The most common reason to find yourself at a fertility specialist is if you’ve been trying to conceive without success. Early on in the treatment process, your doctor will request a number of tests. They can be pretty confusing, so below is a general overview. A number of these tests will also apply to LGBT couples, single parents, or women freezing their eggs, who may not initially appear to have fertility issues.
Fertility specialists focus primarily on four things when evaluating female patients: the health of your ovaries, uterus and fallopian tubes, and your hormone levels. Your doctor will want to look for imbalances or find underlying conditions that can cause fertility issues, like polycystic ovary syndrome (PCOS).
Starting Point: Your History
Before they even write up the first laboratory order, most doctors start by taking a thorough history, as there’s a lot that it can tell them about underlying issues.
Expect to walk your doctor through your menstrual history, and be ready to fill in details on the frequency, duration and level of pain, if any, associated with your periods.
Your doctor might need a sexual history as well, trying to understand if there is a history of STDs, sexual dysfunction or diminished libido.
Your doctors will also want to know if there is a family history of infertility or early menopause.
Finally, your doctor will pay close attention to whether you smoke or drink excessively, and whether your body mass index falls outside the range of normal, as each of these factors impinge on the reproductive process.
Ovarian Reserve: Antral Follicle Count
Doctors will try to assess a patient’s ovarian reserve, or the quantity of eggs being produced by the ovaries.
One of the first tests your doctor will deploy is a transvaginal ultrasound. This in-office ultrasound will show images of your follicles and ovaries. The follicles sit on the surface of the ovaries, and this is where eggs mature and are released. The number of follicles growing, the Antral Follicle Count (AFC) test, indicates roughly how many eggs would likely be retrieved if the ovaries were stimulated using prescription hormones.
Generally speaking, having more follicles is a good thing. If there are very few follicles on the ovaries, that will raise concerns of diminished ovarian reserve. But, if there are more than 12 follicles on one ovary, then an ovary is polycystic, meaning a patient is more likely to suffer from hyperstimulation if hormones are used, and there could be other difficulties if the full definition of PCOS is met.
Ovarian Reserve: AMH Level
The most common way to measure ovarian reserve is via a blood test done to detect levels of the anti-Mullerian hormone (AMH). AMH is directly correlated with the number of small follicles on the ovary, which gives doctors a hint at what overall ovarian reserve quantity might be. This hormone can be measured at any time during the month.
AMH levels peak during puberty, then work their way down to zero at the time of menopause. In general, a higher AMH means the ovaries should have a larger reserve of eggs. But, like AFC, a higher AMH can mean a greater risk of PCOS or hyperstimulation if hormones are used.
AMH is often used in conjunction with AFC to estimate how many eggs are left in the ovaries and predict what a patient’s response will be to hormone stimulation as part of an IVF cycle.
Ovarian Function: FSH
Follicle-stimulating hormone (FSH) is the hormone that the pituitary releases to stimulate the follicles on the ovaries to produce an egg. As ovarian function slows down, more FSH needs to be released to prompt the remaining follicles to grow. Doctors will view an elevated FSH level as a possible indicator that a woman’s ovaries aren’t functioning optimally.
FSH needs to be taken on the second or third day of a woman’s cycle, and it is taken in conjunction with an estradiol, E2 level.
During the ultrasound used to assess a woman’s follicle count, doctors can also get rough images of the shape and lining of the uterus.
Most doctors will want to study the endometrial lining, any abnormalities in the structure or shape of the uterus, and any growths that might linger inside such as fibroids or polyps.
A hysterosalpingogram or HSG, provides doctors with more than the basic ultrasound. During this test, dye is pushed through the fallopian tubes while X-ray imaging is taken. This gives doctors images to understand whether the fallopian tubes are blocked, and also images of the uterus.
If a doctor suspects they need to look further into what’s happening in the uterus, they may order tests that provide more granularity, like a saline sonogram, where the uterus is filled with saline and imaged via ultrasound, or a hysteroscopy, where a fiber optic camera is inserted into the uterus to give a very detailed picture of the inner uterine walls.
An HSG test is used to assess the fallopian tubes. If the HSG shows that the fallopian tubes are blocked, then most minimally invasive fertility treatments like IUIs probably won’t work. In this case, IVF is the more likely route, as it’s the only way to bypass the fallopian tubes. Women can have blocked or scarred fallopian tubes for many reasons, including a sexually transmitted disease, such as chlamydia.
The Endocrine System: Other Hormone Levels
The endocrine system is of paramount importance in the path to pregnancy. It’s responsible for everything from stimulating the ovaries so they produce follicles, to triggering ovulation, to preparing the endometrium so that it will allow an embryo to implant. If any one of a number of hormones are not secreted in the proper proportion, a woman’s reproduction process can be thrown off.
There are a handful of standard tests to gauge whether a woman’s endocrine system is functioning properly.
Some clinicians may ask for the results of at-home urine tests that predict ovulation by measuring luteinizing hormone (LH). Knowing when you ovulate during your cycle, or if you’re ovulating at all, is a key piece of information. To verify ovulation, blood levels of progesterone are measured, usually on day 21 of the cycle.
Other key hormones that doctors will test and pay attention to are prolactin, androgens such as testosterone and DHEAS, and thyroid hormones.
Typically, when men’s fertility is evaluated by reproductive endocrinologists, the first step is a semen analysis. This requires a man to produce a semen sample following two to five days of abstinence from all ejaculation. The sample will be tested looking at a number of factors, most important of which are sperm count (how many sperm there are), motility (what percentage are moving forward), and morphology (what percentage are normally shaped).
The semen analysis has its fair share of detractors, in part because the same man can get very different results each time he produces a sample. But, it is still the standard starting point. If any of those parameters is significantly out of the healthy range, he will likely undergo a second semen analysis. If the results continue to look concerning, then he should see a urologist, who is specifically trained in male anatomy and focused on male reproduction. There, he will have a much more in-depth exam, which will look for conditions such as varicocele that might be causing the sperm parameters to be abnormal.
A Quick Note on Testing for Fertility vs. Infertility
As egg freezing is gaining popularity, many younger women are wondering how they can do testing to get a handle on their future fertility prospects. This is a controversial topic, and experts have widely varying opinions on what the answer is. Many argue that getting a baseline AMH, AFC, and FSH level starting at a younger age is helpful tool for understanding your personal fertility, and to provide a heads up should things change dramatically.
Others argue that there isn’t enough data on what these tests mean for young women who have never tried to get pregnant. A low AMH and a high FSH definitely mean that it’s harder for women to conceive with IVF. But that does not tell us anything useful for a younger woman who has yet to try and conceive.
As one doctor puts it, “the only test of fertility is trying to get pregnant. If you get pregnant, you’re fertile, and if you don’t, you’re not. It’s the only test of fertility.” While that might sound unhelpful to women who have no interest in trying to conceive at the moment, the point he’s driving at is that the tests we currently have, which focus on a woman’s ability to respond to IVF hormones, don’t have a solid track record of predicting future fertility for women with no proven fertility issue (though we hope that will change as more data is accumulated in the coming years). Some doctors are worried that women might be falsely alarmed by a low AMH number, when the reality is that they will go on to get pregnant naturally.
But, if you’re well informed as to what those tests mean, and their limitations in a presumably fertile population, then testing could add to your understanding of your fertility trajectory over time.