Fertility Testing for Women - How Infertility is Diagnosed

If you've been been trying to conceive for several months without success, you may be considering getting tested for infertility.

Not everyone will get pregnant on their first try but there does come a time when the length of time you've been trying to conceive could be an indication that you have infertility and may need to see a doctor to increase your chances of conceiving.

There may not be any issue, but why not get your fertility tested just to make sure and get a doctor's opinion?

Should I have my fertility tested?

The American Society for Reproductive Medicine (ASRM) has specific guidelines on how to know when someone should consider getting evaluated for infertility.

It all depends on your age and how long you've been unsuccessful in trying to get pregnant.

According to the ASRM, if you are younger than 35 years old and have been trying to conceive for 12 months, you should get evaluated for infertility.

If you are 35 or older, you should try to conceive for 6 months before getting your fertility tested.

If you are 40 or older, some doctors recommend trying to conceive for 3 months while others recommend you have an infertility evaluation immediately.

At this point, reaching out to a fertility doctor to figure out what is causing your infertility is very important.

How is fertility tested in women?

We spoke with Dr. Matrika Johnson at Reproductive Specialists of the Carolinas in Charlotte, North Carolina to get the details on what tests are done to evaluate fertility in women.

We learned that fertility doctors run a lot of different tests to evaluate female infertility but some tests are more informative than others when it comes to deciding how to move forward with treating infertility.

The first thing to know is that most fertility testing can only be done at the start of your menstrual cycle when your hormone levels are lowest.

Fertility testing is usually done on Day 3 of your period. This is when fertility hormones are lowest, which helps get your baseline levels for Follicle Stimulating Hormone (FSH), Estradiol (E2), Luteinizing Hormone (LH), and Progesterone (P4).

The purpose of day 3 fertility testing is to get a measurement of your hormone levels when they are at baseline.

📉 Fertility testing is usually done on Day 3 of the menstrual cycle when hormone levels are lowest.

Your doctor then compares your levels to normal ranges to see whether you are high or low for certain reproductive hormones and how that could affect your ability to get pregnant.

Fertility Tests for Women

To identify where the issues may lie and why you've not been able to get pregnant, a fertility doctor runs several different blood tests looking at your hormone levels and looks at your uterus and fallopian tubes to see if there are any anatomical issues.

There are several different blood tests and exams done to evaluate women for infertility. Fertility hormones need to be tested around Day 3 of the menstrual cycle when hormone levels are lowest in order to get a baseline.

A full infertility testing evaluation includes:

Fertility blood tests

AMH (anti-müllerian hormone)
FSH (follicle stimulating hormone)
E2 (estradiol)
LH (luteinizing Hormone)
P4 (progesterone)

Ultrasound of Ovaries

AFC (antral follicle count)

X-ray of Uterus and fallopian tubes

HSG (hysterosalpingogram)

Other hormone levels

PRL (prolactin)
TSH (thyroid stimulating hormone)

Normal Fertility Test Results

Here are the normal levels for Day 3 fertility testing.

Normal Day 3 Fertility Blood Hormone Levels

✅ AMH >1ng/mL
✅ FSH <10mIU/mL
✅ E2 (Estradiol) <80pg/mL
✅ LH <7mIU/mL
✅ Progesterone (P4) <1.5ng/mL

Normal TSH and Prolactin Levels for Fertility

✅ Prolactin <24ng/mL
✅ TSH ≤2.5mIU/mL

Normal Day 3 Antral Follicle Count

✅ Antral Follicle Count (AFC) >9

Normal HSG results

✅ Fallopian tubes are open
✅ Uterus
✅ normal uterine shape
✅ normal uterine size
✅ no polyps
✅ no fibroids

How can I get my fertility tested?

If you are looking to check whether you have infertility, you need to go see a reproductive endocrinologist at a fertility clinic.

These doctors specialize in helping people get pregnant and will be able to run all of the necessary tests to assess your fertility.

Check out fertility doctors in your area using our fertility clinic search directory.

We'd recommend checking out the 'Data' tab to see success rates for different clinics as well as reading any past patient reviews of the doctors and staff.

Testing How Many Eggs You Have Left

Typically, the tests that tell your doctor the most about your fertility are the blood tests that assess your ovarian reserve, which is an estimation of how many eggs you have remaining.

🥚 Ovarian reserve is an estimation of the number of eggs that you have.

Measuring your ovarian reserve can also indicate to your fertility doctor what treatment option may be best for you if you will need fertility treatment.

How is Ovarian Reserve Tested?

Ovarian reserve is tested by looking at a few different markers.

Your doctor will look at your blood levels of anti-Müllerian hormone (AMH) and Follicle Stimulating Hormone (FSH) as well as do an ultrasound of your ovaries to get an antral follicle count.

Tests for Ovarian Reserve

🩸 AMH (Anti-Müllerian hormone)
🩸 FSH (Follicle Stimulating Hormone)
🔍 AFC (Antral Follicle Count)

Studies have found that the most accurate measurement of ovarian reserve is your AMH level.

AMH stands for Anti-Müllerian hormone and is secreted by small follicles in your ovaries, known as the antral follicles.

Each follicle contains an egg.

So measuring your AMH level gives your fertility doctor a good estimation of how many follicles, and therefore, how many eggs that you have.

Fertility doctors also look at your FSH level and your antral follicle count to help with their estimation of ovarian reserve.

They want to see a low FSH, less than 10 mIU/mL and a high follicle count, greater than nine follicles.

A low FSH means that your brain is getting a good signal from your ovaries that your body is preparing an egg for ovulation. As follicles grow during the follicular phase of the menstrual cycle, they secrete estrogen. An increase in estrogen levels signals to your brain that your body is preparing an egg for ovulation.

If your FSH is elevated, that can mean that your brain is getting a weak signal from your ovaries, which likely means you have a low number of follicles and therefore eggs.

How is diminished ovarian reserve diagnosed?

If your AMH is less than 1ng/mL, your doctor will likely diagnose you with diminished ovarian reserve.

Diminished ovarian reserve means that you have a low number of eggs.

Diminished ovarian reserve is indicated by:

AMH level of <1ng/mL
FSH level of >10mIU/mL
Antral Follicle Count of <9

Something to keep in mind is that diminished ovarian reserve means that you likely have a low numbers of eggs available and that you may not get as many eggs during IVF treatment than someone with a higher AMH.

Diminished ovarian reserve does not affect egg quality. Age affects egg quality.

So don't panic.

Studies have found that women with diminished ovarian reserve have similar pregnancy success rates compared to women with a normal ovarian reserve.

It's age that really will affect your ability to get pregnant. As you age, egg quality lowers and this affects women's ability to get pregnant.

What is a normal AMH level?

AMH is currently considered to be the best indicator of ovarian reserve.

There are several classifications for diminished ovarian reserve and Dr. Johnson mentions that it does depend on the physician for what AMH cutoff level they use.

Some doctors use an AMH of < 1ng/mL to classify someone as diminished ovarian reserve while other doctor prefer to classify anyone with an AMH of < 0.5ng/mL with diminished ovarian reserve.

Dr. Johnson says that while AMH declines with age, no matter what age you are, she wants to see an AMH level of at least 1 ng/mL.

How does diminished ovarian reserve affect your fertility?

While having a low ovarian reserve may mean that you won't be able to get as many eggs during an IVF cycle, it says nothing whatsoever about your egg quality.

However, because you typically don't respond as well for fertility medications and women with a low AMH often retrieve a lower number of eggs, diminished ovarian reserve could mean that you'll need more than one cycle of IVF to get pregnant. It just depends on the person.

A recent study found that women with a very low AMH of < 0.5ng/mL who were doing IVF had reasonable pregnancy success rate but the success rate was significantly affected by age. Older women had lower success rates than younger women.

What is a normal Day 3 FSH level?

FSH stands for Follicle Stimulating Hormone.

It's the hormone released by your brain to stimulate your ovaries to start developing an egg to produce for ovulation.

When your FSH levels are too high, it means that your ovaries are not responding normally and the brain is sending out a higher amount of FSH to try to stimulate your ovaries to prepare an egg for ovulation.

An unusually high FSH could indicate diminished ovarian reserve.

However, FSH levels can be sneaky.

Sometimes even women with diminished ovarian reserve have a normal FSH but the tell is that their estradiol (E2) levels are elevated, which due to negative feedback in the brain, can artificially lower FSH back into what looks like the normal range.

So often, a fertility doctor will look at your FSH and estrogen levels together to make sure they're getting the full picture.

👍 A normal Day 3 FSH level is <10 mIU/mL.

👎 An abnormal FSH level is >10 mIU/mL.

If your Day 3 FSH is extremely elevated, such as being ≥30 mIU/mL, then you may not respond well to the fertility medications used for IVF.

When we say that you may not "respond well", it means that you may not be able to retrieve eggs or that you will retrieve a low number of eggs.

What is a normal Day 3 Estradiol (E2) level?

This is something we found interesting!

According to Dr. Johnson, while fertility doctors do test your estradiol (E2) level on Day 3, they don't pay too much attention to what the specific number is as long as it is in range.

Your estradiol level is used confirm that your FSH test result is accurate. Your Day 3 estradiol level should be less than 80pg/mL.

If your E2 is higher than that, your doctor will likely need you to repeat testing in order to ensure they get an accurate read of your baseline FSH level.

What is a good Day 3 Antral Follicle Count (AFC)?

The antral follicle count (AFC) is also done on Day 3 of the menstrual cycle.

It is done via an transvaginal ultrasound, which doesn't sound like the most fun thing - but it does give your doctor the best view of your ovaries and your follicle count.

What your doctor is looking for on this ultrasound are the tiny follicles in your ovary that each contain an egg.

They are counting up the antral follicles, which are ovarian follicles with a diameter of 2-10 mm.

According to Dr. Johnson, it's ideal to have an antral follicle count (AFC) that is greater than 9.

A Day 3 follicle count of less than 9 could indicate diminished ovarian reserve.

Fertility Treatment Options

Fertility testing will help your doctor understand what is causing your infertility and which treatment option is recommended to help you get pregnant.

The most common treatment options are intrauterine insemination (IUI) or in vitro fertilization (IVF).

Intrauterine Insemination (IUI)

Who is an ideal candidate for IUI?

IUI is often recommended as the first line of treatment for:

women <38 years old
unexplained infertility
ovulatory dysfunction (e.g. PCOS)
mild male factor infertility
same-sex female couples
woman who is a single-parent-by-choice

If you'd like to learn more, check out our guide to IUI, which details the timeline, process, cost, and success rates of intrauterine insemination.

In Vitro Fertilization (IVF)

There are certain situations in which IVF has shown to be the most effective for certain infertility diagnoses and that any less invasive treatment may not be worthwhile.

Dr. Johnson suggests that IVF is recommended for:

women aged 38-42 years old
blocked fallopian tubes
diminished ovarian reserve (DOR)
male infertility

In these cases, research has shown that IVF is the best option in order to increase your success rates and help you get pregnant the fastest.

You can check out the most up-to-date data on national IVF success rates in our article where we break down the CDC data into charts by female age.

Why would IVF be better in these cases?

Check out Dr. Johnson's explanation on when to go straight to IVF.

Up Next: What to ask your doctor during your first fertility appointment