How to Know If You're Infertile: Warning Signs and When to Get Tested

The Question Nobody Wants to Ask

This is one of those searches that probably took some courage to type. If you're here because you're worried something might be wrong, I want to acknowledge that first. It's a scary thing to even consider. The good news? Most fertility issues are treatable. But let's start by understanding what infertility actually means - because it might not be what you think.

Here's the first thing I want you to know: the word "infertile" is a medical term, not a verdict. Being diagnosed with infertility does not mean you will never have children. It means you've hit a roadblock, and that roadblock often has solutions.

What Does "Infertility" Actually Mean?

The clinical definition of infertility varies slightly depending on the source, but the most commonly accepted definition comes from the World Health Organization (WHO) and NICE (National Institute for Health and Care Excellence):

• Under 35: Not conceiving after 12 months of regular, unprotected sexual intercourse
• Over 35: Not conceiving after 6 months of trying
• Over 40: Immediate referral for fertility testing is recommended

It's also important to distinguish between primary infertility (never having conceived) and secondary infertility (having conceived before but unable to conceive again). According to Mascarenhas et al. (2012), secondary infertility accounts for approximately half of all infertility cases globally.

Something that surprises many people: infertility is incredibly common. The WHO estimates that approximately 1 in 6 people worldwide experience infertility at some point in their lives (Cox et al., 2022). You are far from alone in this.

Warning Signs in Women

I want to be upfront: many women with infertility have no symptoms at all. Their periods are regular, they feel healthy, and the issue only becomes apparent when they start trying to conceive. However, there are some signs that may indicate underlying fertility issues.

Irregular or Absent Periods

If your cycles are consistently longer than 35 days, shorter than 21 days, or highly unpredictable, it may indicate ovulation problems. Conditions like PCOS (polycystic ovary syndrome) commonly cause irregular cycles and are a leading cause of anovulation (not ovulating).

Balen et al. (1995) found that approximately 70-80% of women with chronic anovulation had PCOS as the underlying cause. If your periods have always been irregular, it's worth investigating before you start trying to conceive.

Very Painful Periods

Severe period pain that interferes with daily life - not just "uncomfortable" but genuinely debilitating - can be a sign of endometriosis or adenomyosis. Both conditions can affect fertility, though many women with these conditions do conceive naturally.

A study by Prescott et al. (2016) found that women with endometriosis had significantly lower fertility rates than the general population, but that early diagnosis and treatment improved outcomes.

Very Heavy or Very Light Periods

Unusually heavy periods (soaking through a pad or tampon every hour for several hours) can indicate fibroids, polyps, or adenomyosis. Very light periods (barely there, lasting less than 2 days) may suggest thin uterine lining or hormonal issues. Both deserve investigation if you're trying to conceive.

Recurrent Miscarriage

If you've had two or more consecutive miscarriages, this falls under the definition of recurrent pregnancy loss and warrants investigation. Rai and Regan (2006) found that recurrent miscarriage affects approximately 1-2% of couples trying to conceive, and causes can include chromosomal abnormalities, uterine structural issues, antiphospholipid syndrome, and hormonal factors.

Pelvic Pain Outside of Periods

Chronic pelvic pain, particularly if it worsens around ovulation or during intercourse, can be associated with endometriosis, pelvic adhesions, or blocked fallopian tubes - all of which can affect fertility.

Pain During Sex

Persistent pain during intercourse (dyspareunia) can sometimes indicate endometriosis, vaginal dryness from low oestrogen, or pelvic floor dysfunction. While not always linked to fertility, it's worth discussing with your doctor, particularly if you're trying to conceive.

Warning Signs in Men

Male factor infertility is responsible for approximately 40-50% of all infertility cases (Agarwal et al., 2015), yet it receives far less attention in the fertility conversation. This is partly because male infertility often has no visible symptoms.

Erectile or Ejaculation Problems

Difficulty achieving or maintaining an erection, or problems with ejaculation (premature, delayed, or retrograde - where semen enters the bladder instead of exiting through the urethra) can all affect the ability to conceive naturally.

Testicular Issues

A history of undescended testicles (cryptorchidism), testicular surgery, or testicular injury can all affect sperm production. Varicocele (enlarged veins in the scrotum) is present in approximately 35-40% of men with infertility (Gorelick and Goldstein, 1993).

Small or Painful Testicles

Very small testicles or testicular pain/swelling should be investigated regardless of fertility plans, but they can also indicate underlying issues with sperm production.

Changes in Body Hair, Libido, or Breast Tissue

Hormonal imbalances in men can manifest as reduced body or facial hair, decreased sex drive, or gynecomastia (breast tissue development). These may indicate low testosterone or other hormonal issues that affect fertility.

Factors That Increase Infertility Risk

While infertility can affect anyone, certaors increase the risk. Understanding these can help you assess whether earlier testing might be worthwhile.

Age

I know nobody wants to hear this, but age is the single most significant factor in female fertility. A woman's egg quantity and quality decline naturally, with a more pronounced decline after age 35. ACOG (2014) guidelines reflect this reality.

For men, age also matters but the decline is more gradual. Johnson et al. (2015) found that advanced paternal age (over 40) was associated with reduced fertility and increased time to conception.

Medical History

• Previous pelvic or abdominal surgery (can cause adhesions)
• STIs, particularly chlamydia and gonorrhoea (can cause tubal damage)
• PCOS, endometriosis, or fibroids
• Cancer treatment (chemotherapy and radiation can damage eggs and sperm)
• Thyroid disorders
• Diabetes

Lifestyle Factors

• Smoking - significantly reduces fertility in both men and women (Augood et al., 1998)
• Excessive alcohol consumption
• Being significantly underweight or overweight
• High stress levels (though this is a contributing factor, not usually a sole cause)
• Certain medications (some antidepressants, some blood pressure medications)

Occupational and Environmental Exposures

Prolonged exposure to certain chemicals, pesticides, heavy metals, or excessive heat (e.g., frequent hot tub use, working with laptops on the lap) can affect sperm quality. Sheiner et al. (2003) reviewed occupational exposures and fertility and identified several workplace hazards.

When to Get Fertility Testing

The guidelines are fairly clear, but I want to add some nuance:

Seek Testing If:

• Under 35: You've been trying for 12 months with regular unprotected sex
• Over 35: You've been trying for 6 months
• Over 40: You should be referred for testing immediately
• Any age: You have known risk factors (irregular periods, history of pelvic surgery, endometriosis, PCOS, previous STI)
• Any age: You have a history of recurrent miscarriage (2 or more)
• Any age: Your partner has known sperm issues

Don't Wait If:

One thing I hear too often is people saying "we haven't been trying that long, so we can't get tested yet." While the 12-month guideline exists for a reason (many couples do conceive within that time), if something feels wrong - if you have irregular periods, if you have a known condition, if your gut is telling you something's off - ask for testing earlier. The worst they can say is "let's wait a bit longer."

What Fertility Testing Involves

Knowing what to expect can reduce the anxiety around fertility testing. Here's a typical workup:

For Women

• Hormone blood tests: FSH, LH, oestradiol, AMH (anti-Müllerian hormone), thyroid function, prolactin, progesterone (day 21 - to confirm ovulation)
• Ultrasound scan: Transvaginal ultrasound to check ovaries, follicle count, and uterine structure
• Hysterosalpingogram (HSG): An X-ray dye test to check if fallopian tubes are open
• Sonohysterogram: Saline-infused ultrasound to look for polyps, fibroids, or adhesions inside the uterus
• Laparoscopy: Keyhole surgery to directly visualise the pelvic organs (usually reserved for suspected endometriosis)

For Men

• Semen analysis: The cornerstone of male fertility testing. Measures sperm count, motility (movement), morphology (shape), and volume. Should be done after 2-5 days of abstinence.
• Hormone blood tests: Testosterone, FSH, LH (if semen analysis is abnormal)
• Physical examination: To check for varicocele, testicular size, and other physical issues
• Scrotal ultrasound: If physical examination reveals abnormalities

Important Notes on Semen Analysis

One result is not a diagnosis. Cooper et al. (2010) showed significant natural variation in semen parameters between samples. If the first result is abnormal, it should be repeated after 2-3 months before drawing conclusions. Lifestyle changes made during that interval (reducing alcohol, quitting smoking, avoiding heat exposure) can also improve results.

The Emotional Side of a Diagnosis

Getting a fertility diagnosis can feel like the ground has shifted under you. Whether it's "unexplained infertility" (which accounts for about 25-30% of cases and is its own special kind of frustration) or a specific condition like blocked tubes or low sperm count, the emotional impact is real.

I want to validate something: it's okay to grieve. You can grieve the easy conception you expected, the timeline you imagined, the sense of control you thought you had. Peterson et al. (2007) found that receiving a fertility diagnosis was associated with increased anxiety and depression, regardless of whether treatment options were available.

But I also want to offer hope. A fertility diagnosis is not a full stop - it's a signpost. It tells you which direction to go. The vast majority of infertility has treatments available, and many couples who receive a diagnosis go on to have healthy pregnancies and babies.

What If Tests Come Back Normal?

If all your tests come back normal but you still can't conceive, you may receive a diagnosis of unexplained infertility. This is more common than you'd think - affecting approximately 25-30% of infertile couples (Smith et al., 2003).

Unexplained infertility is frustrating because there's nothing obvious to "fix." However, it generally responds well to fertility treatments. Pandian et al. (2015) found that couples with unexplained infertility had good success rates with treatments like IUI (intrauterine insemination) with ovulation stimulation, and IVF.

The important thing to remember: "unexplained" does not mean "untreatable." It means the current tests haven't identified the specific issue - which could be related to egg quality, subtle sperm function issues, or implantation factors that we don't yet have good tests for.

Next Steps

If you suspect you might be dealing with infertility, here's what I'd suggest:

1. Track your cycle. Use an app or paper chart to log your periods, any symptoms, and if possible, your basal body temperature or ovulation test results. This data is incredibly useful for your doctor.
2. Book a GP appointment. Explain your concerns clearly. Request basic blood tests (FSH, LH, oestradiol, AMH, thyroid, progesterone on day 21) and ask your partner to arrange a semen analysis.
3. Don't self-diagnose. Google is not a fertility specialist. Many of the "signs of infertility" you'll read about online are vague, misleading, or simply wrong. Rely on medical professionals.
4. Be kind to yourself. Whatever the tests reveal, remember that a diagnosis is information, not a life sentence. There are treatments, there are options, and there are paths forward.

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Medical Disclaimer: This article is for informational purposes only and does not constitute medical advice. If you are concerned about your fertility, please consult a qualified healthcare professional for personalised testing and guidance.