Most of the attention around trying for a baby goes to timing: the fertile window, ovulation, the two or three days each cycle when conception is most likely. Far less is said about the period before conception, which is where a good deal can be optimised and where treatable issues are most easily found. A preconception assessment is the structured version of that groundwork. It brings together a review of both partners’ health, a set of investigations, and an honest read of where things stand, ideally before trying begins or soon after.
Dr Maree Lee, a fertility specialist and gynaecologist consulting in Bella Vista, Wahroonga and Westmead, approaches a preconception assessment as a way of replacing guesswork with information. Around one in six Australian couples experience difficulty conceiving, and in most a clear reason can be found (RACGP, Australian Journal of General Practice). Finding it earlier, rather than after months of uncertainty, tends to open up more options.
Preconception care ideally begins two to three months before trying, and much of it is straightforward. Folic acid is the single most important supplement: 400 to 500 mcg daily, started at least a month beforehand, substantially reduces the risk of neural tube defects. A higher dose of 5 mg is recommended for women with a BMI over 30, diabetes, epilepsy treated with anticonvulsants, or a personal or family history of neural tube defects. Iodine at 150 mcg daily supports fetal brain development and is advised through the preconception period, pregnancy and breastfeeding (RANZCOG pre-pregnancy counselling guideline).
Lifestyle carries real weight. Stopping smoking, limiting alcohol, keeping caffeine under about 200 mg a day (roughly two coffees), reaching a healthy weight and having regular moderate exercise all support fertility. When it comes to diet, the Mediterranean-style of whole grains, legumes, fish, vegetables and olive oil associated with better outcomes. Immunity to rubella and varicella (chickenpox) is worth confirming before conceiving, since both infections can seriously harm a developing baby, and vaccination is given before conception if immunity is absent. Existing conditions, such as PMOS, endometriosis, thyroid dysfunction, diabetes and high blood pressure, should be reviewed and optimised, with medications adjusted where needed.
The same applies to the male partner. A healthy weight, a good diet, stopping smoking and recreational drugs, and limiting alcohol all measurably affect sperm quality, and anabolic steroids in particular sharply reduce sperm production. Heat is a commonly overlooked factor: raised testicular temperature increases DNA damage in sperm, so spas, saunas and resting a laptop directly on the lap are worth avoiding.
A preconception assessment looks at the couple, not the woman alone. Male factors contribute to around half of difficulty conceiving, which is the reason both partners are investigated from the outset rather than sequentially (RACGP, AJGP). A semen analysis is a simple, non-invasive starting point, and investigating both partners together avoids the common situation where months pass before a straightforward male factor is identified.
Assessment starts with a history and examination, then a set of blood tests. These typically include a general panel (full blood count, kidney and liver function, iron and vitamin D), screening for infections and immunity (hepatitis B and C, HIV, syphilis, and immunity to rubella and varicella), and a haemoglobin electrophoresis to screen for thalassaemia, which is relevant when planning a family.
Ovarian reserve and cycle function are investigated through AMH, FSH, LH and oestradiol, usually taken on days two to five of the cycle, or at any time if cycles are irregular, alongside TSH for thyroid function. It is worth being clear about what AMH does and does not tell you: it reflects the size of the follicle pool, not a direct egg count, and it speaks to egg quantity rather than egg quality. Quality is largely a function of age, which is why AMH is read as one part of a wider picture rather than a verdict on its own. An HbA1c investigates for insulin resistance or diabetes, and a karyotype is done, especially if you have a history of recurrent miscarriage.
Imaging completes the picture. A pelvic ultrasound assesses the antral follicle count and looks for fibroids, polyps, ovarian cysts and signs of endometriosis, a condition that affects around one in seven Australian women and can be present with few symptoms beyond difficulty conceiving (AIHW). For endometriosis in particular, who performs the scan counts for more than the technology, and Dr Maree recommends a sonographer experienced in this area at a dedicated women’s ultrasound facility. Tubal patency is assessed at the same time.
A thorough assessment does not promise an answer to every question, but it turns a vague worry into a specific, workable picture of where you stand.
The central investigation is a semen analysis performed at an accredited laboratory using WHO reference ranges. If the first result is abnormal, a repeat six to eight weeks later is recommended before drawing conclusions, because sperm parameters vary and an illness in the preceding three months can temporarily depress them. The same general bloods, haemoglobin electrophoresis and infection screening apply, with a karyotype where there is recurrent miscarriage or severely abnormal semen parameters.
A meaningful recent addition to the preconception picture is publicly funded carrier screening. Since 1 November 2023, Medicare has covered reproductive genetic carrier screening for cystic fibrosis, spinal muscular atrophy and fragile X syndrome for people who are planning or in early pregnancy, and their reproductive partner where required. Around one in twenty Australians screened are carriers of at least one of these conditions, usually without any family history, and RANZCOG, the RACGP and the RCPA all recommend that it be offered (Medical Journal of Australia, 2024). It is worth raising as part of a preconception assessment rather than left to chance.
There is clear guidance on timing. Current advice is to seek review after twelve months of regular unprotected intercourse if under 35, after six months if aged 35 to 39, and without delay from age 40, since egg quantity and quality decline more steeply through the late thirties (RACGP, AJGP). At any age, irregular or absent periods, known or suspected endometriosis, a history of recurrent miscarriage, known uterine or ovarian conditions, or an abnormal semen analysis are all reasons to be seen sooner.
Seeing a fertility specialist is not the same as committing to IVF. Much of the value lies in a personalised reading of the results, simpler measures such as timing advice or ovulation induction where appropriate, and honest reassurance when everything looks normal. IVF is one tool among several rather than an automatic destination, and a specialist assessment is often the step that makes clear whether it is even needed.
A preconception assessment is worth understanding for what it offers: not a guarantee, but a clear starting point and a plan built around your own situation. The investigations are the same whether the news turns out to be straightforward or not, having answers is almost always easier than not knowing, and the timing of that first conversation is yours to choose.
Male factor affects around half of couples trying to conceive, yet the man is often the last to be tested. Dr Maree Lee explains what a semen analysis really tells you and why both partners should be investigated from the start.
Age is information, not a verdict. Dr Maree Lee explains what fertility decline after 35 really means, why AMH doesn’t tell the whole story, and when to investigate.
An evidence-based guide to elective egg freezing by fertility specialist Dr Maree Lee: what it preserves, success rates by age, the process and the Australian rules.
