Fertility evaluation – what is tested?

The main goal of a fertility evaluation is to identify the reasons behind difficulties trying to conceive, so that the correct treatment method can be used.

There is no one definitive test that doctors conduct, unfortunately fertility is more complex than that. Instead, several factors need to be investigated for both men and women, through a range of methods, to get the full picture. 

Not every available method is used from the get-go as some are invasive and/or very expensive. It’s always good to know about all the options though, so that you can feel in control and secure about all relevant tests being done.

Before testing and examinations begin, you should go through questions about your background together with the doctor. The answer to these questions can provide many clues and will help doctors figure out the best plan of action for you.  

• How long have you been trying to conceive?
• Have you had any previous pregnancies?
• Have you suffered any miscarriages?
• How is your menstrual cycle working?
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• Have you had any sexually transmitted diseases in the past?
• Have you had any gynecological or abdominal surgeries (such as appendix surgery)?
• Have you suffered any testicular infections or traumas or had surgery in the area?
• How is your general health? Any diagnoses?
• Are you on any medications?

Ovarian reserve assessment

The concept of ovarian reserve can be really confusing, and it’s often misrepresented, so it's important to understand the basics. 

First of all, fertility depends on both egg quantity and quality, and how well the ovarian follicles respond to hormonal signals from the brain - the ability to ovulate. And these three factors are investigated separately. 

Number of eggs; Egg reserve

The egg reserve is tested via a blood test (AMH, FSH, and estrogen) and an ultrasound. It’s important to know that all tests provide an indication rather than an exact answer and also that the number of eggs you have is only one part of the equation – it doesn’t say everything about your fertility. Identifying a significantly low egg reserve or early menopause (when egg reserve is depleted at an earlier age than on average), is important though.

• AMH – anti-Müllerian hormone, can be measured via a blood test at any day in your cycle. It’s a hormone produced by the cells in your immature follicles and is thus an indicator of your egg reserve; the higher value, the higher the number of follicles. AMH naturally drops with age. 
• Ultrasound should always be done in combination with an AMH test. Through a vaginal ultrasound, your gynecologist counts the number of antral follicles (follicles size 2-10 mm)  on your ovaries. This can confirm the indication that the blood test gave.
• FSH – follicle stimulating hormone, used to be the blood test that was used to indicate egg reserve. Growing follicles produce estrogen and if ovaries have a hard time releasing estrogen, the body compensates by releasing more FSH so a high FSH can indicate a diminishing reserve. But FSH fluctuates a lot so AMH is nowadays considered a much more secure test and FSH is only looked at in combination with AMH and estrogen. 

Egg quality

Unfortunately, there’s no way to measure egg quality proactively. 

When undergoing IVF embryologists watch embryos develop in the laboratory and can then conclude poor egg quality (if other factors can be excluded), but you don’t go through IVF just to diagnose your egg quality. During IVF it’s also possible (in some countries) to perform so-called PGT-A testing through which embryos are screened for chromosomal defects before being transferred back to the uterus. The best indicator of egg quality is your age since your egg quality will naturally diminish by age.

Ovaluation assessment

An ovulation disorder is actually the most common reason behind female factor infertility. Ovulation is a sensitive process that depends on the right hormonal balance at each stage of the menstrual cycle. 

A regular menstrual cycle is a good indicator of functioning ovulation. You can read more here about how to confirm ovulation. In case of an irregular cycle or repeatedly anovulatory cycles, a range of hormones should be evaluated via a blood test, and looking at these test results in combination with your cycle and sometimes other symptoms, the reason for your ovulation issues can be identified. Read more here about potential hormonal issues that can disrupt ovulation. 

Ovulation can be stimulated using hormone medicines, but it’s always great to find the reason because a hormonal imbalance can have other implications and symptoms than “only” ovulation issues.

Thyroid tests

A functioning thyroid gland is important for a functioning menstrual cycle, and also crucial for the development of the embryo during early pregnancy. Doctors, therefore, conduct blood tests to check the woman’s thyroid function as part of a fertility investigation. 

The blood tests TSH, fT4, and fT3. If deviations are found, further testing for antibodies could be done.

Thyroid issues can normally be regulated via medication.

Checking the fallopian tubes

Fallopian tubes are crucial to getting pregnant naturally and the main thing you want to check is whether they’re open - that there are no blockages. There are three options to do this. 

HSG

The first, and most widely used test, is called a hysterosalpingogram or HSG.

Dye is injected through the uterus and fallopian tubes while x-ray images are taken. On the positive side, it's good at showing if the tubes are open, and it's both diagnostic and therapeutic - women who have their tubes flushed are nearly 3 times more likely to get pregnant the following month than similar women who don't have their tubes flushed. You also get a partial view of the uterus at the same time. For example, it can uncover congenital anomalies like a T-shaped uterus or a unicornuate uterus.

The negatives are that it can be painful and it has some error margin. Tubal blockage is misdiagnosed a little more than a third of the time, and when tubes are thought to be open, HSG can be wrong about 15% of the time. Finding blockages right where the uterus meets the tubes can be more challenging for example.

HyCoSy

A hysterosalpingo contrast sonography or HyCoSy is a pelvic ultrasound where a liquid containing bubbles fills the uterus and an ultrasound shows the bubbles going through the tubes if they're open.

It's a bit less painful than the HSG, and you can do a 3-D ultrasound at the same time which will show the muscular part of the uterus. 

Chromotubation

This is a laparoscopic surgery and the most accurate way to evaluate the tubes, but it’s invasive and entails risk so it’s not recommended unless you're having pelvic surgery for another reason.

Evaluating the uterine cavity

There are a few methods for evaluating the uterine cavity - some show the inside of the uterus, or the cavity, others can also show the outside of the uterus.

As mentioned above, HSG can give a partial view of the uterus. For example, it can uncover congenital anomalies like a T-shaped uterus or a unicornuate uterus. If an HSG raises any questions, there will probably need to be a follow-up with a hysteroscopy or a 3-D ultrasound.

Hysteroscopy

An optic camera goes into the uterus, allowing the doctor to see inside the uterine cavity. This is the only way to definitively diagnose some abnormalities because you can actually see them directly inside the uterus.

Sometimes there is anesthesia and sometimes there’s not—it depends on the clinic. If there is anesthesia and the procedure happens in an operating room, some small issues can be treated during diagnosis, like removing small polyps.

Many clinics don’t perform this procedure unless there are any other indications of issues or many failed attempts with IVF where everything else looks good because it’s invasive and expensive. 

Saline Sonogram

Saline is injected into the uterus and a transvaginal ultrasound is performed.

It shows information about the shape of the uterus, can identify problems like fibroids or polyps, and it's possible to do a 3-D ultrasound at the same time.

Sperm analysis

There is a lot of focus on women when it comes to fertility, but in fact, 50% of the time, male factors are a contributing element to infertility cases. In almost a third of cases, it is the direct cause.

The first-line fertility test for men is a semen analysis, which provides an overview of sperm production. A total motile count (TMC) is calculated, and this information is used to decide what treatment could be necessary. 

To calculate the TMC, the concentration of sperm is multiplied by the motility and then multiplied by the volume or the number of milliliters of semen produced.

• Concentration: the amount of sperm produced within a milliliter of semen, 
• Morphology: the percentage of sperm that are of the correct shape, 
• Motility: the percentage of sperm that can swim forward. 

Doctors could use the TMC to decide on the right treatment. Generally, if the TMC is:

• 20–40 million per milliliter: natural conception is likely
• 3–5 million per milliliter: conception might be possible with Intrauterine insemination (IUI)
• <3 million per milliliter: only <1% chance of natural conception, so IVF might be recommended.

Since the man constantly produces sperm, test results may vary over time. A test that shows deviating results is thus usually re-done to confirm results.

Infection screening

For both men and women, doctors usually conduct screenings for infections such as HIV, Syphilis, and Hepatitis B and C via blood tests.

Will I always find out what’s wrong?

Unfortunately not all fertility evaluations find the reasons behind difficulties trying to conceive. 

Unexplained infertility is a very frustrating diagnosis to receive, but it’s not uncommon. Around one in four couples struggling will be told there is no explanation. It’s really a diagnosis of elimination, meaning your doctor has determined you do not have this, this, and this problem, and yet, you’re not able to conceive. This doesn’t mean that there are no options, just that more trial and error may be needed than when there's a clear diagnosis.

Where can I do a fertility evaluation?

Fertility evaluations can be done at gynecologist- or fertility clinics – the more experienced the doctor is with fertility and hormonal health the better.