Fertility testing, checking your ability to get pregnant, and find possible problems, usually consists of several stepwise tests to detect and then treat fertility issues. 

There are many companies trying to sell you tests to check your fertility. It would be ideal to have screening methods to evaluate a woman's ability to get pregnant and give feedback about her future ability to get pregnant. Unfortunately, such testing does not exist. 

The basic fertility tests

1. History and physical examination for him and her
2. Diminished ovarian reserve testing (anti-mullerian hormone and/or inhibin-B; FSH)
3. Progesterone (ovulatory dysfunction testing)
4. Thyroid function (problems with the thyroid may cause infertility)
5. Prolactin levels (high levels can disrupt ovulation)
6. Ultrasound for count of antral follicles
7. Tubal factor and uterine factors (uterine sonography; sonohysterography; hysteroscopy; hysterosalpingo-contrast sonography, (hysterosalpingogram) 
8. Semen analysis

What causes fertility problems?

About 80% of fertility issues are caused by one or more of these three problems. 

1. His issues: Sperm problems: Does he have enough and good sperms? 
2. Her issues: Is she ovulating regularly? What is her ovarian reserve, eg are her eggs OK and of good quality? 
3. Fallopian tube problems: Are her fallopian tubes open? 

The very first fertility test should always be a sperm count.

Fertility testing and checkups can be done to prospectively counsel women about their future chances of fertility and having a baby. These include information on:

• A woman's age and her chances of getting pregnant based on her age
• Ovarian reserve and other testing (FSH, antral follicle count, anti-mullerian hormone, estradiol, TSH, Free thyroxine, Prolactine, LH, Testosterone)
• Common problems with fertility (pelvic surgery, h/o sexually transmitted diseases (STD), endometriosis, autoimmune conditions, medications, menstrual issues

Fertility testing should answer which of these may affect a couple's ability to get pregnant. Most of these tests can be completed within less than 5-6 weeks. If the tests are all OK and no specific cause is found, and that happens in about 1 in 7 couples, then the diagnosis is unexplained infertility.

Fertility testing: Step 1 — His fertility

Finding out about his fertility is the second most important information to know when trying to get pregnant. Find the most important information about fertility here.

Male infertility can primarily be classified as:

• obstructive 
• non-obstructive

More infrequent are retrograde ejaculation, sexual dysfunction, and congenital abnormalities.

Obstructive disorders which are caused by a former vasectomy must be attempted re-anastomosed prior to other treatment.

Non-obstructive disorders are often detected because of impaired sperm quality – from a slightly reduced sperm count and morphology to no sperm cells at all in the ejaculate. Patients who lack spermatic cords or have less than 1 mill. sperm cells per ml in the ejaculate must be evaluated genetically prior to treatment where own sperm cells will be used. 

• Patients with male infertility are treated according to a step-by-step process
• Treatment of severe male infertility is most effective with in-vitro fertilization IVF
• Genetics and cancer risks at male infertility:

The below-stated guidelines are due to the fact that many men with a severely reduced sperm count have micro-deletions on the Y-chromosome or chromosome aberrations. Furthermore, these men have a considerable risk of developing testicle cancer, as compared to normospermic men. Today it is possible to evaluate for this diagnosis by an ultrasound scan of the testes, as this will disclose a possible preliminary stage of carcinoma in situ. Men with cystic fibrosis deletions might also have a congenital absent vas deferens (CAVD) as the only symptom, whereas their children can get the disease. Now, where it is possible via ICSI (Intra Cytoplasmatic Sperm Injection) to treat almost all men with reduced or lacking spermatogenesis, there are great worries about the increased genetic risk these parents expose their offspring to. Therefore – this genetic evaluation of the man.

A semen analysis, also known as a sperm count measures the quality, the amount, number, and other parameters of semen a man produces. A man can only find out through a semen analysis if he is fertile or not. The semen analysis helps determine whether a man is fertile and is usually one of the first tests done to help determine whether a man has a problem fathering a baby. 

More than 40% of couples who are unable to have children (infertile) will be infertile because of his sperm problems. The sperm count should be the #1 fertility test done when you evaluate your fertility. It is obtained through masturbation, it's noninvasive and it guarantees the person getting tested an orgasm. What a great deal! 

According to WHO World Health Association criteria, these are the major parameters a sperm count checks for are:

1. Volume (over 2 cc is normal)
2. Sperm count (over 20 million per cc or 40 million total is normal).
3. Sperm morphology (percentage of sperm that have a normal shape)
4. Sperm motility (percentage of sperm that can move forward normally)

The sperm count checks to see if there are enough sperms. If the sample has less than 20 million sperm per ml, this is considered to be a low sperm count. Less than 10 million is very low. The technical term for a low sperm count is oligospermia (oligo means few). 
Some men will have no sperms at all and are said to be azoospermic. This can come as a rude shock because the semen in these patients look absolutely normal - it is only on microscopic examination that the problem is detected.

What is normal sperm motility?

Motility checks whether the sperms are moving well or not (sperm motility). The quality of the sperm (morphology) is often more significant than the count. Sperm motility is the ability to move. There are two types of sperm — those that swim, and those that don't. Remember that only the sperm that are able to move forward fast are able to swim up to the egg and fertilize it — the others are of little use.

Motility is graded from A to D, according to the World Health Organisation (WHO) Manual criteria as follows.

• Grade A (fast progressive) sperms are those which swim forward fast in a straight line - like guided missiles.
• Grade B (slow progressive) sperms swim forward, but either in a curved or crooked line or slowly (slow linear or nonlinear motility).
• Grade C (non-progressive) sperms move their tails but do not move forward (local motility only).
• Grade D (immotile ) sperms do not move at all.

Sperms of grade C and D are considered poor. If motility is poor (asthenospermia), this suggests that the testis is producing poor quality sperm and is not functioning properly — and this may mean that even the apparently motile sperm may not be able to fertilize the egg.

This is why we worry when the motility is only 20% (when it should be at least 50%). Many men with a low sperm count ask, "But doctor, I just need a single sperm to fertilize my wife's egg. If my count is 10 million and motility is 20%, this means I have 2 million motile sperm in my ejaculate - why can't I get her pregnant? "

The problem is that the sperm in men with a low sperm count are often not functionally competent — they cannot fertilize the egg. The fact that only 20% of the sperm are motile means that 80% are immotile — and if so many sperm cannot even swim, there is worry about the functional ability of the remaining sperm. After all, if 80% of the television sets produced in a factory are defective, no one is going to buy one of the remaining 20%, even if they seem to look normal.

What is normal sperm morphology?

Normal sperm morphology is whether the sperm are normally shaped or not, which is called their form or morphology. Ideally, a good sperm should have a regular oval head, with a connecting mid-piece and a long straight tail. If too many sperm are abnormally shaped (this is called teratozoospermia, when the majority of sperm have abnormalities such as round heads; pin heads; very large heads; double heads; absent tails) this may mean the sperm are functionally abnormal and will not be able to fertilize the egg. 

Many labs use Kruger "strict " criteria (developed in South Africa ) for judging sperm normality. Only sperm that are "perfect" are considered to be normal. A normal sample should have at least 15% normal forms (which means even up to 85% abnormal forms is considered to be acceptable!)

Sperm clumping or agglutination

Under the microscope, this is seen as the sperm sticking together to one another in bunches. This impairs sperm motility and prevents the sperm from swimming up through the cervix towards the egg.

Putting it all together, one looks for the total number of "good" sperm in the sample - the product of the total count, the progressively motile sperm and the normally shaped sperm. This gives the progressively motile normal sperm count which is a crude index of the fertility potential of the sperm. Thus, for example, if a man has a total count of 40 million sperm per ml; of which 40% are progressively motile, and 60% are normally shaped; then his progressively motile normal sperm count is: 40 X 0.40 X 0.60 = 9.6 million sperm per ml. If the volume of the ejaculate is 3 ml, then the total motile sperm count in the entire sample is 9.6 X 3 = 28.8 million sperm.

What does the presence of pus cells in the semen signify?

While a few white blood cells in the semen is normal, many pus cells suggest the presence of seminal infection. Unfortunately, many labs cannot differentiate between sperm precursor cells ( which are normally found in the semen) and pus cells. This often means that men are overtreated with antibiotics for a "sperm infection" which does not really exist!

Some labs use a computer to do the semen analysis. This is called CASA, or computer-assisted semen analysis. While it may appear to be more reliable (because the test has been done "objectively" by a computer), there are still many controversies about its real value, since many of the technical details have not been standardized, and vary from lab to lab.

What does a normal semen analysis report mean?

A normal sperm report is reassuring, and usually does not need to be repeated. If the semen analysis is normal, most doctors will not even need to examine the man, since this is then superfluous. However, remember that just because the sperm count and motility are in the normal range, this does not necessarily mean that the man is "fertile". Even if the sperm displays normal motility, this does not always mean that they are capable of "working" and fertilizing the egg. The only foolproof way of proving whether the sperm work is by doing IVF (in vitro fertilization).

What are the reasons for a poor semen analysis report?

Poor sperm tests can result from:

• incorrect semen collection technique, if the sample is not collected properly, or if the container is dirty
• too long a time delay between providing the sample and its testing in the laboratory
• too short an interval since the previous ejaculation
• recent systemic illness in the last 3 months (even the flu or a fever can temporarily depress sperm counts)

If the sperm test is abnormal, this will need to be repeated several times over a period of 3-6 months to confirm whether the abnormality is persistent or not. Don't jump to a conclusion based on just one report - remember that sperm counts do tend to vary on their own! It takes six weeks for the testes to produce new sperm - which is why you need to wait before repeating the test. It also makes sense to repeat it from another laboratory, to ensure that the report is valid.

A male fertility test is the sperm analysis or sperm count and this test should be the very first step in fertility testing. This is a test done usually in a male infertility clinic or a urologist. It should be done even before the woman has any specific testing done.

The ejaculate is obtained through masturbation, placed in a sterile collection cup, and brought to the laboratory. The best results are obtained when the partner abstains for three days, and the sample arrives at the lab within an hour of ejaculation. The sample is then evaluated for volume, sperm count, motility (how many are swimming) and morphology (how many are a normal shape).

Although normal values vary between laboratories, a normal count is typically >20 million/mL and normal motility and morphology are >50%. This test is done to rule out male causes for infertility, and to see if the couple might benefit from treatment such as artificial insemination.

Fertility testing: Step 2 — Ovulation detection

The first question that must be answered is whether she is ovulating normally. Are there typical signs of ovulation?. Are the eggs of good enough quality and has the couple made love regularly during the 5-6 fertile days before and the day of ovulation.

There are several ways to find out if and when you ovulate:

1. Calculation: Ovulation and Fertility Charting and Calculator
2. Temperature charting
3. Cervical mucus changes
4. Mittelschmerz
5. OPK Ovulation Predictor

Female fertility tests

There are several tests that can be done to ensure your fertility health:

One test that can be done is to check for her Ovarian Reserve. Tests that can be done at any time during the menstrual cycle include Prolactin, Thyroid Stimulating Hormone (TSH), Free T3, Free Thyroxine (T4), Total Testosterone, Free Testosterone, DHEAS, and Androstenedione. Prolactin and Progesterone should be tested seven days post LH surge. Individual normal values may vary from one to the other laboratory.

Normal laboratory values for female tests:

• Progesterone 
  Day of LH Surge: <1.5 ng/ml; 
  Mid Luteal Phase (seven days after Ovulation) >10-15 ng/ml
  Pregnancy: In a pregnancy cycle, progesterone should be greater than 10 to 12 ng/ml to have a better chance of a good pregnancy outcome, but even when not pregnant it can reach 20 ng/ml. 
• Luteinizing Hormone (LH) Follicular Phase (day two or three): <7mIU/ml; Day of LH Surge: >15mIU/ml
• Follicle Stimulating Hormone (FSH) Follicular Phase (day two or three): <13mIU/ml; Day of LH Surge: >15 mIU/ml
• Estradiol Day of LH Surge: >100 pg/ml; Mid Luteal Phase (seven days after Ovulation): >60 pg/ml; Cycle Day 3: < 60 ng/ml
• Prolactin:<25 ng/ml
• TSH (Thyroid Stimulating Hormone):0.5 - 5.5 mIU/L
• Free T3: 1.4 to 4.4 pg/ml
• Free Thyroxine (T4): 0.8 to 2.0 ng/dl
• Total Testosterone: 6.0 to 89 ng/dl
• Free Testosterone: 0.2 to 0.6 ng/ml
• Dehydroepiandrosterone sulfate (DHEAS): 0.80-35 microgram/ml Dehydroepiandrosterone (DHEA): 2.7-7.8 ng/ml
• Androstenedione: 0.7 to 3.1 ng/ml
• Anti-Mullerian hormone: Normal 1.5 - 4.0 ng/ml; High (often PCOS) Over 4.0 ng/ml;  Low Normal Range 1.0 - 1.5 ng/ml; Very Low 0.5 - 1.0 ng/ml

Fertility testing: Step 3 — Egg quality and hormones

Testing both the quality and quantity of a woman's egg is a major part of a fertility evaluation (Ovarian Reserve testing: Good eggs and bad eggs).

Cycle Day 3:

• FSH Level FSH is a pituitary-gland hormone that normally increases as menopause approaches and the ovary begins to show signs of aging. Blood is drawn as close as possible to day 3 of the cycle. A high level suggests that the ovaries are not responding well to brain signals and do not develop follicles for ovulation. A high FSH may mean that chances for achieving pregnancy are poor.
• Prolactin is a pituitary gland hormone that may go up in women with small benign growths of the pituitary gland and those on certain medications.
• Thyroid tests help to determine if there may be a problem with the thyroid, whether there is not enough or too much thyroid hormone. Both too much or too little thyroid hormone can prevent ovulation and pregnancy.
• Testosterone, DHEAS, and 17-hydroxyprogesterone are androgens (male hormones) that may be useful to check in women who also have excessive hair growth (hirsutism)
• Anti-Mullerian Hormone: Tests for ovarian reserve (Good eggs and Bad eggs)

7-10 Days after Ovulation

• Progesterone Test This is a blood test drawn about 7-10 days after ovulation at a time when progesterone levels peak. A good level of progesterone (usually above 10 ng/ml) usually confirms ovulation.

Fertility testing: Step 4 —Fallopian tube patency

Testing the fallopian tubes is essential when checking fertility. This can be by with an HSG or a laparoscopy.

• Hysterosalpingogram (HSG): The HSG is an X-ray test in which dye is injected through the cervix and up into the uterus and fallopian tubes, while the doctor watches on a video screen. The HSG is usually done in the first half of the menstrual cycle, between the end of the menstrual period and before ovulation. The HSG is useful in determining if the fallopian tubes are open and if the cavity of the uterus is a normal shaped. There is a slight increase in fertility after this test.

• Laparoscopy: A laparoscopy is a surgical procedure in which a telescope is inserted into the abdomen, usually in the area around the belly button, and the pelvic organs are examined. This is usually done under general anesthesia, but in some instances is done under local anesthesia only. A laparoscopy is 'diagnostic' if used only to look at the organs, and it's 'therapeutic' when additional surgery is done as treatment.

• Sonohysterogram: A sonohysterogram is similar to an HSG except it is done in the doctor's office with ultrasound rather than an X-ray machine. Saline is injected through the cervix into the uterus, and the uterus and fallopian tubes are examined with ultrasound on a monitor.

Fertility Testing: Step 5 — Other tests

• Postcoital Test (PCT, Huhner Test): The PCT is not dissimilar from a Pap smear, but it requires a couple to have intercourse 2-8 hours beforehand. The PCT is done at the time of ovulation when the cervical mucus is thin and receptive to sperm. A small sample is removed, placed on a slide and examined with the microscope. If good, it suggests that the cervix is not a barrier to fertilization. If the test is poor, the couple may benefit from artificial insemination.
• Endometrial Biopsy: A small sample of the lining of the uterus (endometrium) is obtained in the latter part of the cycle to see if the endometrium has properly matured, under the influence of the hormone progesterone. If there is a "lag" (that is, the endometrium has not reached the proper stage), the condition is known as a Luteal Phase Defect, which can be treated with hormones.
• Transvaginal Ultrasound (TVS): A plastic ultrasound probe is inserted into the vagina so that the uterus and the ovaries can be seen on a monitor. The TVS is used to look for such things as fibroid tumors of the uterus and ovarian cysts, as well as to follow patients on fertility medications and in early pregnancy.
• Hysteroscopy: During a hysteroscopy, a telescope is inserted through the cervix into the uterus. The inside of the uterus can then be examined, and surgical procedures such as removal of a fibroid tumor, polyp, or scar tissue can be performed. When done for diagnostic purposes, this can often be done in the office under local anesthesia.