Fertility testing typically starts with blood work and a semen analysis, then moves to imaging or specialized tests depending on what those initial results show. Most guidelines recommend starting an evaluation after 12 months of unprotected sex without pregnancy, or after 6 months if you’re over 35. If you’re over 40, there’s no reason to wait before seeking testing.
When to Get Tested
The American College of Obstetricians and Gynecologists recommends an infertility evaluation after one year of regular, unprotected intercourse without conception. That timeline shortens to six months for anyone over 35, reflecting the natural decline in egg quantity and quality that accelerates in the mid-30s. For those over 40, the recommendation is to begin evaluation right away rather than waiting a set number of months.
These timelines apply to couples, but individuals who aren’t actively trying to conceive can also request baseline fertility testing. Knowing where you stand can help with family planning decisions, especially if you’re considering egg freezing or want to understand your reproductive window.
Ovulation Tracking at Home
The simplest first step is confirming that ovulation is actually happening. Over-the-counter ovulation predictor kits detect the surge in luteinizing hormone (LH) that triggers egg release. These kits tell you ovulation is about to happen, but they can’t confirm it already did.
To confirm ovulation after the fact, newer urine-based tests measure a progesterone byproduct called PDG. Research using ultrasound-confirmed ovulation found that three consecutive PDG readings above 5 micrograms per milliliter, taken after an LH surge, confirmed ovulation with 100% specificity. Some consumer fertility monitors now incorporate this marker alongside LH tracking, giving you both a prediction and a confirmation in the same cycle.
Basal body temperature charting is another low-tech option. Your resting temperature rises slightly (about 0.5 to 1 degree Fahrenheit) after ovulation due to progesterone. The shift only shows up after ovulation has occurred, so it’s useful for confirming a pattern over several cycles rather than timing intercourse in real time.
Blood Tests for Ovarian Reserve
Ovarian reserve testing estimates how many eggs you have remaining. It does not measure egg quality or predict whether you’ll get pregnant naturally. What it does well is predict how you’d respond to fertility treatments like IVF, which is why clinics rely heavily on these numbers.
The two key blood tests are anti-Müllerian hormone (AMH) and follicle-stimulating hormone (FSH). AMH is produced by the follicles in your ovaries, so higher levels suggest a larger remaining egg supply. Levels below 1 nanogram per milliliter may indicate a declining reserve, though this alone doesn’t determine your ability to conceive. AMH can be drawn on any day of your cycle, which makes it convenient. FSH, on the other hand, is typically drawn on day 2 or 3 of your period. FSH is the hormone your brain releases to stimulate egg growth. When your ovaries have fewer eggs to respond, your body compensates by producing more FSH, so elevated levels can signal diminished reserve.
Your doctor may also check estradiol (a form of estrogen) alongside FSH, since high estradiol early in your cycle can artificially suppress FSH and mask a problem. Thyroid hormones and prolactin are often included in the initial workup too, because abnormalities in either can disrupt ovulation without causing obvious symptoms.
Antral Follicle Count
An antral follicle count (AFC) is done via transvaginal ultrasound, usually early in your cycle. The technician counts the small, fluid-filled follicles visible on each ovary. Each follicle potentially contains an egg that could mature that cycle or in future cycles, so the count provides a snapshot of your remaining supply.
Rather than a single universal cutoff, fertility specialists increasingly use age-specific ranges to interpret your AFC. A count that’s normal for a 28-year-old would look different from what’s expected at 38. Falling below the 10th percentile for your age group generally indicates poor ovarian reserve, while dropping below the 3rd percentile signals very poor reserve. Your clinic will interpret your AFC alongside your AMH and FSH results to build a fuller picture.
Checking the Fallopian Tubes
If your blood work and ovulation look normal, the next step is usually checking whether your fallopian tubes are open. Blocked or damaged tubes are a common cause of infertility, and you’d have no way of knowing without imaging.
The standard test is a hysterosalpingogram, or HSG. A small catheter is placed through the cervix, dye is injected into the uterus, and X-ray images track whether the dye flows freely through both tubes. The procedure takes about 15 to 30 minutes and doesn’t require anesthesia, though many women describe it as uncomfortable, with cramping similar to a bad period. One limitation: tubal spasm during the procedure can make a healthy tube look blocked, producing a false positive. Compared to surgical evaluation, HSG is about 83% specific for detecting whether tubes are open and roughly 53% to 65% sensitive for detecting actual blockages.
A saline infusion sonography (SIS) is an alternative that uses saline and ultrasound instead of dye and X-rays. It avoids radiation exposure, can be done in a regular clinic room rather than a radiology suite, and lets the doctor visualize the ovaries and uterine wall at the same time. Studies comparing the two found no difference in pregnancy rates between women who had tubal patency confirmed by HSG versus SIS, so both are considered valid options.
Semen Analysis
Male factor issues contribute to roughly half of all infertility cases, so a semen analysis should happen early in the evaluation, not as an afterthought. The test is straightforward: a sample is collected (usually through masturbation) and examined in a lab.
The World Health Organization’s most recent reference values set the lower normal thresholds at 39 million total sperm per ejaculate, 42% total motility (the percentage of sperm that are moving), and 4% normal morphology (the percentage with typical shape). These are fifth-percentile values, meaning 95% of fertile men score above them. Falling below one threshold doesn’t necessarily mean you can’t conceive, but it does flag an area worth investigating further.
The WHO now emphasizes total sperm count per ejaculate over concentration per milliliter, since total count better reflects the full picture. If results come back abnormal, a repeat test is usually done 2 to 3 months later, since sperm production takes about 72 days and a single sample can be affected by illness, heat exposure, or stress.
At-Home Sperm Tests
Several consumer devices now let you analyze sperm at home using a smartphone or a small reader. One of the more studied options, the YO Home Sperm Test, showed over 97% accuracy when used by untrained consumers compared to professional lab users. These kits typically assess concentration and motility but can’t evaluate morphology or provide the full breakdown a lab analysis offers. They’re a reasonable screening tool if you want a quick check before committing to a clinical visit, but an abnormal result still needs lab confirmation.
Specialized Testing
When standard results come back normal but pregnancy still isn’t happening, doctors may recommend more targeted tests.
Sperm DNA Fragmentation
A standard semen analysis looks at count, movement, and shape, but it doesn’t assess the integrity of the DNA inside each sperm. DNA fragmentation testing measures how much of the genetic material is damaged. This test is particularly useful for couples with unexplained infertility, recurrent pregnancy loss, or repeated IVF failures. High fragmentation can also help guide treatment decisions, such as using surgically retrieved sperm instead of ejaculated sperm for IVF, or prioritizing lifestyle changes like quitting smoking, reducing alcohol, and avoiding heat exposure to the testicles.
PCOS Screening
Polycystic ovary syndrome is one of the most common causes of irregular ovulation. Diagnosis requires two of three findings: elevated androgen levels (measured through total and free testosterone blood tests), irregular or absent ovulation, and polycystic-appearing ovaries on ultrasound. As of the 2023 international guidelines, an elevated AMH level can now substitute for the ultrasound criterion. The ultrasound threshold for polycystic morphology in adults is 20 or more follicles in at least one ovary when using modern imaging equipment. If you have irregular periods and signs of excess androgens like acne or unusual hair growth, PCOS testing should be part of your initial workup.
What Testing Can and Can’t Tell You
Fertility testing is better at identifying specific obstacles, like blocked tubes or very low sperm counts, than it is at predicting your overall odds of conceiving. Ovarian reserve tests estimate egg quantity, not egg quality, and egg quality is often the more important factor, especially after 35. A normal set of results doesn’t guarantee quick conception, and an abnormal result doesn’t mean pregnancy is impossible.
What testing does give you is a starting point. It narrows down where the issue might be, helps your doctor recommend targeted treatment rather than a generic approach, and in many cases provides reassurance that the basics are working as expected. If you’re weighing whether to start testing, the practical barrier is usually lower than people expect: the initial round of blood work and a semen analysis can often be completed within a single menstrual cycle.