Female Fertility Testing: How Does it Work?

By (embryologist), (gynecologist), (embryologist) and (babygest staff).
Last Update: 07/05/2019

To study female fertility, they perform a series of exams including transvaginal ultrasound, blood hormone analysis and hysterosalpingography. The set of results obtained will serve the specialist to indicate the state of the patient's fertility and, therefore, determine which is the most appropriate assisted reproduction treatment to achieve pregnancy.

In this article we explain what the main female fertility tests are.

Complete Gynecological Check-Up

The most important examination of the gynecological check-up is the vaginal ultrasound. Through the ultrasound, the specialist checks the condition of the uterine cavity and ovaries. In this way, it is possible to see if there is any alteration or abnormality that may prevent conception.

In addition, thanks to this test we can carry out an antral follicle count in order to have an approximate idea of the woman's ovarian reserve. A value equal to or greater than 8 follicles is usually indicative of a good ovarian reserve. Follicles are structures of the ovary in which the ovules develop and mature before ovulation.

Another test that is usually included in the gynecological check-up is the cytology, also known as a Pap test. It consists of taking a small sample of cells from the cervix for analysis. This test allows us to detect infections and strange changes in the cells that may indicate the development of cervical cancer.

Female Hormone Analysis

A woman's menstrual cycle is regulated by hormones. Any irregularity in hormone levels can affect fertility, so doing an analysis to determine the level of these hormones in the blood is of great help in knowing the fertility status of women.

Generally, the blood test is done on day 3 of the ovarian cycle, considering that it begins on the day when periods starts. It is also possible to analyze some hormones, such as progesterone, on day 21 of the menstrual cycle.

In short, these are the main hormones evaluated through this blood work:

  • FSH (Follicle Stimulating Hormone): a gonadotropin released by the pituitary gland and responsible for activating ovarian development. Normal values are between 3 and 10 mUI/ml. Levels below 6 indicate an excellent ovarian reserve, values of 6 to 9 are good, 9 to 10 moderate and above 10 usually indicate a low ovarian reserve.
  • LH (Luteinizing Hormone): it is also a gonadotropin released by the hypophysis that acts on the ovary, causing ovulation. A normal value is from 2 to 10 mIU/ml LH. It is important that there is a correlation with FSH of approximately 1:1. If the LH hormone does not follow this relationship and is higher, it could be an indicator of Polycystic Ovary Syndrome (PCOS). In that case, additional tests may be needed.
  • Estradiol: released by the ovary as oocyte development progresses. It should have a blood value between 25 and 75 pg/ml. However, ideally on the third day of the cycle it should be below 50 pg/ml.
  • Prolactin: This hormone is released by the pituitary gland. Its normal level is between 0 and 20 ng/ml. Very high values give rise to what is known as hyperprolactinemia, which seriously affects the hormonal regulation of fertility.
  • Progesterone: On day 3 of the cycle, this hormone must have a level below 1.5 ng/ml, as it is released by the corpus luteum and this is not generated until ovulation occurs (which is normally mid-cycle). For the value of this hormone to give us information, it must be analyzed on day 21 of the cycle. At this time, it must have a blood level higher than 5 ng/ml, as this indicates that ovulation has taken place. In any case, it should ideally be above 10 ng/ml.
  • AMH (Anti-müllerian hormone): is a hormone released by the follicles of the ovary. It is considered a good indicator of ovarian reserve. It can be analyzed on any day of the cycle, as it is independent of the cycle. An AMH value of between 0.7 and 3.5 ng/ml is related to a good ovarian reserve. The lower the ovarian reserve is, the lower the AMH value.

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Blood tests to evaluate hormones such as TSH (thyroid-stimulating hormone), free thyroxine (T4), free triiodothyronine (FT3), prolactin, and total testosterone may also be required. Although these are not sex hormones, if their levels are above or below the average, they can have a negative impact on the hormones that control the menstrual cycle and the ovulation in particular.

Hysterosalpingography (HSG)

Hysterosalpingography is a diagnostic test to study the permeability of the fallopian tubes. Since fertilization (union of egg and sperm) takes place inside the tubes, it is essential to see if passage through them is possible.

This test also makes it possible to analyze the structure of the uterine cavity.

A radiopaque contrast medium (a liquid that does not let radiation through and therefore allows visualization when x-rays are applied) is passed through the woman's reproductive tract through a catheter placed in the vagina. If the fluid does not find any obstacles in its way, it will exit into the pelvic cavity. If, on the other hand, there is a blockage in the fallopian tubes, the fluid will stop.

The application of x-rays will make it possible to visualize the path of the contrast and analyse if there is any blockage in the tubes, as well as any malformation in the uterine cavity.

The result can be:

  • Positive Cotte: indicates that the tubes are permeable and, therefore, the contrast passes through the two tubes and is expelled into the abdominal cavity.
  • Negative Cotte: whether unilateral or bilateral, means that one or both tubes are blocked and, as a consequence, do not allow contrast to pass through their structure, causing them to inflate. It is also possible that the fallopian tubes cannot be seen due to tubal or uterine malformation.

If the tubal obstruction is mild, this test can help unblock the tube and allow passage through it again. However, this occurs in rare cases.

Other Supplementary Testing

In some cases, additional tests are required. These are studies that are only necessary to deepen the study of female infertility.

The most common are:

  • Karyotype: This is a study of a woman's chromosomes. A blood test checks whether the woman has a 46XX karyotype (normal) or if there is any chromosomal alteration that may prevent the search for pregnancy.
  • Hysteroscopy: this is a medical procedure that allows the visualization of the uterine cavity thanks to the introduction of an endoscopic camera. It is a simple ambulatory intervention of short duration, which allows to see the presence of polyps, fibroids and other uterine malformations.
  • Endometrial Biopsy: this involves removing a small fragment of the endometrium for analysis in the laboratory to study the presence of any pathogenic agent or abnormality that may be preventing embryo implantation or the ascent of sperm in search of the egg.

There are other less common tests such as the coagulation test, urinary sediment analysis, etc.

FAQs from users

What are the main female infertility tests?

By Dr. Joel G. Brasch (.).

The main female infertility tests include:

  • Blood test – Day FSH and E2, Anti mullerian hormone (AMH), TSH, Prolactin
  • Tube test – Hysterosalpingogram
  • Pelvic ultrasound with antral follicle count

How much does a female fertility test cost?

By Sara Salgado (embryologist).

It depends on the tests required and the location where they are performed, but in general the cost of a basic female fertility study can range from $150 to $500 on average.

A hysterosalpingography can cost up to $800-3,000. As for a pelvic ultrasound, a pap smear, and a gynecological exam, the price can be $200 in total, and hormone blood tests can cost up to $50-200 each.

Are these tests painful?

By Andrea Rodrigo (embryologist).

The gynaecological examination is usually not painful, nor is the blood test. On the contrary, hysterosalpingography can cause discomfort or pain. There are women who simply notice a small discomfort of the same intensity as the cytology or any other gynaecological check-up, while there are other women who feel more pain.

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Authors and contributors

 Andrea Rodrigo
Andrea Rodrigo
Bachelor's Degree in Biotechnology from the Polytechnic University of Valencia. Master's Degree in Biotechnology of Human Assisted Reproduction from the University of Valencia along with the Valencian Infertility Institute (IVI). Postgraduate course in Medical Genetics. More information about Andrea Rodrigo
Dr. Joel G. Brasch
Dr. Joel G. Brasch
Dr. Joel Brasch is the Medical Director of Chicago IVF, founded in 2005. He is board certified by the American Board of Obstetrics and Gynecology, and has over 25 years of direct experience in fertility treatment and reproductive care. He is also the Director of Mount Sinai Medical Center’s Division of Reproductive Endocrinology and Infertility. More information about Dr. Joel G. Brasch
 Sara Salgado
Sara Salgado
Degree in Biochemistry and Molecular Biology from the University of the Basque Country (UPV/EHU). Master's Degree in Human Assisted Reproduction from the Complutense University of Madrid (UCM). Certificate of University Expert in Genetic Diagnosis Techniques from the University of Valencia (UV). More information about Sara Salgado
Adapted into english by:
 Marie Tusseau
Marie Tusseau
Babygest Staff
Editorial Director of Babygest magazine in French and English. More information about Marie Tusseau

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