There are a variety of tests that can assess fertility potential:
Hormone testing to determine how the ovaries are functioning
Pelvic exam via ultrasound to assess the physical function of the uterus, fallopian tubes, and ovaries.
Other tests to learn more about whether fallopian tubes are functioning properly and whether the uterus is normally shaped and - for some individuals and couples - genetic carrier testing where relevant to determine whether they are at risk of passing on a hereditary condition
Conducting a fertility assessment can help you understand various things based on what your goals are. Here are a few examples:
"I'm not trying to get pregnant, just want to know how fertile I am."
Fertility testing can help you understand:
How many fertile years might I have left before I hit menopause (estimated)?
Am I at risk of reaching menopause early?
Am I at risk of reproductive issues like PCOS?
"Am I a candidate for egg freezing?"
Once you’ve reviewed your fertility tests with your doctor, he or she will be able to advise on questions like:
What type of outcome can I expect?
How many cycles will I need to get the result I desire?
Am I at a high risk for Ovarian Hyperstimulation Syndrome (OHSS)?
Are there any other risks that are specific to me?
"I'm trying to get pregnant."
Whether you're just getting started or you've been trying for a while and are figuring out next steps, your doctor may want to run a variety of hormone tests as well as ultrasound tests. Because you are trying to actually carry a baby, there are some additional considerations that will go into an ultrasound such as: the condition and size of the ovaries; checking the growth of follicles in the ovary; the condition of the lining within the uterus, uterine structural issues; and, any abnormal growths in the organs such as uterine fibroids and ovarian cysts. At this stage, you can help uncover:
Are there any hormonal issues that are/will preventing me from creating quality eggs?
Are there any "structural" issues that might prevent me from having a healthy baby?
Do I have any reproductive issues that I might need to address?
What does ovarian reserve testing involve?
The gold standard of fertility assessment involves two relatively simple things: a hormone blood test and a transvaginal ultrasound of your ovaries.
The blood draw primarily tests levels of two key fertility hormones (AMH and FSH) and the ultrasound of the abdomen checks physical structures while offering a sense of how many follicles there are in the ovaries that may contain eggs - or, your ovarian reserve.
Ovarian reserve is the quality and quantity of eggs and can inform you and your doctor about your fertility options now and in the future.
There are three tests that doctors use to predict ovarian reserve: AMH and AFC (together the 'gold standard') and FSH, which can also be a useful indication.
1. Anti-Mullerian Hormone (AMH) Screening
To conduct a thorough fertility test, most doctors will request that you start by getting a blood test to measure your anti-Mullerian hormone (AMH) levels.
This is one of the two main tests used by doctors to understand how many eggs you may still have left in your ovaries, which forms part of what is often referred to as your “ovarian reserve.”
AMH is the secret sauce fertility doctors are looking for. Put simply, it is a hormone emitted by the antral cells in your ovaries until menopause.
The more resting follicles you have, the higher your AMH levels, and vice versa, so testing this hormone level can give fertility specialists a good indication of egg supply and ovarian reserve.
Seeing as your follicle count decreases with age, you can expect that your level of AMH will decline accordingly until they head towards zero around menopause.
There are age-based averages for AMH levels, but for some people, this rate of decline comes sooner than later.
Lower AMH levels can indicate a likely lower egg yield in IVF and other fertility treatments like egg freezing, but AMH testing is not a perfect science and AMH levels do not predict pregnancy likelihood (so if you are not actively trying to conceive you should still use contraception even if you are told you got a low AMH reading).
Although AMH hormone tests are good for measuring, well, your AMH levels, researchers have found there’s little correlation between these egg store test scores and your chances of actually getting pregnant.
In a study of women who were trying to get pregnant naturally, low AMH levels indicating diminished ovarian reserve were not associated with infertility. Basically, ovarian reserve tests are a good measure of how many eggs you have left (and could be a good indication of how you might respond to ovarian stimulation in an egg freezing cycle), but that alone doesn’t predict your reproductive potential, or rather, your fertility.
AMH level simply indicates likely response to fertility stimulation drugs: in general, women who have higher AMH levels need less medication in IVF and egg freezing cycles and often generate a larger quantity of eggs.
Your AMH levels may be affected by factors such as oral contraceptives and smoking. And, this test only hints at the quantity of eggs you have left, which ignores an equally important factor, the quality. Regardless of its limitations, it is very helpful to guide your doctor in advising you on good treatment options for you.
AMH can be tested at any day in your cycle as it stays relatively consistent throughout, and can even be done if you’re taking oral contraception.
How can I test my fertility hormones at a clinic?
Expert doctors and other practitioners can perform a variety of tests to assess your fertility potential.
You can ask your OB-GYN or contact a fertility clinic directly to arrange for ovarian reserve testing. Many doctors actively encourage people over 30 to come in and have this kind of check up proactively, even if they are not ready to try to conceive or experiencing any trouble conceiving, as it can help with planning for the future wisely.
The fertility hormone blood test will be done in conjunction with an ultrasound of your pelvic region.
Many clinics also test individuals and couples for infections, including chlamydia, gonorrhea, hepatitis B and C, HIV, human T-cell lymphocyte virus types 1 and 2, and syphilis - as they are known to impact fertility.
Immunity testing for diseases that can affect pregnancy (measles, cytomegalovirus, chicken pox, and rubella) can also be done and booster vaccinations recommended if necessary.
How can I test my fertility hormones at home?
There are many options now for testing fertility at home nowadays - but not all are created equal in terms of the support they provide and so you should choose your service with caution.
Fertility test results are potentially anxiety inducing when they are received in a vacuum by untrained eyes, or the results are taken out of context. Fertility doctors are specifically trained to perform a variety of tests and blend the results with questions about your medical history to best interpret the results.
Be careful not to come to any conclusions based on the results of one of these tests alone. Always seek a full consultation with a fertility specialist doctor if you van.
“I did an AMH test and the results came back suggesting that I was completely infertile at age 34! While I wasn’t ready for kids at that moment, I knew I wanted them one day and I was totally crushed. Because I was ‘infertile’ I decided to be a little more liberal in the bedroom with a guy I was very casually seeing. And then, literally the next month I was pregnant. I was totally unprepared for a child, emotionally or practically, but I felt like it could be my only chance. I might be an extreme case, but one little stick changed the entire course of my life.” - Malia, 36
2. Antral Follicle Count (AFC) Screening
In addition to the screening tests already mentioned, most doctors will want to conduct an ultrasound to determine something called your antral follicle count (AFC). This, combined with the results from your anti-Mullerian hormone (AMH) test are considered the best means in which to understand your fertility.
Antral cells are small cells that house eggs and they can be measured and counted via ultrasound. These are the same cells that release AMH.
They are also known as resting follicles and the total number of them can predict likely response during an egg freezing or IVF cycles.
The pelvic ultrasound scan is an internal scan of the womb and the ovaries. It will also check for any polyps, fibroids, cysts or other problems likely to affect fertility.
To get this measurement, the doctor or an ultrasound technician will take a look at your ovaries.
Usually it is conducted via transvaginal ultrasound (a smooth wand shaped device inserted carefully into the vagina). Although for some women it may be a little uncomfortable, it is not overly invasive and this method allows for a clearer image than an abdominal scan. You might feel a pressure sensation but it’s not generally painful.
While the doctor or technician moves the wand around to get a good look at both your ovaries, she or he is looking to measure the quantity and size of your follicles (i.e. the fluid-filled sacs that contain your eggs).
If required, however, you can request a standard non-vaginal ultrasound at some clinics.
The specialist will discuss your medical history with you alongside your results to advise you on your fertility status.
How many antral follicles are considered “normal?”
Doctors say that this number can fluctuate from zero to 30 for a woman the same age.
Keep in mind that this only tells part of the story behind your fertility potential.
DOCTOR INSIGHT: “Antral follicle counts can vary from provider to provider, as there is no real accepted consensus on how small is too small to count as an antral follicle. Also, the antral follicles present in an ovary at any one moment in time are always in transition. Some are just coming into the antral pool and some are on their way to the fate of almost all antral follicles and eggs within: reabsorption by the body. We cannot tell the difference. This is why I tell my patients that I do the count as a guideline to choose the dose of stimulation medication for them and to help to set a “ballpark” estimation on the final number of eggs we might obtain at a subsequent egg freezing cycle.” - Dr. Carolyn Givens, Pacific Fertility Center, San Francisco, CA
3. FSH Screening
FSH (follicle stimulating hormone) is a hormone that stimulates the growth of follicles and tells the ovary to release an egg, or ovulate.
High FSH may indicate a low ovarian reserve, and researchers have found that women undergoing IVF who had the highest levels of FSH had the lowest average pregnancy rates and the highest miscarriage rates.
However this test is more difficult to take than AMH levels as it can fluctuate naturally during the menstrual cycles. Usually, FSH is tested on Day 2 or 3 of the menstrual cycle and fertility doctors would ideally like to see a level of 10 or less.
Men also produce FSH, which helps to regulate the production and transportation of sperm so the test can also be used to determine sperm count.
Fertility tests can help you understand your ovarian reserve but there is no correlation between ovarian reserve and your ability to get pregnant.
That's worth repeating: Research has shown that there is NO correlation between the ovarian reserve and the ability to get pregnant.
So, if your fertility tests have indicated that you have a diminished ovarian reserve — low AMH — you are no less likely to get pregnant than women with a normal AMH level.
So, although AMH is a great way to predict how close you are to menopause or what your egg yield in an ovarian stimulation cycle, it’s not a good biomarker for actual conception.
Women with low ovarian reserves may conceive naturally without issue.
All three of these tests are important predictors of ovarian reserve, and will be included at the time of an initial consultation with a fertility doctor (reproductive endocrinologist).
According to the American Society for Reproductive Medicine:
These tests try to predict a woman’s response to fertility treatment and how likely she is to get pregnant compared to other women of the same age. Abnormal ovarian reserve test results suggest that fertility potential has declined but they do not tell who will or who will not conceive...Results may vary from cycle to cycle; however, any one abnormal test generally shows that fertility potential has decreased. No single test of ovarian reserve can predict a woman’s ability to get pregnant. These tests are often used to develop a treatment plan, including the need for donor eggs or embryos.