Fertility testing typically starts with blood work, an ultrasound, and a detailed medical history, then expands to more specialized tests depending on what those initial results show. The process evaluates three core things: whether you’re ovulating, whether your reproductive anatomy is clear of blockages or structural problems, and whether your partner’s sperm is healthy. Most people get answers within one to two menstrual cycles.
When to Get Tested
The general guideline is to seek a fertility evaluation after 12 months of regular, unprotected sex without becoming pregnant. If you’re over 35, that window shrinks to 6 months. If you’re over 40, the American College of Obstetricians and Gynecologists recommends talking to your doctor right away rather than waiting.
These timelines aren’t arbitrary. Egg quantity and quality decline with age, and earlier testing means more options if something needs to be addressed. You can also request testing proactively, before you start trying, if you want a general picture of where you stand.
The First Appointment: Medical History
Before any lab work, your doctor will spend time gathering information. This conversation covers more ground than most people expect. You’ll be asked about your menstrual cycle length and regularity, pain during periods or between periods, any bleeding between cycles, prior pregnancies, sexually transmitted infections, and previous surgeries. Your doctor will also ask about your sexual history, including how often you’re having sex now.
Some questions target specific hormonal conditions. Rapid weight gain or loss, excessive hair growth, and persistent acne can all point toward hormonal imbalances like polycystic ovary syndrome. A family history of fibroids or endometriosis is also relevant, since both can affect fertility. Your doctor will ask about prescription medications, caffeine and alcohol intake, and whether your work exposes you to chemicals or toxins.
Blood Tests That Measure Hormone Levels
Fertility blood work checks whether your hormones are at the right levels to support egg development and ovulation. The timing of these blood draws matters because hormone levels shift throughout your cycle.
On day 3 of your cycle (counting from the first day of your period), your doctor will typically check FSH, or follicle-stimulating hormone. FSH is the most commonly used marker for ovarian reserve, which is a way of estimating how many eggs you have left. When FSH rises above normal on day 3, it suggests your ovaries are working harder to develop eggs, a sign that your egg supply is declining. Your doctor may also check another hormone called LH at the same time. The ratio between these two hormones can reveal diminished ovarian reserve even when FSH looks normal on its own.
A second key blood test is AMH, or anti-Müllerian hormone. Unlike FSH, AMH can be drawn on any day of your cycle. It gives a more direct estimate of your remaining egg supply. Typical AMH values vary significantly by age: the median for a 25-year-old is about 3.3 ng/mL, while a 35-year-old’s median drops to 1.4 ng/mL, and by age 40 it’s around 0.5 ng/mL. These numbers help your doctor gauge whether your egg reserve is typical for your age or lower than expected.
Other hormones commonly checked include estradiol (drawn on day 3 alongside FSH), thyroid-stimulating hormone, prolactin, and progesterone. Each one plays a different role in fertility, and an imbalance in any of them can interfere with egg production or the ability to sustain a pregnancy.
Confirming That You’re Ovulating
Regular periods usually indicate ovulation, but not always. To confirm it, your doctor will order a progesterone blood test about a week after you’re expected to ovulate, typically around day 21 of a 28-day cycle. Progesterone rises sharply after an egg is released, so this test acts as proof that ovulation actually happened. A result above 10 ng/mL indicates normal ovulation. Below that threshold suggests you may not be ovulating, or that progesterone production after ovulation is too low to support a pregnancy.
Ultrasound and Follicle Counting
A transvaginal ultrasound is one of the first imaging tests your doctor will order. A small probe is inserted into the vagina to produce detailed images of the uterus and ovaries. This lets your doctor check for structural issues like fibroids, ovarian cysts, or other abnormalities that could affect fertility.
During this same ultrasound, your doctor will count the small, fluid-filled sacs visible on each ovary, called antral follicles. These are follicles between 2 and 10 millimeters in size, and each one contains an immature egg. The antral follicle count is a direct reflection of how many eggs remain in your ovaries overall. Research in Fertility and Sterility confirmed that the number of antral follicles visible on ultrasound closely correlates with the actual number of eggs stored in the ovaries. Combined with your AMH blood test, this gives your doctor a reliable picture of your ovarian reserve.
Checking the Fallopian Tubes
Even if your hormones and egg supply look fine, a pregnancy can’t happen if the fallopian tubes are blocked. To check this, doctors use a procedure called a hysterosalpingogram, or HSG. A small amount of contrast dye is injected through the cervix into the uterus, and X-ray images are taken as the dye flows through. If the dye moves freely through both fallopian tubes and spills into the pelvic cavity, the tubes are open. If the dye stops at any point, that indicates a blockage.
The HSG also reveals the shape of the uterine cavity, which can identify structural problems like a septum (a wall dividing the uterus) or scar tissue. The procedure takes about 15 to 30 minutes and can cause cramping similar to menstrual cramps. Sometimes a tube appears blocked simply because of a temporary muscle spasm. If that’s suspected, your doctor can administer medication during the procedure to relax the tube muscles and recheck the flow.
In some cases, doctors may follow up with a sonohysterogram (which uses saline and ultrasound to get a clearer view of the uterine interior) or a hysteroscopy, where a thin, lighted tube is inserted through the cervix to directly examine the uterus from the inside. If there’s concern about endometriosis or pelvic adhesions that wouldn’t show up on imaging, a laparoscopy (a minimally invasive surgical procedure) may be recommended. This allows the doctor to both see and potentially treat problems at the same time.
Testing Your Partner’s Sperm
Fertility evaluation always includes the male partner, because sperm-related factors contribute to roughly half of all infertility cases. The primary test is a semen analysis, which evaluates a sample provided after 2 to 5 days of abstinence.
The World Health Organization sets the lower reference limits for a normal result. Sperm concentration should be at least 16 million per milliliter. Total motility, meaning the percentage of sperm that are moving at all, should be 42% or higher. Progressive motility, which measures sperm swimming forward effectively, should be at least 30%. And normal morphology, the percentage of sperm with a typical shape, only needs to be 4% or above. That last number surprises many people, but it’s normal for the vast majority of sperm to have irregular shapes.
If the semen analysis comes back abnormal, your doctor may order hormone blood tests for your partner (checking testosterone, FSH, and other levels) along with a testicular ultrasound. In rare cases where no sperm appear in the ejaculate, a urine test after ejaculation can determine whether sperm are being redirected into the bladder instead.
Genetic Testing
Either partner can undergo genetic testing to look for gene changes that could affect fertility or increase the risk of passing on certain conditions to a child. This is typically a blood test or cheek swab. It’s not part of the standard initial workup for everyone, but your doctor may recommend it based on your family history, ethnic background, or if other test results suggest a genetic component to the problem.
What the Full Picture Looks Like
Most fertility evaluations follow a logical sequence. Blood work and ultrasound come first because they’re simple, relatively inexpensive, and provide immediate answers about hormones, ovulation, and egg supply. A semen analysis happens in parallel. If those results are normal, the investigation moves to structural tests like the HSG. More invasive procedures, such as hysteroscopy or laparoscopy, are reserved for cases where earlier tests raise specific concerns. The combination of transvaginal ultrasound, HSG, and blood work is frequently recommended as the standard evaluation for people struggling to conceive. In many cases, this combination identifies a clear cause and points toward the most effective next step.