First principle: conception is a chain; test the whole chain, in parallel
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Five compartments: male, ovarian, tubal/peritoneal, uterine/cervical, unexplained. Evaluate the couple in parallel — do not investigate the woman first by default.
When to start
| Situation | Begin evaluation after |
|---|---|
| Woman <35 | 12 months of regular unprotected intercourse |
| Woman ≥35 | 6 months |
| >40, or a known cause (amenorrhoea, prior PID, endometriosis, chemo, known male factor) | immediately 🚩 |
The three pillars
Discriminators / a worked prioritisation
- Amenorrhoeic → ovulatory factor dominates → localise on the axis (Concept 31, 36).
- Prior PID/TB/endometriosis → tubal factor likely → HSG (Concept 32).
- Abnormal semen → male factor → localise (Concept 30).
Pitfalls
- Delaying work‑up in a woman ≥35 or with obvious risk.
- The old bias of investigating the woman while ignoring the man (semen analysis is the simplest, highest‑yield first test).
Pearls
- 🎯 Start at 12 months (<35) / 6 months (≥35) / now (high risk). Test sperm + ovulation + tubes.
- 🩺 Frame it explicitly as a couple's evaluation from the first consultation — it is kinder and faster.
Next → Begin with the simplest, highest‑yield partner (Concept 30).