We have been trying for a year and nothing has happened

If you are under 35, the usual advice is to come after a year of trying without contraception. If you are 35 or older, after six months. Come sooner, whatever your age, if your periods are irregular or have stopped, if you have had more than one miscarriage, if either of you has a known reason (PCOS, endometriosis, a low sperm count, a previous operation on the tubes or the testes, cancer treatment), or if you simply want to know where you stand.

Coming early does not commit you to anything. It gives you information sooner, and time is the one thing in fertility that cannot be bought back.

Both of you, if you can manage it. Part of the answer is often on his side, and his test is the simplest one in the whole work-up.

The visit starts with the story. How long you have been trying and how you have been trying. How your cycles run: how often, how heavy, how painful. Any previous pregnancies, for either of you, with anyone. Illnesses, medicines, operations. Smoking, alcohol, weight, shift work. Whether anyone has tested anything before, and what it showed. Bring every report you have, however old; nothing is repeated without a reason.

Then an examination, and a scan of the uterus and ovaries. The scan shows the shape and lining of the uterus, whether there are fibroids or cysts, and the number of small follicles on each ovary, which is a picture of your egg reserve on the day. It takes a few minutes and it is not painful.

You leave the first visit with a list of tests and a reason for each one. Not a diagnosis, because there is not one yet, and not a treatment plan, because a plan built before the tests is a guess.

For you. Hormone tests, timed to your cycle: a few in the first days of a period, and a progesterone level about a week before the next one is due, which tells whether an egg was released. AMH, which reads the reserve. Thyroid and prolactin, both of which quietly stop ovulation and both of which are easily corrected. Where the tubes need checking, a tube test: either an X-ray with dye (an HSG) or a saline scan. Which one, and whether it is needed at all, depends on what the story and the scan have already shown.

For him. A semen analysis. One sample, after two to five days of abstinence, read by a laboratory that does this every day. It is one of the most useful tests in the work-up, and often the one that is skipped, usually because nobody asked him. If the result is abnormal it is repeated after a few weeks before anything is concluded, because one sample can be wrong.

The reason can be on his side, on hers, in both, or not found. “Not found” is a real category with its own name (unexplained infertility) and its own treatments. It does not mean nothing can be done. It means the ordinary tests are normal, which is good news of a kind.

The order matters. The simplest thing that could work comes first, and each step is given a fair number of cycles before the next one is considered.

• Timing. The fertile window is the five days before ovulation and the day itself. For most couples, intercourse every two to three days across the middle of the cycle covers it without turning it into a schedule. Ovulation kits and temperature charts help some couples and make others miserable; you will be told which you are.
• Putting right what the tests found. A thyroid or prolactin level corrected with a tablet. Weight moved in the right direction: with PCOS, a modest loss often restarts ovulation on its own. Smoking stopped, for both of you. None of this is glamorous and all of it works.
• Helping an egg release. Tablets (letrozole is now the usual first choice, clomiphene the older one) taken for five days early in the cycle, followed by a scan or two to see whether a follicle grew and released. Usually tried for three to six cycles, not indefinitely.
• Then, and only then, IUI, and after that, IVF, if it is the right answer for you. The section below says when.

You have had tests somewhere else and were told to go straight to IVF. Bring the reports. Sometimes that advice is right: blocked tubes, a very low count, an age at which waiting loses more than it gains. Often it is a step or two early. A second opinion is a full consultation and it is allowed to end with “not yet”.

You have been trying for four months and you are already frightened. Come. There is no rule that says you must wait a year to ask a question. The first visit will either reassure you or find something worth knowing early; both are better than four more months of guessing.

Your husband will not come. Come alone, and bring his questions. Most men come to the second visit once they understand that his test is a single sample and that nothing about the process blames him. The page for him is written for exactly this: For him.

• You are 35 or older and have been trying for six months
• You are 40 or older: do not wait at all
• No period for three months, or fewer than eight periods a year
• Very painful periods, or pain with intercourse
• Two or more miscarriages
• A known low count, an undescended testis in childhood, or cancer treatment on either side
• Any previous operation on the tubes, ovaries or uterus

IUI places prepared sperm inside the uterus at the moment of ovulation, usually with tablets or injections to help an egg release first. It needs at least one open tube and an adequate count, it takes a few minutes, and it is tried for a limited number of cycles because the chance does not keep rising after that. The cycle is planned here and the follicle scans are done here; the insemination itself is done at a registered ART centre.

IVF is for the situations where the ordinary route cannot work or has not worked: both tubes blocked, a count too low for IUI, several failed IUI cycles, endometriosis that has damaged the ovaries, or an age at which each month matters. It is planned and followed up here; the laboratory part of the cycle, the egg collection and the transfer, happens at a registered ART centre, and you are told which one, and why, before anything is decided.

We do not give a percentage before the tests are done. After them, you will be told what your own numbers mean, in plain words, and what they do not mean.