What To Expect When You’re (Not) Expecting: Fertility Testing Basics

By Alyssa Dweck

Not everyone is a “Fertile Myrtle”… the endearing term we OB-GYNs often give to those women who get pregnant in the blink of an eye. We’ve probably all known someone who can conceive effortlessly, it seems!

In actuality, although studies demonstrate that the large majority (80 to 90 percent) of seemingly healthy couples will conceive within the first year of trying, they also show that the fecundability, or the probability of being pregnant in a single menstrual cycle, declines with age.

These days, pregnancy and family planning are often purposefully put on hold. Many women choose to pursue other goals before starting a family, and thus they may face fertility challenges later. The good news is that the opportunities for education, testing, and treatment for infertility have never been richer.1

What is infertility?

Infertility is defined as the inability to conceive after actively trying (regular intercourse without contraception) for 12 months for women who are younger than 35 years old, and after six months for those aged 35 and older. Studies suggest the incidence of infertility in the US is estimated at 12 to 18 percent.2 Women who have not achieved pregnancy after 12 months have even lower fecundability.

Five to 15 percent of seemingly normal couples will conceive in the second 12 months of attempted conception; after 24 months of trying to become pregnant, 95 percent of couples will have conceived.1

When is a woman’s peak fertility?

A woman’s fertility peaks between 20 and 30 years old and gradually declines with age, starting as early as 32, with a more notable decline at 35. The decline is even more significant at 40. Miscarriage rates also increase with age. If you are counting on having on a larger family, it’s important to plan accordingly. Keep in mind, women are born with a finite number of eggs and that number naturally decreases over time.

Age & Number of oocytes (eggs)

Female Fetus 2o weeks: 6–7 million
Birth: 1–2 million
Puberty: 300,000–500,000
Age 37: 25,000
Age 51 (average age of menopause in the US): 1,000

In addition to advancing age, issues that negatively impact fertility include hormonal imbalances including thyroid irregularities, PCOS (polycystic ovarian syndrome), irregular menses or absent menses (amenorrhea), uterine fibroids, tubal disease, endometriosis, prior gynecologic surgery, chemotherapy, radiation, smoking, pelvic infection, and early menopause or family history of such.Causes and risk factors for infertility

The World Health Organization (WHO) task force on Diagnosis and Treatment of Infertility studied 8500 infertile couples to determine causes of infertility.3 In developed countries, female factor infertility was reported in 37 percent of infertile couples, male factor infertility in eight percent, and both male and female factor infertility in 35 percent. Five percent of couples had unexplained infertility.

Another study reported the following causes:

Male factor: 26%
Ovulatory dysfunction: 21%
Tubal damage: 14%
Endometriosis: 6%
Coital problems: 6%
Cervical factor: 3%
Unexplained: 28%

The frequency of these factors in infertility is similar whether attempting pregnancy for the first time or in subsequent attempts, and has not changed significantly over the past 25 years in developed countries.4 The bottom line is that not all infertility is caused by female disorders.

How long should you try before getting tested?

Couples who have been unable to conceive after 12 months of actively trying (unprotected and frequent intercourse) should consider an infertility evaluation. The American College of Obstetricians and Gynecologists (ACOG) and the American Society for Reproductive Medicine (ASRM) recommend that women over 35 receive an expedited infertility evaluation and consider treatment after six months of unsuccessful attempts to conceive, and earlier if clinically indicated due to additional risk factors other than age. In women over 40, immediate evaluation and expedited treatment are recommended.

Should your partner get tested?

Since in more than one-third of couples, male factor infertility is to blame, evaluation of the male partner is vital. Risk factors include a history of testicular trauma requiring treatment, mumps as an adult, erectile dysfunction, chemotherapy and/or radiation, or a history of difficulty conceiving with another partner. A simple semen analysis to check sperm count (the number of sperm per ejaculate), motility (sperm swimming ability) and morphology (sperm shape) is usually the first step. A urology consultation is typically requested with any semen irregularity or obvious anatomic abnormality. A comprehensive physical exam, an ultrasound of the scrotum, and blood hormone levels might be obtained for further evaluation.

What can you do to enhance your fertility?

First and foremost, education about the menstrual cycle, the optimal fertility window during the cycle, and appropriately-timed intercourse are essential. In general, sex every one to two days around the expected time of ovulation or according to an ovulation predictor kit is recommended. If you have a regular cycle, ovulation predictor kits and period tracker apps make timing ovulation and noting ideal times for intercourse easier than ever.

Making certain lifestyle changes such as smoking cessation, reducing excessive caffeine intake and alcohol consumption, and optimizing body weight and exercise routines can further improve fertility.6,7

How Stress Can Affect Fertility

Our busy lives and multitasking nature lead to increased stress, not to mention the added stress of trying to get pregnant.

Prolonged or chronic stress may make it difficult to conceive, and difficulty conceiving usually increases stress further. It’s a double-edged sword. In the simplest of terms, stress may be a signal to the body that now is not the best time to become pregnant. In a recent Fertility and Sterility study of approximately 250 women ages 18 to 40, biomarkers of stress were inversely associated with probability of conception; that is, as stress indicators increased, probability of conception decreased.8

However, other studies have found little to no relationship between anxiety levels, cortisol levels, and successful conception. Therefore, it’s unclear exactly how stress impacts conception. What is known, however, is that stress impacts the body’s hormone levels, menstrual cycle, and immune function. I advise stress reduction measures including yoga, relaxed paced breathing exercises and mindfulness training in women to reduce stress during fertility work-up and treatment.

How Exercise Can Affect Fertility

Aside from being an effective stress reducer, exercise provides preparation for the physical demands of pregnancy and delivery. In addition, increasing lean, metabolically-active muscle mass encourages healthy body composition and insulin responses, thereby reducing the risk of both infertility and, after becoming pregnant, gestational diabetes.6

How Nutrition Can Affect Fertility

A body mass index (BMI) lower than 18 to 19 as a result of chronic dieting, eating disorders, and over exercising, can lead to infertility due to hypothalamic amenorrhea and resulting anovulation.9 That said, regardless of the cause, increasing caloric intake and/or decreasing exercise to increase BMI typically restores ovulation.

Can supplements help improve fertility?

Taking a prenatal vitamin (over-the-counter or prescription)when trying to get pregnant is critical to providing the body with the nutrients necessary for a healthy pregnancy. Folate prior to conception will help eliminate birth defects. In addition, fish oil is vital for healthy development, and for many women dietary intake may be inadequate. Many prenatal vitamins contain fish oil or omega-3 fatty acids. Research published in Obstetrical & Gynecological Survey shows that omega-3 fatty acids increase blood flow to the reproductive organs to aid conception in women dealing with infertility.10

Who To See For Fertility Testing

In general, the OB-GYN generalist is well equipped to initiate a fertility work-up. They can refer couples with abnormal testing or complex issues, as well as heightened anxiety, to an infertility specialist (reproductive endocrinologist). Because time is of the essence, women over 40 with fertility concerns should see a specialist immediately. Keep in mind that the fertility work-up and treatment regimens can be stressful for most, and emotions are heightened; depression, anger, anxiety, and marital discord are not uncommon. A specialist often works with full team, including mental health support, as part of their in-office staff.

What does fertility testing entail?

Since multiple factors are often at play, a complete initial diagnostic evaluation may be performed, including: a history and physical examination, blood work, imaging, cultures, and other testing. Both partners undergo evaluation concurrently. The same approach is used whether trying to conceive for the first time or attempting a subsequent pregnancy.

The following tests are typical, however this is not an exhaustive list:

  • Semen analysis to assess male factor infertility.
  • Cervical cultures for gonorrhea, chlamydia and times mycoplasma, ureaplasm
  • Ovulatory assessment noting LH surge in urine prior to ovulation, and/or luteal phase progesterone level to assess ovulatory function
  • Hysterosalpingogram (HSG) a radiological test to assess whether the fallopian tubes are patent (open) or if there’s any blockage, and to check the structure of the uterine cavity.
  • Pelvic ultrasound to check for uterine fibroids and ovarian cysts
  • Laparoscopy to identify endometriosis or other pelvic abnormality.
  • Other assessments of ovarian reserve in women (clomiphene challenge test, ultrasound for follicle count)

In addition, the following hormonal blood tests for women are also performed:

  • FSH: Follicle stimulating hormone (FSH) is released by the pituitary gland in the brain and stimulates the follicles of the ovaries to grow and mature an egg. This test is usually performed on the second or third day of the menstrual cycle, with the first day being the first day of menstrual bleeding.
  • LH: Luteinizing hormone (LH), also released from the pituitary gland. This might also be assessed by urine testing in an ovulation kit
  • Estradiol: This hormone is produced by a maturing egg. Adequate estrogen is an indication that ovulation is occurring
  • Progesterone: This hormone (checked on day 21 of the cycle) is produced by the corpus luteum, which is what’s left of the follicle from which an egg matured and was released. In anticipation of an embryo implanting in the uterus, the corpus lutem releases progesterone, which builds a thick cushiony lining which is ultimately shed as the menstrual period if no implantation occurs.
  • AMH: This blood test is a check for ovarian reserve and need not be done at any particular time of the cycle. Bear in mind that there are other causes of either low or elevated AMH levels, so the results of this test should be interpreted in context with other variables.
  • Thyroid function studies (TSH, free t4) assesses function of the thyroid gland, which regulates metabolism and if altered might impair ovulation and fertility
  • Prolactin: Prolactin is made by the pituitary gland in the brain and and stimulates milk production in the breasts. It increases dramatically during pregnancy and will continue to be released during breastfeeding. Elevated prolactin can impair ovulation and in the absence of lactation, might signal a growth in the pituitary gland, a pituitary adenoma, or benign tumor that may be treated with medication or surgery.

If you’re not ready right now...

If you’re still not ready to get pregnant, but think you may want to get pregnant in the future, you can ask your OB-GYN about embryo or egg cryopreservation options. This can be a good option for some women who want to delay starting or growing their family but have concerns about their fertility as they get older.

If you’re actively trying to get pregnant, be strong and positive — and consider this: the best surprise of all often comes when you’re least expecting it!

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About the author:  Alyssa Dweck

Alyssa Dweck, M.D., F.A.C.O.G. is a full-time practicing OB-GYN at the Mount Kisco Medical Group in Westchester County, New York and has delivered thousands of babies. She is also the co-author of the upcoming book The Complete A to Z for your V. Dr. Dweck has a master’s degree in human nutrition from Columbia University and a Medical Degree from Drexel University (formerly Hahnemann University School of Medicine). She trained at Lankenau Hospital where she was chief resident in 1994. This mother of two is a fellow of the American College of Obstetricians and Gynecologists and has been voted “Top Doctor” in Westchester County. Learn more about Dr. Dweck at drdweck.com.


  1. American College of Obstetricians and Gynecologists Committee on Gynecologic Practice and Practice Committee. Female age-related fertility decline. Committee Opinion No. 589. Fertility and Sterility. 2014; 101:633. http://www.fertstert.org/article/S0015-0282(13)03464-X/abstract
  2. Infertility Fact Sheet. U.S. Department of Health and Human Services, Office on Women’s Health. July 2009. https://www.womenshealth.gov/publications/our-publications/fact-sheet/infertility.html#b
  3. WHO Technical Report Series. Recent Advances in Medically Assisted Conception. 1992; 820: 1-111 http://apps.who.int/iris/handle/10665/38679
  4. Overview of infertility. Wolters Kluwer Uptodate.com. http://www.uptodate.com/contents/overview-of-infertility?source=search_result&search=infertility&selectedTitle=1~150
  5. FAQ 135: Evaluating Infertility. The American College of Obstetricians and Gynecologists. June 2012. http://www.acog.org/Patients/FAQs/Evaluating-Infertility
  6. Hart RJ. Physiological Aspects of Female Fertility: Role of the Environment, Modern Lifestyle, and Genetics. Physiological Reviews. 2016; 96(3): 873–909. http://physrev.physiology.org/content/96/3/873.long
  7. Ziomkiewicz A, Ellison PT, Lipson SF, Thune I, Jasienska G. Body fat, energy balance and estradiol levels: a study based on hormonal profiles from complete menstrual cycles. Human Reproduction. 2008; 23(11): 2555-2563. https://academic.oup.com/humrep/article/23/11/2555/2913840/Body-fat-energy-balance-and-estradiol-levels-a
  8. Buck Louis GM, Lum KJ, Sundaram R, et. al. Stress reduces conception probabilities across the fertile window: evidence in support of relaxation. Fertility and Sterility. 2011; 95(7):2184-2189. http://www.fertstert.org/article/S0015-0282(10)01031-9/abstract
  9. Mczekalski B, Podfigurna-Stopa A, Warenik-Szymankiewicz A, Tenazzani AR. Functional hypothalamic amenorrhea: current view on neuroendocrine aberrations. Gynecological Endocrinology. 2008; 24(1): 4-11. http://www.tandfonline.com/doi/abs/10.1080/09513590701807381?journalCode=igye20
  10. Sadden P, Saldeen T. Women and omega-3 Fatty acids. Obstetrical & Gynecological Survey. 2004 Oct;59(10):722-30 https://www.ncbi.nlm.nih.gov/pubmed/15385858

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