Fertility testing typically starts with blood work and a semen analysis, then moves to imaging if needed. The process is different for each partner, but most initial results come back within one to two days. Testing usually begins after 12 months of unprotected sex without pregnancy, or after 6 months if you’re 35 or older.
Blood Tests for Hormones
The first step for most women is a series of blood draws to check hormone levels tied to egg supply and ovulation. These are simple blood tests from a vein in your arm, but the timing within your menstrual cycle matters.
An anti-müllerian hormone (AMH) test estimates your remaining egg supply, sometimes called ovarian reserve. AMH can be drawn on any day of your cycle and requires no special preparation. FSH (follicle-stimulating hormone) and estradiol are typically drawn on day 2 or 3 of your period because that’s when baseline levels are most informative. High FSH at the start of a cycle can signal that the ovaries are working harder than expected to develop eggs, which points to a lower reserve.
A progesterone blood test is drawn later, usually around day 21 to 23, to confirm whether ovulation actually occurred. Progesterone rises sharply after an egg is released. A level above 10 ng/mL indicates normal ovulation, while a level below that suggests you either didn’t ovulate that cycle or the sample was drawn at the wrong time. Your doctor may also check thyroid hormones and prolactin, since imbalances in either can quietly interfere with ovulation.
Semen Analysis
For the male partner, the cornerstone test is a semen analysis. You provide a sample by ejaculating into a sterile cup, usually at a lab or clinic, though some clinics allow home collection with a special container if the sample reaches the lab within a set time window. The WHO recommends abstaining from ejaculation for 2 to 7 days beforehand, with European guidelines favoring a tighter window of 3 to 4 days. Too short or too long an abstinence period can skew results.
The lab evaluates several characteristics. Current WHO reference values set the lower limits of normal at 16 million sperm per milliliter for concentration, 42% for total motility (meaning the percentage of sperm that are moving), and 4% for normal morphology (meaning the percentage of sperm with a typical shape). Falling below these numbers doesn’t necessarily mean pregnancy is impossible, but it does flag areas that may need treatment or further investigation. Because sperm counts naturally fluctuate, a second analysis is often requested a few weeks later if the first result is abnormal.
Results from a semen analysis are usually available within one to two days.
Checking the Fallopian Tubes
If blood work and semen analysis look normal, the next question is whether the fallopian tubes are open. Blocked tubes prevent sperm from reaching the egg, and they’re responsible for a significant share of female infertility. The standard test for this is a hysterosalpingogram, commonly called an HSG.
An HSG is an X-ray procedure done in the first half of your menstrual cycle, between days 1 and 14. You lie on your back with your feet in position as for a pelvic exam. The doctor cleans the cervix and may inject a small amount of local anesthesia, which can feel like a slight pinch. A thin tube or cannula is then inserted through the cervix, and contrast dye is pushed through it into the uterus and fallopian tubes. The dye shows up on the X-ray screen, outlining the inner shape of the uterus and revealing whether the tubes are partly or fully blocked. If the dye flows freely out the ends of the tubes, they’re open.
The whole procedure takes about 5 to 10 minutes. Cramping during and shortly after is common, similar to period cramps, and most women take an over-the-counter pain reliever beforehand. You can usually go back to normal activities the same day.
Evaluating the Uterus
A transvaginal ultrasound is often one of the first imaging tests performed. A slim ultrasound probe is inserted into the vagina to view the uterus lining, its thickness, and the ovaries. This baseline scan can reveal ovarian cysts, fibroids, or other structural issues.
If the standard ultrasound raises questions or doesn’t show enough detail, your doctor may recommend a sonohysterogram (also called saline infusion sonography). This builds on the transvaginal ultrasound by adding a step: after the initial scan, the doctor inserts a speculum, threads a thin catheter through the cervix, and injects sterile saline into the uterine cavity. The fluid expands the cavity and outlines the lining in sharper detail, making it much easier to spot polyps, fibroids, or abnormal tissue that a routine ultrasound might miss. The speculum is removed before the ultrasound probe goes back in, so the saline-enhanced images are captured the same way as a regular transvaginal scan.
What the Timeline Looks Like
Because several tests are tied to specific days in the menstrual cycle, a full fertility workup rarely happens in a single visit. A realistic timeline is one to two menstrual cycles to complete everything. A typical sequence might look like this:
- Cycle day 2 or 3: Blood draw for FSH, estradiol, and AMH (AMH can also be done separately at any point).
- Cycle days 5 to 12: HSG or sonohysterogram, scheduled after your period ends but before ovulation.
- Cycle day 21 to 23: Blood draw for progesterone to confirm ovulation.
- Any time: Semen analysis for the male partner, with results in one to two days.
Most hormone results return within a day or two from the lab. Imaging results from an HSG or sonohysterogram are often available immediately or within a few days. Once all results are in, your doctor will review them together to identify whether the issue is with ovulation, sperm, the tubes, the uterus, or some combination.
Less Common Tests
If initial testing doesn’t explain the problem, additional procedures may follow. A hysteroscopy involves inserting a tiny camera through the cervix to directly view the inside of the uterus, and it allows the doctor to remove polyps or scar tissue during the same procedure. Laparoscopy is a minimally invasive surgery using small incisions in the abdomen to look at the outside of the uterus, tubes, and ovaries. It’s the most reliable way to diagnose endometriosis, which doesn’t always show up on imaging.
Genetic testing through a blood sample may be recommended if there’s a history of recurrent miscarriage, a known family genetic condition, or if the male partner has very low or absent sperm. These tests look for chromosomal abnormalities or specific gene mutations that could affect fertility or embryo development.
In roughly 10 to 15 percent of couples, all test results come back normal. This is called unexplained infertility. It doesn’t mean nothing is wrong, just that current testing hasn’t identified the cause. Treatment options still exist and are often effective even without a specific diagnosis.