As a GP, I refer people into the NHS fertility pathway. As a patient, I have been referred into it. From the inside, the system is logical. From the outside, it can feel like a series of closed doors with no map. This is the map.
It describes the pathway in England in the most detail, because that is where funding varies most. Scotland, Wales and Northern Ireland have national criteria, which I flag where they differ.
Step 1: when to see your GP
The NHS advises seeing your GP if you have not conceived after a year of regular unprotected sex. Go sooner, after six months, if you are 36 or over, or if either of you has a known reason to expect a problem: irregular or absent periods, a history of pelvic infection or surgery, endometriosis, PCOS, undescended testes, chemotherapy, or a previous fertility diagnosis.
Do not wait for the "right" moment. The pathway has waiting built into every stage, so the earlier the first appointment, the earlier everything else.
Go together if you can. Fertility is assessed as a couple, and around half of cases involve a male factor.
Step 2: what the GP does
The first appointment is history and basic tests. Expect questions about cycles, previous pregnancies, contraception, sexual history, medication, smoking, alcohol, weight and work. Then the initial investigations, which in most areas are:
- A blood test timed to your cycle to check you are ovulating, usually seven days before your period is due (often called the "day 21" test, which is only day 21 if your cycle is 28 days).
- Further hormone blood tests if your cycles are irregular or absent.
- Chlamydia screening, because untreated infection can affect the tubes.
- Semen analysis for your partner, repeated after around three months if the first result is abnormal.
- Height, weight and BMI, because many funding rules and clinic protocols use it.
Your GP will also check folic acid, vitamin D, smoking and rubella status, and can prescribe the 5 milligram folic acid dose if you are in a higher-risk group. If something on the initial tests is clearly abnormal, referral can happen straight away.
Step 3: referral to a fertility clinic
If the basic tests are normal and you meet your area's criteria, the GP refers you to a fertility service. This might be a gynaecology clinic at your local hospital, or a specialist fertility unit. At this stage you can usually expect:
- A pelvic ultrasound, which also counts the small follicles on your ovaries (the antral follicle count).
- An AMH blood test in many units, as a marker of ovarian reserve. It predicts how you may respond to IVF drugs; it does not predict whether you can conceive naturally.
- A tubal test, either a HyCoSy (an ultrasound with dye) or an HSG (an X-ray with dye), to check the fallopian tubes are open.
- A repeat or more detailed semen analysis.
Waiting for this first specialist appointment varies enormously by area, from a few weeks to many months. Ask your GP surgery what the current wait is, and ask to be told if you can be seen sooner elsewhere.
Step 4: diagnosis and treatment options
After the specialist tests, you should get a diagnosis, or the honest answer that no cause has been found, which happens in around a quarter of couples. Treatment then depends on the cause:
- Ovulation problems (PCOS is the commonest) are often treated first with tablets that stimulate ovulation, such as letrozole or clomifene, with scan monitoring.
- Blocked tubes, severe male factor, or unexplained infertility after a long wait usually lead to IVF, or ICSI (where a single sperm is injected into each egg) if sperm quality is the issue.
- Surgery is sometimes offered for endometriosis, fibroids or tubal damage before assisted conception.
Step 5: NHS funding for IVF, and why it varies
This is the step that causes the most anger, so let me be precise.
NICE recommends that women under 40 who have been trying for two years (or have had 12 cycles of artificial insemination) are offered three full cycles of IVF, and that women aged 40 to 42 are offered one cycle if they have never had IVF before and there is no evidence of low ovarian reserve.
In England, the decision about what is actually funded sits with your local integrated care board (ICB). Each ICB sets its own criteria, and they differ. Common conditions include:
- An upper age limit for the woman, often below 40 in practice.
- A BMI range, typically 19 to 30.
- Non-smoking status for both partners.
- No living children from either partner, in many areas.
- A minimum length of time trying, or a minimum time since a previous cycle.
- Fewer cycles than NICE recommends. Many areas fund one.
Scotland funds up to three cycles nationally for eligible couples, and Wales and Northern Ireland have their own national criteria. You can find your local policy by searching your ICB's name with "fertility policy", or by asking your GP practice, which will have it.
If you are turned down, ask for the decision in writing, ask which criterion you did not meet, and ask whether an individual funding request is possible. Some decisions are about timing (weight, smoking) and can be revisited.
Step 6: waiting, and using the wait
Between referral, tests, funding approval and a treatment start date there is usually a gap of months. That time is not dead time. It is when the three-month preparation window matters most. I have written that out in full: preparing for IVF in the UK: a GP's checklist.
Step 7: going private, or mixing the two
Many people end up paying for some or all of their treatment. If you do:
- Use the HFEA clinic finder. Every licensed UK clinic is inspected, and success rates there are verified, unlike the ones on clinic websites.
- Ask for the total cost of a cycle in writing, including drugs and freezing.
- Ask whether your NHS tests can be used, so you do not pay to repeat them.
- Read IVF add-ons: which are worth paying for? before you are offered any.
- Prepare for the appointment with questions to ask at your first fertility clinic appointment.
Where I come in
The gaps in this pathway are not usually gaps in medicine. They are gaps in explanation. Nobody has twenty minutes to walk you through why a day 21 test is not always on day 21, why AMH does not mean what Instagram says it means, or why your friend two counties away got three cycles and you got one.
That is what I built Fertility Foundations for: twelve chapters you can listen to on the commute, including a full chapter on NHS investigations and the funding postcode lottery, and another on private testing and how to read a clinic's numbers.
Sources: NHS: infertility; NHS: treatment for infertility; GOV.UK: NHS-funded IVF in England; NICE guideline CG156; Fertility Network UK: NHS funding.