
- assisted reproduction: intrauterine insemination, in vitro fertilisation (IVF) with or without ICSI, and donor eggs or sperm if needed.
When all tests are normal, this is called unexplained infertility, which has its own approach.
How can we cope with infertility?
Waiting for a pregnancy and going through tests can weigh on the relationship, your sex life and your work. It is entirely legitimate to talk about this during the consultation. Psychological support, offered in many fertility centres, can help. In France, assisted reproduction treatments are covered by the Assurance maladie (the French national health insurance) under defined conditions (in particular age and number of attempts), which the team will explain to you.
Frequently asked questions
Should I chart my basal body temperature?
It can help some women identify ovulation, but it is not essential and can become a source of stress. A well-timed blood test or ultrasound gives more precise information.
Does the man really need to be tested?
Yes. A semen analysis is part of the first-line assessment of every infertile couple, because a male cause is common, on its own or alongside a female cause.
Are urine ovulation tests useful?
They can help pinpoint the fertile days. However, regular sex every two or three days covers the fertile window without having to schedule each time.
Can I see a doctor before a year if I am worried?
Yes, especially from age 35 or with irregular cycles, very painful periods, a history of genital infection or pelvic surgery. A first consultation is also a chance to review lifestyle factors.
Are infertility tests reimbursed in France?
Yes. In France, infertility tests prescribed by a doctor are covered by the Assurance maladie on the usual terms. Assisted reproduction treatments have specific coverage, subject to conditions.
References
- Sonigo C, et al. First-line management of infertile couple. Guidelines for clinical practice of the French College of Obstetricians and Gynecologists (CNGOF) 2022. Gynécologie Obstétrique Fertilité & Sénologie, 2024. doi:10.1016/j.gofs.2024.01.014 — PMID 38311310
- Wilcox AJ, et al. Timing of sexual intercourse in relation to ovulation. Effects on the probability of conception, survival of the pregnancy, and sex of the baby. New England Journal of Medicine, 1995. doi:10.1056/NEJM199512073332301 — PMID 7477165
- Minhas S, et al. European Association of Urology Guidelines on Male Sexual and Reproductive Health: 2025 Update on Male Infertility. European Urology, 2025. doi:10.1016/j.eururo.2025.02.026 — PMID 40118737
Dr Olivier KadochObstetrician-gynaecologist and gynaecological surgeon in Paris (16th and 5th arrondissements). Former chef de clinique-assistant (senior registrar) at the Paris public hospitals (AP-HP); individually accredited by the French National Authority for Health (HAS). RPPS 10003957809. Background and practice locations
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