Before a diagnosis of unexplained infertility can be made, certain tests must be completed — for both partners. This is not a diagnosis given lightly, or one that should be arrived at before a thorough investigation. If you have been told you have unexplained infertility but some of these investigations haven’t been done, it is worth going back and asking why.
This article explains what the standard workup looks like in South Africa’s private fertility sector, what the tests actually measure, what their limitations are — and which additional investigations may uncover factors a standard workup can miss.
The Standard Fertility Workup in South Africa
For the Female Partner
1. Ovarian Reserve Testing
- AMH (Anti-Müllerian Hormone): A blood test that estimates how many eggs remain in the ovaries. It does not measure egg quality — only quantity. A low AMH is a concern, but many women with low AMH conceive with appropriate treatment.
- Day 2–3 FSH and Estradiol: Blood tests taken early in the menstrual cycle that assess pituitary signalling and baseline hormonal environment.
- Antral Follicle Count (AFC): A transvaginal ultrasound performed early in the cycle to count visible follicles. Together with AMH and FSH, this gives a clear picture of ovarian reserve.
2. Ovulation Confirmation
- Urine LH testing or blood progesterone on Day 21 confirms that ovulation is occurring. In irregular cycles, monitoring may be required over several months.
3. Uterine and Tubal Assessment
- HSG (Hysterosalpingogram): An X-ray procedure where contrast dye is injected through the cervix to visualise the uterine cavity and check whether the fallopian tubes are open. It is performed in a radiology suite and is often uncomfortable. Results are available immediately.
- HyCoSy (Hysterosalpingo-Contrast Sonography): A newer ultrasound-based alternative to HSG. Less radiation, often preferred at fertility-specialist clinics.
- Sonohysterogram (SHG) or Hysteroscopy: Used when the uterine cavity needs more detailed assessment — to rule out polyps, fibroids, or adhesions that could interfere with implantation.
For the Male Partner
Standard Semen Analysis
A semen analysis evaluates:
- Sperm count (concentration)
- Motility — percentage of sperm that are moving, and how well
- Morphology — the shape of the sperm (Kruger strict criteria is the gold standard)
- Volume and pH of the semen
A single normal semen analysis does not rule out male factor. Sperm quality varies significantly between samples. If the first analysis is borderline or abnormal, a repeat test 2–3 months later is recommended.
What Standard Tests Do Not Assess
| This is where the gap in unexplained infertility lies. Standard tests tell you whether the obvious machinery is working. They cannot see the subtle dysfunction. |
Sperm DNA Fragmentation
Standard semen analysis does not measure whether sperm DNA is intact. High levels of DNA fragmentation can cause fertilisation failure, poor embryo development, and recurrent miscarriage — even when sperm count, motility, and morphology are normal. DNA fragmentation testing is not standard in South Africa but is available at specialist centres and should be considered when unexplained infertility persists after initial treatment.
Egg Quality and Chromosomal Competence
The only way to assess egg quality at the chromosomal level is through PGT-A (Preimplantation Genetic Testing for Aneuploidy) during an IVF cycle. This tests embryos before transfer for chromosomal abnormalities — and frequently reveals that a significant proportion of embryos from otherwise ‘normal’ couples are chromosomally abnormal.
Endometrial Receptivity
The ERA (Endometrial Receptivity Analysis) is a biopsy-based test that assesses whether the uterine lining is receptive to implantation at the expected time in the cycle. Available at some South African fertility centres, it is typically considered after one or more failed IVF transfers in women with no other identifiable cause.
Immunological Factors
In some cases, immune responses may interfere with implantation. Testing for antiphospholipid antibodies, NK cell activity, and other immunological markers is not standard but may be considered in specific clinical presentations — particularly recurrent implantation failure.
What Does a Workup Cost in South Africa?
Costs vary by clinic, location, and the extent of testing required. As a general guide for the private sector:
- Blood tests (AMH, FSH, Estradiol): approximately R1,500–R3,000 for the full panel
- Semen analysis: approximately R800–R1,500
- HSG: approximately R2,500–R4,500 (radiology fee plus consultation)
- Transvaginal ultrasound + AFC: approximately R800–R1,500
Medical aid note: In South Africa, the investigation of infertility is a Prescribed Minimum Benefit (PMB). This means your medical aid is required to cover the cost of diagnosing infertility — though not necessarily the cost of treatment once diagnosed. Check your specific plan for detail.
If All Tests Are Normal — What Next?
If a thorough standard workup shows normal results for both partners, your options depend on age, duration of trying, and clinical context. Your reproductive endocrinologist will recommend one of the following:
- IUI with ovarian stimulation — appropriate for younger women with good reserve
- IVF — appropriate where time urgency is real or IUI is unlikely to succeed
- Additional investigation — sperm DNA fragmentation, ERA, or hysteroscopy where clinical suspicion warrants it
For a detailed comparison of IUI and IVF in the context of unexplained infertility, read: ‘IUI vs IVF for Unexplained Infertility — Which Should You Choose?’ [link to Article 3 (IUI vs IVF)]
For a complete overview, return to: ‘Unexplained Infertility: A Complete Guide’
| KEY TAKEAWAYS |
| ✓ A complete workup for unexplained infertility includes ovarian reserve testing, ovulation confirmation, uterine/tubal assessment, and semen analysis for both partners. |
| ✓ Standard tests cannot assess egg quality, sperm DNA fragmentation, endometrial receptivity, or immunological factors. |
| ✓ Fertility investigation is a Prescribed Minimum Benefit in SA — your medical aid should cover diagnostic costs. |
| ✓ If tests are normal but you’re not pregnant, additional testing may uncover hidden causes before committing to treatment. |
| ✓ Sperm DNA fragmentation testing is worth requesting — it is not part of standard semen analysis and is frequently overlooked. |
References
- ESHRE (2023). Evidence-based guideline: unexplained infertility. Human Reproduction.
- ASRM (2020). Diagnostic evaluation of the infertile female: a committee opinion.
- BioArt Fertility Centre, South Africa. Treatment cost information, 2025.
