If trying to conceive is taking longer than you’d like, you’re probably ready for some solid answers about your (and/or your partner’s) fertility. This is a good time to set up an assessment with a reproductive endocrinologist—their main goal is to help you make a baby, but they’re going to need to understand what’s going on in your body before they create a personalized plan of attack. That’s where tests, such as a hysterosalpingogram, semen analysis, ovulation reserve tests and laparoscopy for infertility come in.
Before you see your doctor for an initial assessment, the main thing you should do to prep is track your (or your partner’s) period for a few months.
Your doctor will expect you to have a good understanding of your menstrual pattern—even if it’s all over the place—that you can track through apps or your calendar. Record when your period starts and ends, and when you’re having sex.
OTC fertility tests—are they worth it?
Dr. Shaun C. Williams, MD, partner and reproductive endocrinologist at Reproductive Medicine Associates of Connecticut (RMACT) notes that taking drugstore ovulation and sperm count tests aren’t going to give you the types of answers lab tests would—ovulation trackers just tell you you’re ovulating with about the same accuracy as period tracking does. And most sperm count tests only tell you how many sperm are present in a sample, but don’t measure qualities like sperm motility, or how well they move, he says. So for the most firm answers, skip the spend (and awkwardness) of heading to your local drugstore and just head to your doctor’s office.
Tests to kick off a fertility evaluation
Once you find a good doctor to help you along your fertility journey, you’ll start off with a slew of tests to give them a sense of what’s happening in your body (and your partner’s, if you have one). This will give them a foundation for recommending the right course of action for you. Initial testing is likely to include:
For women, it’s important to kick off fertility treatment knowing whether the uterus and fallopian tubes are in working order. A saline ultrasound is an ultrasound that involves adding saline to the uterus to help the doctors see if everything looks normal inside.
First, you’ll get a transvaginal ultrasound and then a speculum will be used to keep the vagina open so a thin tube can be inserted. The saline is delivered through the tube, and through the sound waves it creates, doctors get ultrasound images of your anatomy, so they can diagnose problems like abnormal uterine shape, issues with the uterine lining, fibroids, polyps, uterine scar tissue and blocked fallopian tubes.
The procedure will likely be a little uncomfortable but not so bad, and there might be some cramping, light bleeding and/or watery discharge afterward. There’s a small risk of pelvic infection, however, so keep on the lookout for pain, fever or a change in discharge.
For men, it’s key to know how the sperm are looking and behaving. A semen analysis involves getting a sample of a guy’s semen (you know how this happens!) and testing it for sperm count. It’ll also get tested for motility (the way they move) and morphology (size, shape and structure) to see if there are any clear reasons why the sperm may not be able to reach the egg.
If abnormalities are seen, there may be a follow up test in four to six weeks to see whether it was a one-time thing or if the sperm are consistently of low quantity or quality.
To get a better look at the fallopian tubes, the doctor might order a hysterosalpingogram or HSG. This is an X-ray that must be done during a super specific time window—between the last day of your period and the first day of ovulation, usually around days 5 through 9 of your cycle.
For the HSG, first the cervix is cleaned and then you may get an injection of local anesthesia for numbing purposes. Then, a tube is inserted into the vagina, and dye passes through it and into the uterus. As the dye fills the uterus and fallopian tubes, x-ray images will be taken, and you might be asked to switch positions. As the dye moves through the fallopian tubes, the doctors should be able to see any blockages that might be present.
There can be cramping that feels like menstrual cramps during this procedure, so your doctor might recommend taking an OTC pain reliever beforehand. Afterwards, you may have a bit of bleeding, cramps, dizziness or faintness or nausea. The fluid may drain out like discharge, so you can wear a pad to soak it up, but avoid tampons. With an HSG, there’s a small risk of allergic reaction, injury and pelvic infection. Call your doctor if you experience foul-smelling discharge, fainting, severe pain or cramping, heavy bleeding, fever or chills, or vomiting.
Ovarian reserve testing
Most clinics will perform an assessment of how well the ovaries are working. “We may see that ovulation is occurring if she’s having regular periods, but ovarian reserve tests are done to see how abundant and how good a woman’s eggs are.” In other words, checking to see if you have eggs that can be fertilized and aren’t likely to miscarry.
Ovarian reserve testing is likely to include:
- FSH Test: The follicle stimulating hormone (FSH) stimulates eggs to grow at the beginning of each menstrual cycle. It can be measured using a simple blood test, where you’ll have your blood drawn and then tested in a lab to determine the FSH level. High levels of FSH signal that the quantity of eggs is low. You won’t have to fast or do any other prep for it—what’s most important is that you do it at the right time of the month: the third day of your period.
- Basal Antral Follicle Count: Around the same time of the month—days 2-5 to be exact, antral follicles can be seen on an ultrasound. These follicles each contain an immature egg, so counting them gives doctors an idea of how many eggs are in a woman’s ovarian reserve. If can also help predict how many eggs there might be if they stimulate the ovaries to do in vitro fertilization (IVF). The ultrasound needed to do an antral follicle count is transvaginal, meaning a wand has to be inserted in the vagina to perform it.
- AMH Test: Anti-Mullerian hormone (AMH) is a hormone produced by the eggs remaining in the ovaries. AMH can be detected in a simple blood test as well. Since it’s not affected by your menstrual cycle or hormones, it can be done at any time. And according to Dr. Williams, it’s probably the best assessment for how many eggs a woman has remaining. However, with only an AMH read, it’s still hard to know about egg quality, and it is often done in conjunction with other tests.
But wait, there’s more.
Depending on your or your partner’s health history or your doctor’s recommendations, you may also opt for a few other tests. These are ones that are also routinely done, says Williams:
Laparoscopy for infertility
Endometriosis is a condition where the tissue that normally lines the inside of the uterus—called the endometrium—grows outside the uterus. Eventually, scar tissue can form. This can cause obstruction of the fallopian tube, so the sperm and egg can’t get together for conception. In fact, about a third to a half of women with endometriosis have trouble getting pregnant according to the Mayo Clinic.
So, if you’re experiencing pelvic pain or other symptoms of endometriosis, your doctor might recommend a laparoscopy for infertility.
Laparoscopy is an outpatient surgery in which a camera is passed through a small incision in the belly button, says Dr. Williams. With it, doctors can see the fallopian tubes and ovaries and look for endometriosis and scar tissue that may be able to be removed.
For this surgery, you’ll be given general anesthesia, so you won’t be able to eat or drink after midnight the night before. You’ll likely be discharged the same day but will be unable to drive for 24 hours afterwards. And as you recover for the next few days, you may experience a swollen abdomen, nausea, sore throat and/or gas discomfort.
The chances of complications are very low (about 0.3% according to the Mayo Clinic), but know that there is a risk of injury, bleeding or complications relating to the anesthesia with laparoscopy for infertility. Contact your doctor right away if you have persistent nausea and vomiting, a temperature over 100 degrees for more than 24 hours, problems with the incision such as redness or swelling, or a heavier than normal menstrual flow.
Dr. Williams notes that while laparoscapy used to be part of the initial assessment, it’s not a necessary part of the initial evaluation at most modern clinics anymore, since it’s more invasive than the other standard tests. Doctors can often overcome endometriosis without needing laparoscopy, and a woman who’s already planning to do intrauterine insemination (IUI) or in vitro fertilization (IVF) can get pregnant even if she has endometriosis.
A hysteroscapy isn’t necessary for everyone and is usually done as a follow-up to treat any abnormalities in the uterus. Some common reasons to get a hysteroscopy include diagnosing the cause of repeated miscarriage, to remove adhesions on the inside of the uterus, or to confirm the results of the HSG.
For this procedure, you’ll be given anesthesia and possibly a sedative. Then your cervix will be dilated, and a small telescope-like tube called a hysteroscope is inserted inside so doctors can see the uterine lining and the openings to the fallopian tubes. If you get a hysteroscopy, you’ll be able to go home shortly after your anesthesia has worn off. You may experience mild cramping or blood tinged discharge afterwards.
There’s a small risk of complications, such as excess fluid or injury and, very rarely, life-threatening problems. Call your doctor right away if you have a fever, chills or heavy bleeding afterwards.
Phew, that’s a lot of tests.
For some people, the idea of undergoing a battery of tests is overwhelming, but remember that testing is an important step in understanding how to proceed in your fertility journey.
The good news? Most of these tests are performed in the office and are quick, brief, and not too uncomfortable or invasive. According to Dr. Williams, “We’re able to overcome problems very effectively with the treatments available to us—as long as we know what the abnormalities are.”