Basic Infertility Evaluation – Fertility Tests

What tests should be included in the initial infertility evaluation?

Physical exam

A directed physical exam that may include a pelvic ultrasound should be performed. Ultrasound can help us discover abnormalities with the uterus, fallopian tubes and/or ovaries. We can sometimes see evidence of pelvic scarring, such as when an ovary appears to be stuck to the uterus.

Assessment of ovarian reserve

This is a very important assessment of a woman’s remaining egg supplyIt is done with blood testing and ultrasound:

Blood – day 3 FSH, LH and estradiol hormone testing and AMH hormone levelsUltrasound – assessment of ovarian volume and antral follicle counts

Assessment of adequate ovulation

This can be done in a variety of ways. About 25% of all infertility is caused by an ovulation disorder. One type of ovulation problem, polycystic ovarian syndrome, is effectively treated with medications.

Semen analysis

The semen analysis is a very important test and should be done early in the evaluation process. If a severe sperm defect is discovered, the testing on the female partner should be modified, and therapy can be immediately directed to the sperm problem.


This is a surgical procedure and should not be performed until the basic testing has been done on both partners.

In some cases, laparoscopy for infertility will be indicated to look for pelvic scarring or endometriosis.

Hysterosalpingogram – HSG – fertility test for tubal patency and normalcy of the uterine cavity

What is a hysterosalpingogram?

A hysterosalpingogram or HSG is an important test of female fertility potential. The HSG test is a radiology procedure usually done in the radiology department of a hospital or outpatient radiology facility.

  • Radiographic contrast (dye) is injected into the uterine cavity through the vagina and cervix
  • the uterine cavity fills with dye and if the fallopian tubes are open, dye fills the tubes and spills into the abdominal cavity

HSG with blocked tubes

HSG showing a normal uterus and blocked tubes No “spill” of dye is seen at the ends of the tubes both tubes are slightly dilated and fluid filled – hydrosalpinx this woman went on to have successful in vitro fertilization for her tubal infertility


Ovarian reserve fertility tests – evaluation of egg quantity and quality

  • Female age is a very important consideration when estimating the probability for conception because it is a strong determinant of egg quality.
  • A 45 year old can have good quality eggs (for her age) and still be fertile, although this is rare
  • At the other extreme, a 25 year old can have very poor quality eggs and be infertile
  • These are extreme examples. The point is that egg quantity and quality declines – beginning in the early 30s and faster in the late 30’s and early 40s.
  • Egg quantity and quality in a woman can be average for her age, better than average, or worse than average

It would be nice to have a reliable test to determine how many eggs remain and how good the eggs are in an individual woman at a point in time.

Antral follicle count test

Counting the number of 2-9mm diameter antral follicles that can be seen with transvaginal ultrasound gives us a good idea about a woman’s ovarian reserve.

Day 3 FSH (follicle stimulating hormone) and estradiol (E2) test

By measuring a baseline FSH on day 3 of the cycle, we sometimes get an indication that the women is closer to menopause and has relatively less “ovarian reserve”. In other words, if the day 3 FSH is elevated the egg quantity is reduced.

Clomiphene challenge test

A clomiphene challenge test is a dynamic type of test that can discover some cases of poor ovarian reserve that are still showing a normal day 3 FSH. This test is discussed on the day 3 FSH page.

Anti-Mullerian hormone levels, AMH

Blood levels of the hormone AMH are often used by fertility specialists and gynaecologists as part of the evaluation of ovarian reserve.

In vitro fertilization

This is a treatment for infertility, but at the same time it can give us much useful information about egg and embryo quality. By careful examination of the eggs and embryos during the in vitro incubation process we sometimes get clues about why pregnancy has not occurred previously.

Treatment options for women with reduced ovarian reserve:

  • In vitro fertilization
  • Lupron “flare” protocol for ovarian stimulation in low responders
  • In vitro fertilization with assisted hatching
  • In vitro fertilization with donor eggs

Sperm testing and Male Infertility Tests – check for low sperm count, motility and morphology with semen analysis

Background about male fertility and sperm problems

About 25% of all infertility is caused by a male problem, and in 40-50% of cases it is the main cause, or a contributing cause.

It is sometimes hard to know whether the male factor problem is the only cause, or just a contributing cause to the infertility. Part of the problem is that numbers are just numbers:

  • Men with very low sperm counts and low motility scores can sometimes have children
  • Some men with normal counts are infertile without using IVF and ICSI

Semen analysis – check the sperm count, motility and morphology

This is a very simple and important test and should be done early in the evaluation process.

The most important parameters in a semen analysis are:

  1. Concentration (often called “count”) – how many sperm are in each ml of semen?
  2. Motility – what percent of them are swimming forward?
  3. Morphology – what percent of them are normally shaped?

If a severe male factor defect is found, the amount of testing on the female is often reduced. Treatments, such as inseminations or in vitro fertilization can then be started more directly.

Sperm function tests

Sperm penetration assay, also called the hamster egg test

The sperm is mixed with hamster eggs to see whether they penetrate the eggs. It is expensive and there are many false positives and also false negative results.

Sperm antibody testing

  • Sperm antibodies in the blood of men or women do not affect fertility.
  • Antibodies on the head of the sperm can cause failure of fusion with the egg.
  • Spontaneous pregnancy rates are higher in couples without these antibodies. However, fluctuations are seen even without therapy.
  • Antibody testing can help determine whether sperm should be injected into the eggs if the couple does in vitro fertilization.
  • Sperm injection into the egg is called ICSI


In some cases the man is referred to a urologist to assess whether he might have a correctable condition called a varicocele.

The best treatment option depends on the degree of abnormality in the semen and other factors, such as the age of the female partner, results of her ovarian reserve testing, etc.