The Basic Fertility Work-up

If you decide to be assessed by a fertility specialist there are a number of tests that are routinely ordered.  With a complete work-up, you should be able to determine if you have all of the essential elements for reproduction.  However, approximately 15% of couples will have a completely normal work-up despite having difficulties conceiving.  Investigations are targeted to the causes of reduced fertility, which include the following:

  1. Abnormalities in sperm counts or “male factor”:  35%
  2. Blocked or scarred fallopian tubes:  35%
  3. Ovulation dysfunction: 15%

For men, there is only one test…..the sperm test.  From a semen sample, the volume, sperm count, motility (or movement), and shape can be assessed.  Normal values are derived from the World Health Organization, and the most recent publication in 2009 gives the following reference values:

1.5mL volume

15 millionsperm/mL

32% progressive motility

4% normal shape or “morphology”

If there are abnormalities found, a repeat sample may be ordered, as well as hormone tests, scrotal ultrasound, and/or genetic testing.  The investigations are chosen based on the
severity of the problem.

For women,the testing is a little bit more complicated…. shocking, I know.   All tests are timed to the menstrual cycle.  Hormones should be evaluated on day 3 and day 21 of the menstrual cycle.  The hormones on day 3 include follicle stimulating hormone (FSH), luteinizing hormone (LH), and estradiol.  These tests together should give an idea of how the brain and ovaries are functioning together.  The day 21 hormone assessment is for a progesterone level, and when elevated, indicates that ovulation has taken place.  Ultrasounds are also part of the work-up.  A baseline ultrasound should be completed in the first week of the cycle to assess the general anatomy, as well as to do an “antral follicle count” or AFC.  The AFC gives an estimate of the overall pool of egg follicles in the ovary and thus, the overall “ovarian reserve”.  Women are born with all of the egg follicles they will ever have, and over time the pool of eggs is depleted.  Therefore an AFC estimate will indicate if a woman has an average number of egg follicles for her age.  Finally an assessment of the fallopian tubes should be done to confirm that they are not blocked.  This is typically done by injecting saline into the cavity of the uterus and watching it flow through the fallopian tubes using ultrasound.  This is known as a saline infusion sonogram.  Using dye and x-ray is an alternative approach to assess the fallopian tubes.

After completing a semen analysis, hormone testing, ultrasound and saline infusion sonogram, a couple will have the information they need to know if there is an issue that may be affecting their ability to conceive.  Although the testing may sound daunting, it can be completed on average in three weeks.

27 thoughts on “The Basic Fertility Work-up

  1. Hi Dr. Jackson,

    On the requisition form for bloodwork at OFC, there are many tests listed. One of the tests listed on the form is DHEAS. I’ve had the full day 3 bloodwork done and the progesterone check but never the DHEAS. So, I’m curious what that test is? What does it measure and what does it help assess? Who is it relevant for?

    Thank you!

    • DHEAS is a test of a specific male hormone. This is ordered most commonly ordered for patients where there is a question of possible “Polycystic Ovarian Syndrome” or PCOS. This syndrome is characterized by irregular cycles, polycystic ovaries on ultrasound, and/or high male hormone levels. If patients have a suspicion for PCOS but I am uncertain about the diagnosis, I will order this test to clarify the diagnosis. Hope that helps.

  2. Hello Dr. Jackson,

    I’ll be undergoing a hysterosonogram on Monday as part of my basic fertility workup. Why is it that I am not allowed to have intercourse with my husband until after the test, and why was I told this over the phone (by my doctor’s assistant) as opposed to from reading the information sheet I was given about the test at my 1st appointment. The assistant told me that is is because “they” don’t want patients to be pregnant the day of their test, but how is that even possible? Hysterosonograms are administered between days 6-12 and from what I know, it takes a mininum of 6 days for implantation to occur. So unless a woman ovulates before cycle day 6 (which I know not to be my case: I do ovulation tests and monitor my basal temperature each month) and has her test on day 12, how could she possibly be pregnant on the day of her test? Doesn’t pregnancy officially begin with implantation? Perhaps I am misinformed.

    Many thanks for explaining.

    • Thank you for your question. You are correct in that implantation of a fertilized egg does not occur immediately. An egg is fertilized within the fallopian tube and takes approximately one week to travel the length of the tube and implant within the lining of the uterus. A sonohysterogram involves flushing saline from the cavity of the uterus into the fallopian tubes, and visualizing spill out the end of the tube with ultrasound. This test is done to confirm both tubes are open as part of the fertility work-up.

      The reason for the concern of intercourse prior to the test is that a woman may ovulate prior to the test, and if this early embryo is traveling down the tube, it is theoretically possible for it to be flushed backwards. The risk with this is that the embryo may implant within the tube rather than the cavity of the uterus, or even outside of the tube within the pelvis. This is referred to as an ectopic pregnancy and can be life threatening if not recognized early. It is to avoid an ectopic pregnancy that intercourse is discouraged prior to testing. However, the test is timed so that a couple can continue to attempt conception immediately following the test, and will not miss a month of trying. Sperm can live up to 4 days within the genital tract and it is therefore recommended that at least 4 days of abstince occurs prior to testing.

  3. Hi Dr. Jackson,

    I’m curious how AFC varies over the course of a normal a cycle? I’ve done a couple of cycles now with Clomid and therefore ended up having a couple of ultrasounds on day 10. I noticed that my AFC on day 10 seems to be very similar to my baseline AFC on day 3 (not in terms of dominant follicle/s – but in terms of the smaller follicles that they also count – and knowing that some variation is normal, the difference didn’t seem significant). I know that antral follicles don’t become susceptible to FSH until they become roughly 2mm, but their development prior to that doesn’t seem to be hormone dependent – which would seem to mean that their emergence and demise does not seem to be tied directly to a particular period of time during the menstrual cycle.

    I started to try to find some information about this on the internet, and came across a paper that seemed to say that there is no significant intracycle variability in AFC for follicles measuring 2mm or greater. This was not the case with follicles measuring greater than 6mm, for which there was substantial variation, and which is logical. The paper seemed to suggest that AFC of follicles 2mm and greater and AMH were the two indicators of ovarian reserve with the least variability during a cycle (the paper said that AMH stays more or less constant but does increase marginally in the luteal phase – and I know that this can be measured at any time). If this is correct, I’m wondering why AFC has to be measured between days 2-5 of a cycle? Why can it not be measured at any time, taking into account that later in the cycle, there will be more follicles measuring > 6mm?


    • Great question. The reason for the time sensitive nature of measuring antral follicles is because there is in fact some variability noted during the cycle and studies have shown that early scans are most predictive of ovarian reserve and response to medications during ovarian stimulation. Antral follicle counts (AFC) are defined as follicles measuring 2-9mm, so the smaller ones (2-6mm) may not vary as much, but the larger 6-9mm follicles will vary as FSH changes in the cycle, ultimately changing the overall AFC. Some may become more than 9mm and would no longer be considered antral follicles, and it is for that reason that AFC estimates are obtained early in the menstrual cycle.

      Anti-mullarian hormone or “AMH” is a hormone detected in the blood that does not vary with the menstrual cycle and can therefore be drawn at any time to test for ovarian reserve. All other tests for ovarian reserve to date are cycle day specific. The accuracy of AMH when compared to AFC or hormone levels (FSH) has been shown to be the same.

  4. Hello Dr. Jackson,

    I understand that for the assessment of sperm morphology that there are 2 methods that can be used – the first being a crude estimate and the second using the kruger strict morphology methodology. You’ve posted that the WHO criteria for a normal morphology is > or = 4%. I’m wondering if the 4% cutoff for a “normal interpretation” is also applied to the results of a strict morphology assessment or if there is a different cutoff depending on the method used (i.e. is the 4% the limit for “normal” also for the results from a Kruger strict analysis)?

    Thank you again!

    • Yes, there is a different cut-off depending on the semen analysis performed. For the basic assessment, a visual estimate is given of the number of sperm that appear normal, and anything >30% is “normal”. For the more strict Kruger assessment a special stain is applied and an andrologist reviews 200 individual sperm, assessing the head, tail and midpiece. This is a much more accurate assessment and is the reason for the lower cut-off for normal.

  5. I just got my day 3 blood work results and everything (FSH, estradiol, prolactin, TSH, and progesterone) was in the normal range. However, I ovulate on day 20 of a 28-30 day cycle (clearly indicated on basal body temperature charts for 3 months). So my luteal phase is shorter than typical. I know that luteal phase defect is debated and from my readings it looks like a poor luteal phase is due to a poor follicular phase. My question is, what do I make of my cycle pattern now that my hormones checked out? I’d like to just relax and think there must be nothing wrong, but from my understanding, my luteal phase is too short to support implantation if fertilization actually occurs.

    • Keep in mind that basal body temperature rises after you have ovulated, so if you are seeing the spike in temperature on day 20, you probably ovulated a day or two before that. A short luteal phase is defined as less than 10 days from ovulation to menses. Try testing with ovulation kits to determine when the start of your ovulation is. If you are finding that the majority of your cycles have a luteal phase less than 10 days, you may want to consider trying progesterone supplementation. However, keep in mind that this is highly debated amongst reproductive specialists, some believing that there is something to the “luteal phase defect”, and others not. There is no clear evidence to support luteal phase progesterone, but it has no apparent harm, and may be worth trying in the absence of any other issues found on testing. Talk to your doctor to see if this is an option for you. Good luck.

      • Hello Dr. Jackson,

        My temperature spiked on CD 21 for 3 months in a row, so I took that to mean I was ovulating on day 20. I had positive OPKs on CD17, 19, and 20 (respectively, each of those months). I will speak to my doctor about progesterone supplementation following my upcoming CD21 progesterone blood work. What are your thoughts on clomid to advance ovulation? I worry that having a late ovulation within a typical cycle length indicates poor quality ovulation. Could this be possible in the absence of normal CD3 blood results? I have been referred to an RE but it takes 4-6 months to get in where I live and I have lots of questions.

        • Clomid is also an option to regulate cycles that fall out of the normal range, however it is a medication that puts you at risk of twins (or more) and for that reason I usually try progesterone first. Your physician will be able to guide you with regards to the most appropriate course of action. Good luck.

  6. Hello :),

    I am new to the forum and just had my CD3 / CD21 test results yesterday.. My FSH came back at 13 (im 31)… (I am being re-tested and will have to sched. a AFC… Dr.’s orders :), everything else was good (LH, estradiol, progesterone etc) . Is 13 really really high, Could I still qualify for IVF?? My spouse’s results were not that great either (yep, double whammy for us). I’m hoping that the first FSH results were just a “fluke”. But I’m still very worried and have been stressing over it for about 24 hours now… I wanted to ask our Doctor yesterday but didnt think to ask (shock I guess…)

    • The cut off for a normal FSH is less than 10. However, 13 is not considered to be exceptionally high, and there are women that go on to do IVF with values in your range. It will depend on a number of other factors including your antral follicle count and age. Once all of the investigations have been completed your physician will be able to give you a tailored prognosis for success with IVF. I wish you good luck!

      • Thank you Doctor Jackson. But I was wondering, what is a “normal” antral Follicle count (im 31)? And how many does it take to qualify for IVF? I know that if the count is to low, one may not qualify for IVF. :)

        • Normal antral follicle count depends on age. For your age group, most women will have an AFC of 15 or more. However, lower counts do not necessarily mean IVF is not possible. There are also different ways to do IVF, such as something called natural cycle IVF if FSH values are very high and antral follicle counts are low. I would wait to see what your doctor says about your chance for pregnancy.

  7. I have recently started going to the OFC and would like to know, from the moment you take the all the tests, approximately how much time it should take to get all the results back and what is the average wait time for a second visit with the doctor?

    Thank you!

    • Testing is all timed to your menstrual cycle, so timing for follow-up is usually planned about 4-6 weeks after your first visit to go over all of the results, depending on when you start your period.

    • We do offer scrotal ultrasounds, but only in the setting of a fertility issue, and for men who are currently patients at our clinic. If you are from Ontario it is covered by OHIP. Testicular pain should not be ignored, and I would suggest you see your family doctor or go to a walk in clinic to have it assessed as soon as possible.

  8. hi Dr, Jackson
    I was referred to a gyn since my family doctor said I have PCOS; the Obygyn sent me for a Hysterosalpinogram, everythin was ok, then for some blood tests (FSH, LH and estradiol) in 3rd and 21st day. and last week that we went for follow up, he said i have PCOS and anovulation so he said the only thing was left was to sent me to the infertility clinic to start considering IVF or IUI…
    we are a young couple (me 30 h:32) i dont think we should be sent there yet.. is there any other test to be done??

    • Sometimes with PCOS a pill called Serophene (Clomid) can be used to help with ovulation. Seeing a fertility specialist may be helpful for you to understand what all of your options are, and to review your test results to see if there are any other investigations that can be ordered. It never hurts to get more information. I say go for it. Make an appointment with the fertility clinic and arm yourself with information to help you make a decision about what treatment is best for you and your partner.

  9. Hello!

    I was wondering is there a way to inventagetion ( how it right words spelling) to find out what cause the issue for not able to get sperm to give it to beautiful wife pregnent. All my life wanted a kids but I still not got any luck. So what I want to know is there a doctor specialist to be able to go in to figure out what went wrong… My heart broken for not got my dream true… I hope to hear from you soon for information.

    • You should first see your family doctor about this and they might consider referring you to see a urologist or fertility specialist for help. Good luck.

  10. Hi Dr Jackson, I’m in my forty’s am going to try to conceive a second child. I had no problems with my first child who’s now 11. And was pregnant on first try. Knowing my age is working against me my family dr wrote a requisition for DAY 21 prog and also estradiol and fsh at my request. He said to get the blood work done on day 21. Maybe I misheard him but shouldn’t the fsh and estradiol be done on day 3 and prog on 21? Thanks for your help.

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