Not sure where to start?
Providers have varying opinions on how soon to do a fertility workup. That variation is based on their individual experiences and professional judgment. It’s also based on your health history and potential risk factors. Don’t be afraid to advocate for yourself. If you feel like it is time to do some testing, ask for your provider’s opinion. If you think you’d rather wait awhile longer, ask for your provider’s opinion. Your provider should be your ally and a trusted source of information. Having these conversations will help you determine if your provider is a good fit for you, or if you need to find someone else to manage your care.
Keep your overall health in mind
Thyroid
Issues with your thyroid can affect ovulation, as well as your body’s ability to maintain a pregnancy. They thyroid has to work harder when you are pregnant. For that reason, if your TSH level is borderline, you might want to discuss with your provider the option of managing it with medication. Make sure you get Free T4 and Thyroid Antibodies Test as well. Free T4 most accurately reflects how the thyroid gland is actually working. Antibody tests will let you know if there is an underlying autoimmune disease that needs to be addressed.
Normal TSH for general population: 0.5 – 5 uU/ml
Ideal TSL for fertility: <2.5 uU/ml
Normal Free T4: 0.7-1.9 ng/dl
BMI and Blood Sugar
Weight can be a tricky subject to address because for many women there is a lot of judgment and emotion tied into what we weigh. At the same time, a low BMI or a high BMI can impact your overall fertility. If your weight is below the “normal” BMI for your height, try to add in some extra healthy calories. I’ve had a few patients who simply needed to gain an extra 5-10 pounds in order to get pregnant.
If your weight is above the “normal” BMI and you have an irregular cycle, you may be one of the millions of women who have Polycystic Ovarian Syndrome. If this is the case, switching to a low carb diet and getting moderate exercise is the best thing you can do to improve your fertility. However, don’t feel overwhelmed and think you need to lose a lot of weight in order to get pregnant. I’ve worked with many women who made modest, incremental lifestyle changes and saw significant improvements in their menstrual cycles and/or improved sensitivity to medications to help them ovulate. It will take at least six months to see these improvements, but the habits you set will be with you for a lifetime. If you are overweight, think about getting your blood sugar tested, either through a fasting insulin test or an A1c test.
Remember, just because weight can impact fertility does not mean that weight is impacting fertility in your particular case. There is a well-documented medical bias against people who are heavy, which often leads to poor care. If you think this may be happening to you, educate yourself, advocate for better care, and if necessary, find a new provider.
A step that often gets skipped—do you have any infections?
Chronic bacterial vaginosis, yeast or other infections don’t make you infertile, but they can impact your ability to conceive. This is one of those things women are sometimes embarrassed to talk about with their provider. Don’t be. If you have concerns over discharge, etc., talk to your provider about a vaginal swab at your next appointment.
Understanding your hormone levels
The following hormones make up a general fertility lab workup. Note the units of measure your lab is using. They can vary. If they are different from what you see below, be sure to use the lab ranges provided with your lab report. For more information specific to men, please see the Male Factor Infertility handout.
Estradiol/E2
Cycle Day 2-4: 25-75pg/mL – higher indicates estrogen dominance
Mid-cycle: 150-740pg/mL*
Luteal Phase: 30-450pg/mL
- This level is what one mature follicle would release. In an ART cycle where there are more follicles being stimulated, the E2 gets significantly higher. IVF clinics try to keep E2 levels in ART cycles between 3,500 – 5,000pg/mL
Luteinizing Hormone/LH*
Pre-ovulation: 1-18 mIU/dL
Ovulation: 20-105 mIU/mL
About 24-36 hours prior to ovulation, LH peaks and should be between 25-45 mIU/mL
Post Ovulation: 0.4 – 20 mIU/mL
*Ovulation Preditor Kits (OPKs) test for LH
Progesterone
Pre-ovulation: <20 ng/dL or 0.1-0.7 ng/mL
Post-ovulation: 300-2500 ng/dL or 2-25 ng/mL*
Pregnancy: First Trimester 725-4400 ng/dL or 10-44 ng/mL
Second Trimester 1950-8250 ng/dL or 19.5 – 82.5 ng/mL
Third Trimester 6500-22,900 ng/dL or 65-290 ng/mL
*A growing body of research suggests that progesterone levels may vary dramatically hour to hour or day to day. A low progesterone number might be significant, or might not be.
Prolactin/PRL
Not pregnant or lactating: <25
Pregnant: Rises through pregnancy and is 200-400 ng/mL at full-term
Lactating 3 months postpartum: 100 ng/mL*
Lactating 6 months postpartum: 50 ng/mL*
- Lactating levels are baseline averages and there is some variation based on other factors
Testosterone total
Men: 280-1,100 ng/dL
Women: 15-70 ng/dL
Anti-Mullerian Hormone/AMH
Age 20-24: 0.478-15.7 ng/mL
Age 25-29: 0.493-11.3 ng/mL
Age 30-34: 0.256-9.72 ng/mL
Age 35-49: 0.052-10.9 ng/mL
Age 40-44: 0.030-6.76 ng/mL
Follicle Stimulating Hormone/FSH
Follicular Phase: 3.1-7.9 mIU/mL
Ovulation Peak: 2.3-18.5 mIU/mL
Luteal Phase: 1.4-5.5 mIU/mL
Postmenopausal: 30.6-106.3 mIU/mL
Looking at the uterus and fallopian tubes
Usually your provider will start with bloodwork and wait awhile before doing any of these tests. An HSG uses dye and x-ray to look inside your uterus and check if your tubes are open. An SIS or SHG is similar, but uses saline instead of dye to look inside the uterine cavity for abnormalities. A hysteroscopy uses a comer to look inside the uterus. Below are some reasons you might want to ask for these tests sooner.
- History of D&C: Scar tissue/retained tissue
- History of uterine surgery: Scar tissue/adhesions
- History of STI/STD: Scar tissue/adhesions
- Person of color: African descent has highest risk of fibroids, also elevated for people of Asian descent
- Older age: Age increases risk of anatomical changes
- Higher BMI: Extra estrogen from fat cells can cause uterine growths
- Family history of uterine masses: Tends to be hereditary
- Big clots, dark menstrual blood, severe cramps: Blockages that make it harder for blood to exit
- Heavy/flooding periods: Fibroids, polyps, etc.
- Abnormal bleeding (irregular, stop and go, spotting): Fibroids, polyps, etc.
- Frequent urination, abdominal heaviness, back aches: Masses pressing on local anatomy
Is pelvic pain normal?
If you get a lot of pain with your menstrual cycle and/or pain with intercourse, you may have endometriosis. It can take years for a women to get properly diagnosed, and endometriosis is linked to fertility concerns. For more information, please see my handout on endometriosis.
Do tests for ovarian reserve really assess your fertile potential?
The answer is, it depends. Looking at your AMH, FSH and antral follicle count is very important if you are considering IVF. They give a good indication as to how well you’re likely to respond to ovarian stimulation. However, there has been little-to-no data demonstrating that these hormone levels have any correlation with natural fertility for women who haven’t tried to conceive, have no reason to believe they’re infertile, and plan on trying to conceive naturally. https://www.fertilityiq.com/topics/egg-freezing/why-you-shouldnt-use-fertility-tests-to-predict-your-ability-to-get
AMH (Anti Mullerian Hormone). An easy option that can be done at any point in the cycle. AMH naturally declines with age. Normal is 1.0-3.0, less than 0.4 indicates the chance of pregnancy with IVF is very low.
FSH (Follicle-Stimulating Hormone). Must be done on cycle day 2-3. Not always accurate. Less than 10 is considered normal. Anything higher than 13 suggests a reduced ovarian reserve, reduced stimulation response, reduction in IVF embryo quality, and reduced live birth rates. Odds decrease the higher the FSH.
AFC (Antral Follicle Count). Number of follicles that could be recruited for retrieval. Counted via ultrasound. Most accurate. Normal is 11-30. As the number decreases below 10, odds of pregnancy with IVF decrease.