Infertility testing typically begins after 12 months of unprotected sex without conception if you’re under 35, or after 6 months if you’re 35 or older. For women over 40, testing may start even sooner. The process involves a series of blood tests, imaging, and physical exams for both partners, since male and female factors contribute roughly equally to infertility cases.
Testing usually unfolds over one to two menstrual cycles. Your doctor will likely evaluate both partners at the same time rather than finishing one person’s workup before starting the other’s.
Semen Analysis: The First Step for Men
A semen analysis is almost always the starting point on the male side because it’s simple, inexpensive, and highly informative. You provide a sample (usually through ejaculation into a sterile cup), and the lab evaluates sperm count, motility (how well sperm swim), and morphology (whether sperm are normally shaped). If the first result comes back abnormal, a repeat test is usually done a few weeks later to confirm, since sperm quality can fluctuate.
If the semen analysis is abnormal, your doctor may order hormone testing. The key hormones are FSH, LH, testosterone, estradiol, and prolactin. Each one tells a different part of the story. FSH is the hormone that signals the testicles to produce sperm. If it’s low, the signal isn’t reaching the testicles. If it’s high, the testicles aren’t responding properly. LH signals testosterone production, and when it’s elevated alongside low testosterone, the testicles aren’t keeping up. Prolactin, when too high, can disrupt the entire hormonal chain. Elevated prolactin sometimes points to a benign pituitary tumor that’s treatable with medication.
Blood Tests That Assess Ovarian Reserve
For women, one of the first priorities is measuring ovarian reserve, which is an estimate of how many eggs remain. This doesn’t tell you egg quality, but it gives a sense of your remaining reproductive window and helps guide treatment decisions.
Three blood tests form the core of this evaluation:
- AMH (anti-Müllerian hormone) is produced by the small follicles that house your eggs. It can be drawn on any day of your cycle, making it convenient. Lower levels suggest a smaller pool of remaining eggs.
- FSH (follicle-stimulating hormone) is drawn on day 3 of your menstrual cycle. Higher day-3 levels mean your body is working harder to stimulate egg development, which usually indicates declining reserve.
- Estradiol is also drawn on day 3. When it’s elevated early in the cycle alongside high FSH, it reinforces the picture of reduced ovarian reserve.
One important caveat: abnormal ovarian reserve results suggest that fertility potential has declined, but they don’t predict who will or won’t conceive. These are probability markers, not certainties. Normal ranges also vary between labs, so results from different facilities aren’t always directly comparable.
Confirming Ovulation
Even if your periods seem regular, your doctor will likely verify that you’re actually ovulating. The standard method is a blood draw on day 21 of your cycle (about a week after expected ovulation) to check progesterone levels. A progesterone concentration above 10 ng/mL generally confirms that ovulation occurred. Levels below that threshold suggest you either didn’t ovulate, your body isn’t producing enough progesterone after ovulation, or the blood was drawn on the wrong day.
At-home ovulation predictor kits that detect a surge in luteinizing hormone can supplement this information, but they only confirm your body is attempting to ovulate. They don’t prove the egg was actually released. The blood progesterone test provides that confirmation.
Checking the Fallopian Tubes and Uterus
A hysterosalpingogram, commonly called an HSG, is a specialized X-ray that maps the inside of your uterus and checks whether your fallopian tubes are open. Blocked tubes prevent sperm from reaching the egg and are a common cause of infertility.
The procedure is done in a radiology suite and takes about 15 to 30 minutes. You’ll lie on a table as you would for a pelvic exam. Your provider inserts a speculum, cleans the cervix, and threads a thin catheter through it. A contrast dye is slowly pumped through the catheter while X-ray images are taken. If the dye flows freely through both fallopian tubes and spills out the ends, the tubes are open. If the dye stops at a certain point, that indicates a blockage. Your body absorbs the dye naturally afterward.
Most women describe the sensation as moderate cramping, similar to period cramps, particularly when the dye is being injected. The discomfort usually passes quickly. Your doctor may recommend taking an over-the-counter pain reliever beforehand.
A transvaginal ultrasound is also typically performed early in the workup. It can identify uterine fibroids, polyps, ovarian cysts, and structural abnormalities. In some cases, a saline infusion sonogram (where sterile saline is used to expand the uterine cavity during ultrasound) provides a clearer picture of the uterine lining.
Thyroid and Prolactin Screening
Thyroid function affects fertility in both men and women. An underactive or overactive thyroid can disrupt ovulation and menstrual cycles, so a simple blood test for TSH (thyroid-stimulating hormone) is part of most infertility evaluations. Prolactin levels are often checked in women as well, since elevated prolactin can suppress ovulation. As with men, a high prolactin level in women sometimes signals a small, treatable pituitary growth.
When Laparoscopy Is Recommended
Laparoscopy is a minimally invasive surgery where a small camera is inserted through a tiny incision near the navel. It’s not part of the initial workup for most couples. Doctors typically recommend it when they suspect endometriosis, pelvic adhesions, or other structural problems that don’t show up on imaging.
Endometriosis is a condition where tissue similar to the uterine lining grows outside the uterus, and it can impair fertility even in mild cases. Common symptoms that might prompt a laparoscopy include pelvic pain, painful periods, and pain during sex. During the procedure, the surgeon can both identify and often treat endometriosis at the same time by removing abnormal tissue. Research shows that visual identification by the surgeon picks up endometriosis about 90% of the time, though tissue biopsy during the procedure provides the most reliable confirmation.
Genetic Testing
Genetic screening isn’t routine for every couple, but it becomes relevant in certain situations: recurrent pregnancy loss (two or more miscarriages), severely low sperm count, or a known family history of genetic conditions.
Karyotyping is a test that examines your chromosomes for structural abnormalities. In some cases of recurrent miscarriage, one partner carries a chromosomal rearrangement that doesn’t affect their own health but increases the chance of pregnancy loss. Carrier screening can also test whether you carry genes for conditions like cystic fibrosis. Screening options range from tests targeted to your ethnic background (if your group has known higher risk) to expanded panels that screen for many disorders at once.
If both partners are carriers for the same condition, preimplantation genetic testing during IVF can identify embryos that are unaffected before transfer.
What Happens When All Tests Are Normal
Up to 30% of couples who complete a full infertility evaluation receive a diagnosis of unexplained infertility, meaning no specific cause is identified. This can be frustrating, but it doesn’t mean nothing can be done. It means current testing tools haven’t pinpointed the problem, which could involve subtle issues with egg quality, sperm function, embryo implantation, or other factors that standard tests don’t measure.
Treatment for unexplained infertility typically follows a stepwise approach, starting with less invasive options like timed intercourse with ovulation-stimulating medication, then moving to intrauterine insemination, and eventually IVF if earlier steps don’t succeed. Many couples with unexplained infertility do conceive with treatment, and some conceive on their own during the evaluation process.