Seek advice from a fertility specialist if:

• You have failed to achieve a pregnancy after 12 months or more of regular unprotected intercourse.
• You are aged 35 or above, with no pregnancy after 6 months of regular unprotected intercourse.
• You have irregular menstrual periods.
• You have had previous pelvic surgery, pelvic infection, ectopic pregnancy or other known gynaecological problems.
• Your male partner has a history of chemotherapy, radiotherapy, genital trauma, surgery or infection.
• You have difficulty in sexual intercourse.

Your fertility specialist will take a detailed history from you and your partner, perform a physical examination and perform other investigations that may be necessary. These aim at identifying any potential factors that might impact fertility so as to tailor your individualized treatment plan.

Possible investigations for women include:

• Ultrasound of the pelvis:
  • Check for any abnormality in the uterus and ovaries, e.g. uterine fibroids, adenomyosis, endometrial polyp, uterine septum or ovarian cysts.
  • An additional 3D USG can be done to give a better view of the uterine cavity.
  • Antral follicle count (AFC): The number of small follicles (antral follicles) in the ovaries is a measure of the ovarian reserve.
• Checking tubal patency:
  • Hysterosalpingography (HSG): A more traditional way. A small catheter is put into the uterine cavity through the neck of the womb for injection of dye. X-ray is then used to see if the dye can flow into the fallopian tube and then the peritoneal cavity.
  • Hysterosalpingo-Foam Sonography (HyFoSy) or Hysterosalpingo-Contrast Sonography (HyCoSy): Newer ultrasound-based techniques to examine the fallopian tubes by injecting ultrasound-visible foam or contrast through the neck of the womb. It avoids the X-ray radiation with traditional HSG. It can be done in the fertility clinic and allows an integrated assessment of the fallopian tubes, uterus, uterine cavity and ovaries.
  • Laparoscopy + dye test (lap and dye): A keyhole surgery under general anaesthesia, enabling visualization of the pelvis and fallopian tubes. Dye is injected through the neck of the womb and is observed for flow into the peritoneal cavity through the fallopian tubes. Laparoscopy allows unblocking the tubes and other procedures at the same time, but carries risks associated with surgery and anaesthesia.
• Hormonal profile:
  • In women with irregular menstrual cycles, blood tests are done to investigate the cause. The commonly done tests are luteinizing hormone (LH), follicle stimulating hormone (FSH), oestradiol (E2), prolactin level and thyroid function test.
  • Serum progesterone can be done to confirm the presence of ovulation, as progesterone is secreted by the ovulated follicle (called the ‘corpus luteum’).
• Ovarian reserve tests:
  • Anti-mullerian hormone (AMH) (by blood test): The hormone is secreted by the small follicles in the ovaries, and is a good reflection of the ovarian reserve.
  • Antral follicle count (AFC) (by ultrasound): The number of small follicles (antral follicles) in the ovaries is a measure of the ovarian reserve.

Possible investigations for men include:

• Semen analysis: The man submits the semen sample by masturbation. The sample is then examined in the laboratory under WHO semen analysis manual 6th edition criteria. A 2-7 day abstinence is recommended before the test for a more accurate result.
• Hormonal profile: For men with poor sperm quality or no sperm in semen (azoospermia), a male hormone profile (blood tests) may be needed for further evaluation.
• Referral to a urologist is sometimes necessary in men with poor sperm quality or no sperm present in the semen (azoospermia). Imaging of the genital organs may be needed.