Why Both Partners Get Tested
Fertility is a team effort—and so is fertility testing. Infertility causes are distributed roughly equally between male and female factors, with some couples having issues on both sides.
The Basic Fertility Workup
A standard fertility evaluation aims to answer four key questions: Is ovulation occurring? Are the fallopian tubes open? Is the uterus normal? Is sperm healthy? The specific tests ordered will depend on your history and your doctor's approach, but most evaluations include some combination of the tests below.
Testing is usually completed within one menstrual cycle (about 4 weeks), though some tests require specific timing within your cycle.
Blood Tests for Female Fertility
What Blood Tests Reveal
Blood tests measure hormone levels that reflect ovarian function, egg supply (ovarian reserve), and other factors affecting fertility. Most are drawn on specific days of your cycle for accurate interpretation.
FSH stimulates your ovaries to develop eggs. High levels suggest your brain is working harder to stimulate the ovaries, which may indicate diminished ovarian reserve.
What It Measures
Ovarian reserve (how well ovaries respond to stimulation)
Normal Range
- Under 10 mIU/mL: Normal
- 10-15 mIU/mL: Borderline
- Over 15 mIU/mL: Elevated
What Abnormal Means
High FSH may indicate fewer eggs remaining. However, it's just one data point—other factors matter too.
AMH is produced by small follicles in the ovaries. It's the most direct measure of ovarian reserve and can be tested any day of your cycle.
What It Measures
Ovarian reserve (quantity of remaining eggs)
Typical Ranges (by age)
- Under 33: 2.0-6.8 ng/mL
- 33-37: 1.7-3.5 ng/mL
- 38-40: 1.0-3.0 ng/mL
- Over 40: 0.5-2.5 ng/mL
What Abnormal Means
Low AMH (under 1.0) suggests fewer eggs, which affects IVF success. High AMH (over 4.0) may indicate PCOS.
Estradiol is the primary estrogen. It's measured alongside FSH because high early-cycle estradiol can suppress FSH, making FSH results misleading.
What It Measures
Helps interpret FSH; reflects ovarian function
Normal Range (Day 2-4)
- 25-75 pg/mL: Normal
- Over 80 pg/mL: May affect FSH interpretation
What Abnormal Means
Very high early estradiol may indicate an ovarian cyst or diminished reserve (ovaries recruiting eggs earlier).
LH triggers ovulation. The ratio of LH to FSH, especially early in the cycle, can provide clues about ovarian function and conditions like PCOS.
What It Measures
Ovulation trigger; PCOS indicator (with FSH)
Normal Range
- Follicular phase: 2-15 mIU/mL
- LH surge: 20-100+ mIU/mL
- LH:FSH ratio under 2:1
What Abnormal Means
LH:FSH ratio over 2:1 or 3:1 suggests PCOS. Very low LH may indicate hypothalamic dysfunction.
Mid-luteal progesterone confirms whether ovulation occurred and if the corpus luteum is producing enough progesterone to support early pregnancy.
What It Measures
Confirms ovulation; assesses luteal function
Normal Range (7 DPO)
- Over 3 ng/mL: Ovulation occurred
- Over 10 ng/mL: Optimal for conception
- Under 3 ng/mL: Anovulation likely
What Abnormal Means
Low progesterone suggests anovulation or luteal phase defect. May warrant treatment with ovulation induction or progesterone supplementation.
Thyroid dysfunction is common and treatable, yet significantly impacts fertility and miscarriage risk. Even "subclinical" thyroid issues can affect conception.
What It Measures
Thyroid function affecting ovulation and pregnancy
Optimal TSH for TTC
- Under 2.5 mIU/L: Optimal for conception
- 2.5-4.0 mIU/L: May need treatment
- Over 4.0 mIU/L: Hypothyroidism
What Abnormal Means
Both hypo- and hyperthyroidism affect ovulation. Most thyroid issues are easily treated with medication.
Prolactin is the hormone that stimulates breast milk production. High levels outside of pregnancy/breastfeeding can suppress ovulation.
What It Measures
Pituitary function; cause of irregular periods
Normal Range
- Under 25 ng/mL: Normal
- 25-100 ng/mL: Mild elevation
- Over 100 ng/mL: Significant (pituitary imaging)
What Abnormal Means
High prolactin (hyperprolactinemia) can be caused by medications, pituitary adenoma, or thyroid issues. Usually treatable with medication.
💡 Understanding "Day 3" Testing
You'll hear "Day 3 labs" mentioned often. This refers to blood drawn on cycle day 2, 3, or 4 (day 1 = first day of your period). At this point, hormone levels are at baseline, allowing accurate assessment of ovarian reserve and function.
Imaging & Procedures for Female Fertility
Looking Inside
Beyond blood tests, imaging and minor procedures help assess whether the uterus and fallopian tubes are structurally normal and capable of supporting conception and pregnancy.
A baseline ultrasound allows visualization of the ovaries and uterus. It's used to count antral follicles (small developing eggs), check for cysts, fibroids, and other abnormalities.
What It Shows
- Antral follicle count (AFC)—ovarian reserve
- Ovarian cysts or abnormalities
- Uterine fibroids or polyps
- Uterine shape and lining
Antral Follicle Count (AFC)
- Over 12 total: Good reserve
- 6-12 total: Average reserve
- Under 6 total: Diminished reserve
Experience
A slim wand is inserted vaginally. Mild discomfort but not painful. Takes 10-15 minutes.
The HSG is an X-ray procedure that evaluates whether the fallopian tubes are open (patent) and checks the shape of the uterine cavity. Dye is injected through the cervix and tracked as it flows through the uterus and tubes.
What It Shows
- Whether tubes are open or blocked
- Location of any blockage
- Uterine shape (septum, polyps)
- Hydrosalpinx (fluid-filled tube)
How to Prepare
- Take 600-800mg ibuprofen 1 hour before
- Some clinics prescribe antibiotics
- Arrive with a full bladder (empty just before)
- Arrange ride home
Experience
The procedure takes 15-30 minutes. Most women experience cramping similar to period cramps during and briefly after. Discomfort ranges from mild to moderate—rarely severe.
Some studies suggest pregnancy rates increase in the months following an HSG, possibly because the dye "flushes" the tubes. A 2017 study found that oil-based contrast (vs. water-based) led to higher pregnancy rates. Ask your clinic which type they use.
Similar to HSG but uses saline and ultrasound instead of dye and X-ray. Better for visualizing the uterine cavity but doesn't evaluate tube patency as well.
What It Shows
- Uterine polyps and fibroids
- Uterine septum or shape abnormalities
- Endometrial thickness
- Limited tube information
When It's Used
Often ordered instead of HSG if tubes are presumed open, or to get a better look at the uterine cavity.
Experience
Mild cramping during the procedure. Generally less uncomfortable than HSG. Takes 15-20 minutes.
A thin camera (hysteroscope) is inserted through the cervix to directly visualize the inside of the uterus. Can be diagnostic only or include treatment (removing polyps, fibroids, scar tissue).
What It Shows/Treats
- Direct visualization of uterine cavity
- Polyp removal
- Fibroid removal (if submucosal)
- Scar tissue (adhesion) removal
- Septum resection
When It's Done
Usually if HSG or SIS suggests an abnormality. Also done after recurrent miscarriage or failed IVF transfers.
Experience
Office hysteroscopy: Moderate cramping, takes 15-30 min. Operative hysteroscopy: Usually done under sedation in surgery center.
Minimally invasive surgery using small incisions and a camera to view the pelvic organs from outside the uterus. The only way to definitively diagnose endometriosis.
What It Shows/Treats
- Endometriosis (diagnosis and removal)
- Pelvic adhesions (scar tissue)
- Ovarian cysts
- Tubal damage/blockage
- Fibroids (depending on location)
When It's Done
Not routine. Done if endometriosis is suspected, after other tests suggest abnormality, or if cause remains unexplained.
Experience
Outpatient surgery under general anesthesia. Recovery: 1-2 days rest, return to work in 3-7 days. Some temporary bloating and shoulder pain from gas.
Male Fertility Testing
Testing the Other Half
Male fertility testing is simpler than female testing but equally important. A semen analysis is the cornerstone—and often the only test needed unless results are abnormal.
The primary test of male fertility. A semen sample is collected and analyzed for sperm count, movement (motility), and shape (morphology), along with semen volume and other parameters.
| Parameter | WHO Reference (2021) | What Abnormal Means |
|---|---|---|
| Volume | ≥1.5 mL | Low volume may indicate obstruction or retrograde ejaculation |
| Concentration | ≥16 million/mL | Low count (oligospermia) reduces chances per cycle |
| Total Count | ≥39 million | Total sperm in ejaculate |
| Motility | ≥42% moving | Low motility (asthenospermia) means fewer reach the egg |
| Progressive Motility | ≥30% moving forward | Important—sperm must swim directionally |
| Morphology | ≥4% normal forms | Shape matters less than count/motility |
How to Prepare
- Abstain from ejaculation for 2-5 days (not longer)
- Avoid hot tubs/saunas before test
- Sample usually collected at clinic or home (if close)
- Must reach lab within 30-60 minutes
If Results Are Abnormal
- Repeat test (values vary day-to-day)
- Hormone testing (FSH, testosterone)
- Referral to reproductive urologist
- Possible DNA fragmentation test
If semen analysis is abnormal, hormone testing can identify causes related to the pituitary gland or testes.
Tests Included
- Testosterone (total and free)
- FSH
- LH
- Prolactin
- Estradiol (sometimes)
What Abnormal Means
- High FSH: Testicular failure
- Low FSH/LH: Pituitary issue
- Low testosterone: Hypogonadism
- High prolactin: Pituitary adenoma
Measures the percentage of sperm with damaged DNA. Not routine, but may be ordered after recurrent miscarriage, failed IVF, or unexplained infertility even with normal semen analysis.
When It's Done
- Recurrent pregnancy loss
- Failed IVF/ICSI cycles
- Unexplained infertility
- Advanced paternal age (40+)
Results Interpretation
- Under 15%: Normal
- 15-30%: Borderline
- Over 30%: Elevated (may affect fertility)
Typical Testing Timeline
📅 What to Expect Over One Cycle
Most basic fertility testing can be completed in one menstrual cycle (about 4 weeks). Here's a typical timeline:
Period Starts
Call the clinic to schedule Day 3 bloodwork and baseline ultrasound
Baseline Testing
Blood draw for FSH, LH, estradiol, AMH, thyroid, prolactin. Transvaginal ultrasound for antral follicle count.
HSG or Saline Sonogram
After period ends, before ovulation. Evaluates tubes and uterine cavity.
Semen Analysis (Partner)
Can be done any time during this period. Results typically available within days.
Progesterone Test
Confirms ovulation occurred. Drawn 7 days after expected ovulation.
Results Review
Follow-up appointment to discuss all results and treatment plan.
What Fertility Testing Costs
💰 Testing Cost Overview (Without Insurance)
Costs vary significantly by location and clinic. These are typical ranges in the US:
Initial Consultation
Blood Work Panel
Baseline Ultrasound
HSG
Semen Analysis
Total Basic Workup
Insurance note: Many insurance plans cover diagnostic testing even if they don't cover treatment. Check your coverage before starting—you may be pleasantly surprised.
Understanding Your Results
What Results Actually Tell You
Fertility testing provides information, not verdicts. Even "abnormal" results don't mean you can't conceive—they help guide the best approach. Here's how to interpret common findings:
Low AMH / High FSH / Low AFC: Indicates diminished ovarian reserve. This affects how you respond to fertility medications and IVF, but doesn't necessarily prevent natural conception. The quality of remaining eggs matters more than quantity.
Blocked tubes: If one tube is blocked, pregnancy can still occur through the other. If both are blocked, IVF bypasses the tubes entirely. Tubal surgery may be an option in some cases.
Abnormal semen analysis: Many parameters can be improved with lifestyle changes or time. Even severe male factor can often be addressed with IUI, IVF, or ICSI (injecting sperm directly into eggs).
PCOS findings: PCOS is very treatable. Ovulation induction medications work well for most women with PCOS.
"Unexplained" infertility: About 10-15% of couples have normal test results but still struggle to conceive. This doesn't mean nothing can be done—empiric treatments like IUI and IVF still have good success rates.
Frequently Asked Questions
Not necessarily. Your doctor will recommend tests based on your history and initial findings. A young couple with no risk factors might start with just Day 3 labs, ultrasound, and semen analysis. More tests are added if initial results are inconclusive or concerning.
Pain varies widely. Many women describe it as moderate cramping similar to period pain. Some find it minimal; others find it quite uncomfortable. Taking 600-800mg ibuprofen an hour before helps significantly. The discomfort is brief—usually just during and immediately after the dye injection.
Yes! Some clinics offer "fertility assessments" for people who want to understand their fertility before actively trying. This typically includes AMH, ultrasound with AFC, and semen analysis. It can help with family planning decisions, especially if you're considering delaying pregnancy.
This is unfortunately common. Remind him that male factors are responsible for nearly half of infertility cases, and the test is simple, quick, and non-invasive. Some men prefer at-home collection and bringing the sample to the lab. If he still refuses, you can proceed with your testing, but you'll be operating with incomplete information.
Blood work: Usually 1-3 days. Semen analysis: Same day to a few days. HSG: Results are known immediately (the doctor watches the dye flow in real-time). Your clinic will typically schedule a follow-up to review all results once everything is complete.
The Bottom Line
Fertility testing provides answers—not judgments. Whatever your results show, understanding what's happening is the first step toward finding the right path to pregnancy. Most issues identified through testing have treatment options with good success rates.