Couples find it interesting and then frustrating when they have spent so much time and energy avoiding getting pregnant, only to realize that when they want to get pregnant, it may not be as easy as they thought! A fertile couple has about a 25% chance of conceiving in any menstrual cycle and when that couple is over 30, chances get slimmer.
As women age, many factors affecting fertility decline, including:
- number of days you make high-quality cervical fluid
- number of ovulatory cycles vs non-ovulatory cycles
- quality of healthy eggs
- length of the luteal cycle
- estrogen and progesterone release
Fertility Diagnostics Tests & Procedures
| Test | Best time taken | Purpose |
| Body temperature | Throughout the cycle | Determine whether you are ovulating and length of luteal phase |
| Cervical Fluid Ferning Slide | Days of wet & slippery cervical fluid | Determine if your cervical fluid is fertile and if you are producing enough |
| Postcoital Test | Close to ovulation | Determine if the sperm can survive in the cervical fluid |
| Cervical fluid ferning slide | Before ovulation, when cervical fluid is wet & slippery | Determine if your cervical fluid is fertile |
| Ultrasound | Several times before ovulation | Evaluate follicle maturation & size, ovulation, and endometrial thickness |
| Endometrial biopsy | 1 or 2 days before the expected period | Determine if the luteal phase is long enough and the uterine lining is suitable |
| Hysterosalpingogram (HSG) | The week after the period ends | Identify if the fallopian tubes are clear & uterine cavity normal |
| Hysteroscopy | Before ovulation | Examine if the uterine cavity is normal |
| Laparoscopy | Before ovulation | Diagnose & treat pelvic conditions, such as endometriosis |
| Hormone blood tests | Various times during the cycle | Examine if you produce enough of the necessary hormones |
| Ovarian reserve tests | Various times during the cycle | Determine the quality & quantity of your eggs |
Body Temperature
This is the easiest of all the diagnostic tests and you can do it yourself at home. Charting your body temperature can help you identify if:
- You are ovulating
- Your luteal phase is long enough for conception (>10 days)
- Your progesterone levels in the luteal phase are high enough
- You have a thyroid issue
- You are fertile
- You may have conceived (>18 high temps)
- You are in danger of miscarriage (sudden or gradual drop in temperature)
Cervical Fluid Ferning
Cervical fluid is removed from the vagina and is tested to determine if a woman is fertile on any given day. The timing of the test is crucial, as the results will be invalid if performed on the wrong day of the cycle.
Post-coital Sperm Test
A sample of cervical fluid is taken within 2 hours of intercourse and the test determines if the sperm can swim forward to reach the cervical fluid. If the test is performed on day 14 it may give false results since ovulation does not always occur on day 14. Accuracy of this rest requires ovulatory type cervical fluid along with healthy viable sperm.
Vaginal Ultrasound
This diagnostic procedure determines if and when a woman is ovulating or if she suffers from LUFS. LUFS (luteinized unruptured follicle syndrome) is a condition where a woman has all the symptoms of ovulation but without releasing an egg. The timing of the test is crucial, so it is important to chart your cycles and perform the test when you start producing fertile-quality cervical fluid.
Endometrial Biopsy
A small piece of the uterine lining is removed a couple of days before the expected period. This test helps determine if a woman is forming a healthy lining of her uterus post ovulation to allow implantation and healthy growth of a fertilized egg.
HSG (hysterosalpingogram)
This is an X-ray test using a dye that is injected through the cervix into the uterine cavity to see if the fallopian tubes are open in which case the dye will flow through the fallopian tubes and spill out into the abdominal cavity. This flow is documented with x-ray pictures during the procedure.
A positive result confirms that the fallopian tubes are open but does not necessarily confirm optimal function of the fallopian tube which is also necessary for pregnancy to occur. Proper fallopian tube function allows the egg to be picked up after ovulation and transported down into the uterus where implantation and growth occur- all necessary for a successful pregnancy.
If the egg is picked up, transported, and fertilized properly, but tubal damage prevents further transport of the embryo to the uterus, implantation may occur in the fallopian tube resulting in a tubal pregnancy.
Although this test is useful, it can cause discomfort and has its limitations, as it cannot reveal scarring or can give false indications of blocked tubes when they are actually open . Variations of this diagnostic procedure include:
- Fluid ultrasonography (FUS)-a saline solution using vaginal ultrasound checking if the uterine cavity is normal
- Tuboscopy– a thin telescope identifies any inner structural problems of the fallopian tubes, such as polyps or scar tissue
- Falloscopy-A fiber-optic tube evaluated the fallopian tubes
- Selective hysterosalpingogram– A thinner catheter which can clear any obstruction in the fallopian tubes, also acts as therapy to open the blocked tube.
- HyCoSy (Hysterosalpingo-contrast sonography)-a small amount of fluid is injected in the uterus
- Tubal Perfusion Pressure– examines the functioning of the tubes
Hysteroscopy
This procedure, also known as “window to the womb”, identifies if the woman suffers from any conditions which will affect pregnancy, such as fibroids.
Laparoscopy
This exploratory surgery involves a tube inserted into the pelvic region to detect and treat any pelvic issues, such as endometriosis.
Hormone Blood Tests
| Hormone | Best Time Taken | Purpose of the hormone |
| Follicle Stimulating Hormone (FSH) | Day 3 or Day 10, if part of Clomid challenge Test | Triggers follicle development. If FSH too high, possible menopause or low fertility |
| Estradiol | Day 3 & mid-luteal phase | Triggers egg maturation & endometrial maturation for a fertilized egg. Also responsible for the quality of cervical fluid for fertilization |
| Inhibin B | Day 3 | Blocks FSH and can predict ovarian reserve |
| Luteinizing Hormone (LH) | Around ovulation | Stimulates ovulation when it rises |
| Progesterone | Mid-luteal phase (7 -10 days after the LH surge) | Sustains the uterine lining and early pregnancy |
| Pooled Progesterone | Thermal shift days 2,4,6,8, 10 orPeak day plus 3,5,7,9,11 | A more accurate test for progesterone |
| Prolactin | Any cycle day | Triggers breast milk release and blocks the production of estrogen |
| Thyroid Stimulating Hormone (TSH) | Any cycle day | Triggers the production of thyroxine, the hormone responsible for normal thyroid function. Very high or low levels may affect fertility |
| Testosterone | Any cycle day | Stimulates estrogen production. Very high levels may affect fertility |
| Dehydroepiandrosterone sulfate (DHEAS) | Any cycle day | Same effects as male hormones. Very high levels may affect fertility in both men and women |
Ovarian Reserve Tests
Women are born with around 300,000 eggs and as she ages, this quantity declines to cause fertility to decline in a steady way until age 37. After this age, fertility decreases more rapidly in most women until menopause. Some questions that women of a certain age have include:
- What is the status of my fertility?
- How many years of fertility do I have left?
- How well will my body react to assisted reproductive technologies, such as IVF?
Although the quality and quantity of eggs decline for all women, the extent to which they do is unique for every woman, therefore it is important to test your so-called “ovarian reserve”. There are various diagnostic tests, and ideally, you should try two or three of them for better assessment of your ability to conceive.
Antral Follicle Count
Through a vaginal ultrasound, a radiologist can measure the number of immature resting follicles you have available for a given cycle. These follicles can develop into mature follicles that can hold the egg. The number of resting follicles tends to be consistent from one cycle to the next.
This test is done on day 3 of the cycle and is usually done in women who wish to try IVF or women younger than 30 who wish to determine their future fertility.
The more immature follicles you have, the more eggs you can produce that cycle. If you have 6-10, you will likely have a normal response to IVF. As for women younger than 30, the more follicles you have, the more years of fertility you have left.
Anti Mullerian Hormone (AMH) Test
AMH is a hormone produced by immature follicles. The AMH test is a blood test that measures the number of remaining eggs in a woman’s ovarian reserve and can be performed on any day of the cycle. AMH levels are considered to be a better pregnancy predictor than FSH levels.
Typically, AMH levels decrease as women age. Therefore, it is important to consider the AMH levels in relation with the woman’s age. Normally, the higher the AMH levels, the higher the fertility and the better response to IVF.
| Age | AMH Levels |
| < 33 Years | 2.1 ng/mL |
| 33-37 Years | 1.7 ng/mL |
| 38-40 Years | 1.1 ng/mL |
| = 41+ Years | 0.5 ng/mL |
| Interpretation(women under age 35) | AMH Levels |
| High (often PCOS) | > 4.0 ng/mL |
| Normal | 1.5- 4.0 ng/mL |
| Low Normal Range | 1.0- 1.5 ng/mL |
| Low | 0.5- 1.0 ng/mL |
| Very Low | < 0.5 ng/mL |
Considerations!
- AMH levels in women over 42 are considered unreliable.
- AMH levels can predict the number of eggs but do not provide any information about the quality of eggs.
- Women with PCOS typically have very high AMH levels, as they have an excessive number of immature follicles.
Follicle Stimulating Hormone (FSH)
FSH is one of the most important hormones involved in the cycle. It is released by the pituitary gland and is responsible for producing mature eggs in the ovaries. FSH is also the hormone used to produce multiple eggs during infertility treatments.
The FSH test is performed on day 3 of the cycle. Typically, FSH levels increase as women age. Think of FSH like the gas needed to get the ovaries working to develop follicles and eggs. As women age and the number of follicles decline, the woman may need more gas (the FSH goes up) to get the same ovarian function. Therefore, it is important to consider the FSH levels in relation to the woman’s age. The lower the FSH levels, the better the ovarian reserve, and the better the response to IVF.
| Age | FSH Levels |
| < 33 Years | <7.0 mIU/mL |
| 33-37 Years | < 7.9 mIU/mL |
| 38-40 Years | <8.4 mIU/mL |
| = 41+ Years | < 8.5 mIU/mL |
| FSH interpretation for Roche or Immulite assays | FSH Levels |
| Normal FSH level. Good response to ovarian stimulation | < 9 mIU/mL |
| Fair FSH level. The response is between normal and somewhat reduced (response varies widely). Slightly reduced live birth rate. | 9-12 mIU/mL |
| Reduced ovarian reserve. Reduced response to stimulation Reduction in embryo quality with IVF. Reduced live birth rate. | 11-15 mIU/mL |
| Highly reduced response to stimulation Further reduction in embryo quality. Low live birth rates. Antral follicle count is an important variable! | 15-20 mIU/mL |
| This is pretty much a “no go” level in our center. Very poor (or no) response to stimulation. “No go” levels should be individualized for the particular lab assay and IVF center. | > 20 mIU/mL |
Considerations!
• Women in menopause typically have very high FSH levels, over 40 mlU/ml. However, if this happens in a woman under 40 years of age, then it is determined that she has premature ovarian failure or premature menopause.
• Your ovarian reserve is as bad as your worst FSH. If you have an FSH of 15 in one cycle and then a 7 in another cycle – the situation is not improving. Some women “bounce around” with FSH levels in the normal to the abnormal range. However, they tend to respond and have chances for pregnancy predicted by their highest FSH level.
• While a high FSH level predicts low ovarian reserve, a normal FSH level does not necessarily mean that egg quantity is good and pregnancy can occur. There are a significant number of women with normal FSH values that have a reduced egg supply. The lower egg supply is simply not being reflected in their FSH value. This is why doing antral follicle counts and AMH levels can be useful. By doing multiple ovarian reserve tests, we are more likely to find an ovarian reserve problem if there is one.
Clomiphene Citrate (Clomid) Challenge Test
This dynamic test can discover some cases of poor ovarian reserve that are still showing a normal day 3 FSH.
This test is done by:
1. Obtaining a day 3 FSH and estradiol
2. Take 2 tablets of clomiphene (100 mg) on days 5-9 of the cycle
3. Repeat an FSH level on day 10 of the cycle
Normal values include low FSH and low estradiol on day 3 and a low FSH on day 10. Cut off values for the day 3 and the day 10 FSH values are assay dependent and must be determined by experience with the lab being used. However, this test is more expensive and time-consuming than testing an FSH alone and is not more predictive.
Estradiol Test
This blood test performed on day 3 of the cycle can discover some cases of decreased egg quantity and quality that have normal day 3 FSH levels.
Normal values on Day 3 include a low FSH level in conjunction with a low estradiol level. If the FSH is normal but the estradiol level is elevated, the high estradiol will often be artificially “suppressing” the FSH level down to the normal range.
The idea of using day 3 estradiol levels as an adjunct in evaluating egg quantity and quality is relatively recent and so clearly defined cutoff values for normal are not well established. In one lab, normal cut off values for estradiol on day 3 should be less than 80.