Know before you go
Fertility testing.
What they actually check, what the numbers mean, and what to ask for.
Walking into fertility testing without knowing what any of it means is its own kind of stressful. This is the plain language version: every test, what it measures, and the reference points, so the appointment is a conversation rather than a lecture.
None of this is a diagnosis and none of it is advice. It is so you know what to ask for, and what you are looking at when the results come back.
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Where each test happens
The quick version: who you see, where you go, and what actually happens when you get there. Names and routes vary by country and clinic, so treat this as the shape of it rather than the exact path you will be given.
| Where | What it is | What happens |
|---|---|---|
| Your family doctor | The first appointment | History, cycle length, how long you have been trying, medications, weight and blood pressure. This is where the referrals and blood forms come from, and where you ask for insulin and HbA1c to be included |
| Lab or blood clinic | Blood draw, sometimes fasting | Arm, needle, a few tubes, ten minutes. Fasting tests need no food beforehand, usually overnight. Two visits are common: one early in your cycle, one seven days after you ovulate |
| Lab, sample at home | Urine collection | You are given a container and instructions. The 24 hour collection means every sample across a full day, kept cool, returned the next morning. Used to rule out other hormonal causes, not for AMH |
| His appointment | Semen analysis | Booked at a lab or fertility clinic. A private room, or produced at home if you can get it there within the time limit they give you. Two to seven days without ejaculating beforehand |
| Clinic or hospital, imaging | Transvaginal ultrasound, the internal scan | Undress from the waist down, a slim probe, a few minutes. Counting resting follicles on each ovary, checking the lining and looking for fibroids or cysts. Uncomfortable rather than painful |
| Hospital radiology or clinic | Tube test: HSG, or HyCoSy by ultrasound | A speculum, a thin catheter through the cervix, dye or foam pushed through while they watch it travel. Cramping for a minute or two. Take a painkiller an hour before and arrange a lift home if you can |
| Fertility specialist | The results appointment | Everything read together. This is where a diagnosis, a treatment plan, ovulation medication or an IVF conversation comes from. Ask for copies of every result with the numbers on |
Two practical notes. Several of these are cycle timed, so book with your own dates in hand rather than taking the first slot offered. And his test is the quickest and least invasive of the lot, so there is a strong argument for doing it first.
Every test, broken down
Click any section to open it.
His test: the semen analysis
One sample, produced into a cup, usually after two to seven days without ejaculating. Quick, cheap, and it is genuinely the first thing that should be checked, because roughly half of all fertility problems involve the male side and this is the only test needed to find them.
| What is measured | Reference point | What it means |
|---|---|---|
| Volume | About 1.4 ml or more | How much fluid there is |
| Concentration | About 16 million per ml or more | How crowded the sample is |
| Total count | About 39 million or more per ejaculate | The total number available |
| Total motility | About 42% or more moving | How many are alive and moving at all |
| Progressive motility | About 30% or more | How many swim forward in a straight line, which is what actually matters for the journey |
| Morphology | About 4% or more normally formed | Shape. Yes, 4% is the reference point, most sperm are irregular in everyone |
Two things nobody explains. These are not pass or fail lines: they are the lowest fifth percentile of men who got their partners pregnant within a year, so being under one does not mean it cannot happen, and being over them all does not guarantee it will. And results swing a lot between samples, so one poor result should always be repeated before anyone draws conclusions.
The repeat is usually about three months later, and that timing is not arbitrary: sperm take roughly 74 days to develop, so a retest is the first point at which any change to diet, alcohol, heat, smoking or weight could show up.
Her blood tests, and why the timing matters
Most fertility bloods are cycle timed, because the same hormone means completely different things on different days.
Early in the cycle, around day 2 to 5: FSH, LH and estradiol. This is the baseline picture of how hard the body is working to recruit a follicle. A high FSH suggests the ovaries need more prompting than they used to. In PCOS, LH often runs high relative to FSH.
Seven days after ovulation, often called day 21 on a 28 day cycle: progesterone. This is the one that confirms you actually ovulated, and it must be timed to your ovulation, not to the calendar. If you ovulate on day 20, a day 21 test will look falsely low and tell you nothing. This is exactly why tracking your surge matters before you get tested.
Any time: thyroid function (TSH), prolactin, and androgens like testosterone and SHBG. Thyroid and prolactin problems are common, easy to miss and very treatable, so they get ruled out early.
Insulin and glucose, the ones you often have to ask for
This is the part of the picture that changed everything for me, and it is frequently not offered unless you push.
Typical tests: fasting glucose, fasting insulin, HbA1c which shows your average blood sugar over about three months, and sometimes a glucose tolerance test where you drink a sugary solution and get tested at intervals afterwards. Fasting glucose and insulin together can be used to estimate how resistant your body has become to its own insulin.
Why it belongs in a fertility workup: high insulin drives the ovaries to produce more androgens, and that disrupts the signal that matures and releases a follicle. It is one of the main reasons cycles go long or stop being predictable in PCOS. It is also the most responsive to food, which is the entire reason my protocol is built around blood sugar rather than calories.
AMH and what ovarian reserve actually tells you
AMH, anti-Mullerian hormone, is a single blood test that can be taken on any day of your cycle. It is produced by small developing follicles, so it gives an estimate of how many eggs are left in the tank.
What it does not tell you is egg quality, and it is a poor predictor of whether you will conceive naturally. Its real job is predicting how the ovaries would respond to IVF stimulation, which is why clinics lead with it.
A PCOS specific catch worth knowing before you get a number back: AMH is often high in PCOS, sometimes strikingly so, because there are lots of small follicles sitting there. That reads like abundance, and it is not, it reflects follicles that are not maturing and releasing.
One clarification, because it confused me too: AMH is a blood test. The one where you collect urine in a jug over 24 hours is a different test entirely, usually measuring cortisol, and it is used to rule out other hormonal conditions that can look like PCOS.
The internal scan: counting follicles
A transvaginal ultrasound, a slim probe with a camera, usually early in the cycle. Uncomfortable and undignified rather than painful, and over in a few minutes.
The antral follicle count is the main event: the sonographer counts the small resting follicles visible on each ovary. Combined with AMH it gives the same how many are left picture, and it is the other number IVF clinics rely on.
Ovarian appearance: in PCOS, ovaries often show a large number of small follicles arranged around the edge, and the ovary itself may be enlarged. Modern criteria use a high follicle count per ovary or an increased ovarian volume as one of the signs. Note the wording: polycystic ovaries are not actually cysts, they are follicles that stalled.
Everything else in view: the thickness and pattern of the uterine lining, fibroids, polyps, endometriomas, and the shape of the uterus itself.
A scan alone cannot diagnose PCOS, and having polycystic looking ovaries on a scan does not by itself mean you have it. It is one of three criteria, alongside irregular ovulation and raised androgens, and you generally need two of the three.
The tube test: the one people warn you about
Sperm and egg meet inside a fallopian tube, so if the tubes are blocked, nothing else matters. There are two common versions.
HSG, a hysterosalpingogram: a thin catheter through the cervix, a contrast dye pushed through, and X-ray images watching whether the dye spills freely out of the ends of both tubes.
HyCoSy or HyFoSy: the same idea using saline or a foam and an ultrasound instead of X-ray.
On the pain, honestly: it varies enormously. Some people describe strong period type cramping for a minute or two, some barely notice. It is worse if a tube is blocked, because the fluid has nowhere to go. Standard advice is to take a painkiller an hour beforehand, and it is entirely reasonable to ask what pain relief is available rather than assuming you have to grit your teeth.
The part that surprises people: flushing the tubes appears to improve pregnancy rates in the months afterwards, particularly with oil based contrast. In a large randomised trial, ongoing pregnancy within six months was around 40% after an oil based flush compared with around 29% after a water based one. So the test is not purely diagnostic: the few months following it are considered a more fertile window, which is worth knowing when you plan around it.
What it all adds up to, including unexplained
Put together, those tests answer four questions: is he producing usable sperm, are you ovulating, is there a clear path for them to meet, and is the hormonal environment able to support an implantation.
When something specific shows up, treatment usually targets it. If ovulation is the problem, the common first step is a tablet taken early in the cycle to prompt the ovaries to release an egg. Letrozole is now generally preferred over the older option for PCOS specifically, because it produces better live birth rates in that group. Ovulation is then tracked to check it worked.
When everything comes back normal and you still are not pregnant, that is called unexplained infertility, and it accounts for a substantial share of couples. It is a frustrating label because it does not mean nothing is wrong, it means nothing was found by the tests that exist. The usual routes from there are continuing to try with timing support, ovulation medication with IUI, or IVF.
What I would say from the inside of it: a full workup is worth doing even when you are working on things naturally, because it tells you what you are dealing with. We did both. The tests gave us the map, and the protocol was what we could actually change while we decided what to do with it.
Questions worth asking at that appointment
- Can we test him first, before I go through the invasive ones?
- Can my progesterone test be timed to when I actually ovulate, not to day 21?
- Can we include fasting insulin and HbA1c, not just glucose?
- What pain relief is available for the tube test, and can I take something beforehand?
- Is oil based contrast an option, given the pregnancy rates afterwards?
- Can I have a copy of every result, with the numbers rather than just normal?
What this is, and what it isn’t
I am not a doctor and these are not my results to interpret for you. This is the map of what gets tested and what the numbers mean in general, written because nobody laid it out for me. Every actual result belongs in a conversation with your own doctor.
The part you can start today.
Testing tells you where you stand. The protocol is what we could actually change while we worked it out. The free menstrual guide is where the food side starts.