What to Expect at a Female Fertility Assessment

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If you’ve been trying to get pregnant for a year without any luck, it may be time to see your doctor for a fertility assessment. According to experts, a fertility evaluation is appropriate for people who are under 35 and have been unsuccessfully trying to conceive through regular sexual intercourse for 12 months.

For those older than 35, the threshold moves down to six months of unprotected sex without a pregnancy to show for it. The threshold is also six months for those with a history of irregular menstrual cycles, known issues with their uterus or other reproductive organs, or a male partner with fertility issues.

And if you’re 40 or older and want to get pregnant, it's best not to wait on an assessment at all.

“If you are over 40, you should be seeing a fertility specialist immediately,” suggests Jennifer Nichols, DO, a reproductive endocrinologist and director of fertility preservation services at Sincera Reproductive Medicine in Pennsylvania.

But what can one expect at a fertility assessment? We turned to the experts to find out what the evaluation entails—and what the next steps after your assessment might look like.

What Happens at a Female Fertility Assessment?

As part of your evaluation, your healthcare provider will take a complete medical history, do a physical examination, and run some tests. And don’t be surprised if they ask you about your male partner, if you have one. Since male infertility affects 40-50% of couples with challenges trying to conceive, your doctor may want to get a medical history from your partner and run a semen analysis as soon as possible.

Generally speaking, it takes about a month to complete all the testing necessary for a thorough fertility assessment, says Michael Zinger, MD, an OB/GYN and reproductive endocrinologist with RMA Long Island IVF in New York.

Some of it can be done all at the same time. For example, Allison Petrini, MD, an OB/GYN and reproductive endocrinologist with Texas Fertility Center in Austin, says she usually starts with bloodwork and a transvaginal ultrasound at the first visit. One's partner could submit a sample for semen analysis at the beginning, too. Then other tests can then follow as necessary.

“As these results roll in, we’ll identify things that we need to address,” adds Dr. Petrini.

Ultimately, the details revealed by your fertility assessment should give you enough information to make what Dr. Nichols calls “an educated decision about what to do next.” For some, that could mean doing nothing at all, while others might embrace assisted reproductive technology procedures like intrauterine insemination (IUI) or in vitro fertilization (IVF).

Ovarian Reserve Testing

Your ovarian reserve indicates the quality and number of eggs remaining in your ovaries, which can be used to estimate your potential for getting pregnant. Checking your ovarian reserve is a key part of a fertility assessment. Your healthcare provider will be interested in a few different factors:

FSH Levels

A small gland in your brain called the pituitary gland produces a follicle-stimulating hormone (FSH). FSH stimulates your ovaries to produce eggs, and FSH levels reach their highest point right before the ovaries release an egg.

An FSH test can show if there is an issue with your ovarian reserve, with a level higher than 10 IU/L indicating there might be a diminished reserve. However, according to Dr. Nichols, it’s the least reliable of the ovarian factors that are usually assessed.

AMH Levels

Tiny cells inside the follicles of your ovaries produce anti-müllerian hormones (AMH), which are considered essential for fetal development during pregnancy. Your AMH level is also a key indicator of ovarian reserve, as it roughly translates to the number of eggs you have left in your ovaries. A high level of AMH means you have more eggs, and a low level means fewer eggs remaining.

According to the American College of Obstetricians and Gynecologists (ACOG), a low serum level is approximately 1.4 ng/mL, but the monthly probability of conceiving is still about the same as it is for people with normal levels. “If it’s over 1 [1 ng/mL], it’s generally a good sign,” says Dr. Nichols.

Antral Follicle Count

Using an ultrasound, a healthcare professional will look for the number of follicles in your ovaries a couple of days after you start your period. Like the AMH test, it’s considered a surrogate marker for your ovarian reserves, but it has an added advantage by offering a closer look at your ovaries and fallopian tubes. A level consistent with diminished ovarian reserve is a count less than 5-7.

Age can affect the number of follicles, with younger women having more, and older women usually having fewer, notes Dr. Nichols.

It’s helpful to get a handle on your ovarian reserve, because time is of the essence. You only have a finite number of eggs, and they don’t last forever. Egg quality declines over time, too. So you may need to make some decisions.

“If your ovarian reserve has started to decline, you have a smaller window, and you need to move more quickly,” says Dr. Zinger.

However, don’t fret if your test results show low AMH or high FSH. Those results don’t necessarily mean you can’t get pregnant. A 2017 study found that there wasn’t a big difference in natural conception between women with low AMH levels and women with normal AMH levels. Additionally, the researchers cautioned against using AMH levels to fully assess your current fertility.

Additional Bloodwork

Your healthcare provider might also suggest some additional blood tests to check the levels of other hormones.

For example, bloodwork can uncover important information about ovulatory function. This might include a serum progesterone test.

Progesterone is a hormone released by the ovaries that prepares the uterus for implantation and helps sustain the fetus in the early stages. Generally speaking, a progesterone level over 3 ng/mL is a sign of ovulation. Therefore, if your progesterone levels are lower than normal, that could be an indicator that something’s not quite right.

Other blood tests can measure estradiol, which is one of several types of estrogen; luteinizing hormone, a hormone produced by the pituitary gland that helps trigger ovulation; and prolactin, a hormone produced by the pituitary gland that stimulates the breasts to produce milk.

Your doctor may also want to measure your thyroid-stimulating hormone levels, as low levels of this hormone may disrupt your menstrual cycle enough to make it hard to get pregnant.

Additional Reproductive Organ Testing

Other types of diagnostic testing may be used to further investigate possible culprits for your infertility issues. These tests allow your healthcare provider to closely examine your reproductive organs to find out of if something could be wrong.

Transvaginal Ultrasound

During this test, an ultrasound wand is inserted into the vagina and images are produced by sound waves to visualize your uterus, fallopian tubes, and ovaries. “We can get an idea of any abnormalities in the uterus, like growths like fibroids,” says Dr. Petrini. “We can get a look at the uterine shape as well, and we may be able to see things like polyps.”

Hysterosalpingogram

A hysterosalpingogram (HSG) is an X-ray procedure that can determine if something is blocking your fallopian tubes. A thin catheter is inserted through your vagina and cervix, and a contrast fluid is injected into your uterus through the catheter.

Sonohysterography

Filling your uterus with saline might sound like an odd way to see if there’s anything going on that could be impeding your ability to get pregnant. But the saline actually makes it easier for your doctor to get a closer look at the inside of the uterus with a transvaginal ultrasound. This test is sometimes used instead of a hysterosalpingogram.

Hysteroscopy

If something abnormal is spotted during a test like the sonohysterography, your healthcare provider may want to get an even closer look at your uterus. They can insert a lit-up instrument called a hysteroscope through the cervix to to make sure there aren’t any uterine fibroids, adhesions, polyps, or other abnormalities that may be impeding your ability to conceive.

Genetic Testing

Your healthcare provider or OB/GYN may also recommend that you undergo some genetic tests.

A carrier screening is a test that can detect if you or your partner carry a gene for a particular genetic disorder that you might pass down to a potential child. Most carrier screenings are done for recessive disorders that require two copies for the child to actually get the disease.

You’ll probably be offered the opportunity undergo carrier screening for cystic fibrosis, hemoglobinopathies, and spinal muscular atrophy (SMA), but you can opt to undergo screening for other genetic diseases, too, especially since some conditions are more common in people from certain ethnic backgrounds.  

You can also elect other types of genetic tests, such as a karyotype test. A karyotype can detect chromosomal abnormalities that could be making it hard for you to conceive. It’s often recommended to people who've had two or more miscarriages, a history of infertility, or chromosomal disorders.

A Word From Verywell

The whole process of a fertility assessment can be a little—or even a lot—overwhelming. Don’t be afraid to speak up and let your healthcare provider know if you need more information or just more time to grapple with the information you’ve already received. Depending on your age, you may be more inclined to act sooner rather than later, but make sure you get all your questions answered first, no matter what.

11 Sources
Verywell Family uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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  2. American College of Obstetrics and Gynecologists. Infertility Workup for the Women’s Health Specialist.

  3. American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice and the American Society for Reproductive Medicine. InfertilityWorkup for the Women’s Health Specialist

  4. Endocrine Society. Reproductive Hormones

  5. American College of Obstetricians and Gynecologists. The Use of Antimüllerian Hormone in Women Not Seeking Fertility Care.

  6. Coelho Neto MA, Ludwin A, Borrell A, et al. Counting ovarian antral follicles by ultrasound: a practical guide: Consensus OpinionUltrasound Obstet Gynecol. 2018;51(1):10-20. DOI:10.1002/uog.18945

  7. The American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. Female Age-Related Fertility Decline

  8. Steiner AZ, Pritchard D, Stanczyk FZ, et al. Association Between Biomarkers of Ovarian Reserve and Infertility Among Older Women of Reproductive Age. JAMA. 2017;318(14):1367–1376. doi:10.1001/jama.2017.14588

  9. American Society for Reproductive Medicine. Hypothyroidism and Pregnancy: What Should I Know?

  10. American College of Obstetricians and Gynecologists. Carrier Screening

  11. National Infertility Association. What Genetic Testing is Available During My Fertility Care?

Additional Reading

By Jennifer Larson
Jennifer Larson is a seasoned journalist who regularly writes about hard-hitting issues like Covid-19 and the nation's ongoing mental health crisis, as well as healthy lifestyle issues like nutrition and exercise. She has more than 20 years' of professional experience and hopes to log many more.