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What Is Fertility?

Fertility is the ability to conceive and produce a child. Pregnancy begins with the fertilization of an egg by a sperm cell, but there are several steps that male and female bodies must go through for a healthy pregnancy to be possible. Some of the steps include:

  1. Hormones trigger an ovary to release one egg in a process called ovulation.
  2. A partner must produce viable and sufficient sperm.
  3. As the egg travels through a fallopian tube to the uterus, it must encounter a sperm cell to be fertilized.
  4. The fertilized egg must then get implanted in the lining of the uterus, where it can grow and develop during pregnancy.

If an egg is not fertilized in that cycle, the body sheds the egg and the lining of the uterus during menstruation.

What is infertility?

Infertility is a term that describes an inability to reproduce by natural means. It is defined as not getting pregnant after one year of sex without contraception. Infertility is often due to a problem with one or more steps in the process of becoming pregnant.

Infertility is diagnosed after a couple has tried to get pregnant for 12 months without success, or after 6 months if the woman is over age 35.

Infertility affects around 9% of men and 11% of women of reproductive age in the United States. Although a couple’s infertility can sometimes be traced back to one partner, in around one-third of couples, both partners are responsible for the infertility. In 10-20% of infertile couples, no specific cause can be found.

The Role of Fertility Testing

Fertility testing can be used to detect ovulation and/or to diagnose infertility.

Detecting ovulation

Some types of fertility testing can help women know when they’re most fertile and plan for a pregnancy. A woman is most likely to get pregnant if she has sex during a window starting five days before ovulation to around 24 hours after. This is sometimes referred to as the fertile period.

There are many methods of tracking ovulation and the menstrual cycle. Ovulation tracking can help women who are trying to become pregnant and may help some women who wish to avoid becoming pregnant. Ovulation tracking as a form of birth control is called fertility-based awareness. For most women, fertility-based awareness is around 75% effective.

Diagnosing infertility

Fertility testing can also help doctors diagnose the causes of infertility in a couple. Tests used to diagnose the causes of infertility include laboratory, imaging, and other tests that provide information about a couple’s reproductive organs and the process of becoming pregnant.

Who should get testing?

Couples who are experiencing infertility or who have underlying medical issues should speak to their physician to find out if they should get tested and which tests are indicated for their unique situation.

Fertility testing can help a couple plan for pregnancy, whether the goal is to become pregnant or to avoid pregnancy.

In addition to those already experiencing infertility, there are some risk factors to identify that may affect a couple’s fertility. An infertility evaluation may be important when the couple meets one or several of the following risk factors:

  • Women over age 40
  • Irregular or absent menstrual periods
  • Family history of early menopause or premature ovarian failure
  • History of ovarian surgery
  • Advanced stage endometriosis
  • Uterine or tubal disease
  • Exposure to cytotoxic drugs or pelvic radiation therapy
  • Autoimmune disease
  • Smoking
  • Adult mumps
  • History of testicular trauma
  • Impotence or other sexual dysfunction
  • A history of fertility issues with another partner

In women between 35 and 40 years of age without a risk factor, an infertility evaluation may be recommended after attempting to conceive for six months.

In younger couples without risk factors for infertility, experts recommend trying to conceive for a year before having an infertility evaluation. Couples in this category may benefit from tracking fertility and timing intercourse with ovulation. A physician or reproductive endocrinologist can assist couples in creating a tailored plan for fertility testing.

Getting test results

When a fertility test is prescribed by a doctor, results may be discussed during a follow-up appointment or by telephone. At that time, you will typically have an opportunity to ask questions and make sure that you understand your test results and any follow-up testing that may be necessary. Understanding the results of fertility testing can be complex, and decision-making may depend on results of more than one test.

For at-home fertility testing, results may be available immediately, over the phone, or through a website or smartphone app. When using at-home fertility testing, it’s important to discuss results with your doctor to understand what they mean for your fertility.

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Types of Fertility Tests

Fertility tests can help track ovulation to aid couples in identifying the fertile period. There are several tests used to estimate when ovulation occurs:

 

Tests Related to Tracking Ovulation in Women
Test Name Test Sample What It Measures
Luteinizing hormone (LH) test Blood or urine sample A hormone that is elevated before ovulation
Estrogen test Blood sample Levels of  estradiol, which increase prior to ovulation
Pelvic ultrasonography Imaging test Changes in the ovaries that develop near ovulation
Salivary ferning test Saliva sample Microscopic changes in the appearance of saliva that occur around ovulation
Temperature monitoring No sample needed Changes in body temperature after ovulation

Infertility is evaluated differently in men than in women. In order to evaluate the causes of female infertility, doctors begin by understanding a woman’s health history and performing a physical examination. Because problems with ovulation are a common cause of infertility, diagnostic tests may be recommended to ensure ovulation is occuring. There are several tests used to help doctors detect problems with ovulation:

  • Menstrual cycle charting: Tracking menstrual cycles can help doctors determine the likelihood that ovulation is occurring. Menstrual cycles that last between 25 and 35 days usually indicate healthy ovulation, while longer or shorter cycles may suggest that ovulation is not occurring correctly.
  • Basal body temperature monitoring: After ovulation, progesterone is released by the body causing an increase in body temperature. During basal body temperature monitoring, a woman takes her temperature every morning before getting out of bed.
  • Progesterone testing: Progesterone testing measures the concentration of progesterone in a blood sample and can help doctors determine if it is likely that ovulation is occurring.

An infertility evaluation may also involve testing a woman’s ovarian reserve, which refers to the quantity and quality of egg cells in the ovaries. Several tests may be performed to assess a woman’s ovarian reserve:

 

Tests to Evaluate Ovarian Reserve in Women
Test Name Test Sample What It Measures
Anti-müllerian hormone test Blood sample A hormone produced by reproductive tissues, including the testicles in males and the ovaries in females
Follicle-stimulating hormone (FSH) test Blood sample A hormone associated with reproduction and the development of eggs in women and sperm in men
Clomiphene citrate challenge test (CCCT) Blood samples Levels of follicle-stimulating hormone and estradiol before and after a patient receives the fertility drug clomiphene citrate

Doctors may order additional testing to diagnose or rule out an issue with ovulation function in women:

 

Tests Related to Ovulation Function in Women
Test Name Test Sample What It Measures
Progesterone test Blood sample A hormone that is present at higher levels between ovulation and menstruation
Thyroid-stimulating hormone test Blood sample A hormone that reflects thyroid function
Testosterone test Blood sample A hormone that may be elevated in women with  polycystic ovary syndrome
Prolactin test Blood sample A hormone released by the pituitary gland

An infertility evaluation may also involve imaging tests to assess women for health conditions related to the fallopian tubes and/or uterus and chromosome analysis to look for chromosome abnormalities that can cause infertility.

In men, an infertility evaluation begins with understanding a man’s health history and conducting a physical examination and multiple semen analyses. Also called a sperm count, a semen analysis measures the quality and quantity of sperm in a man’s semen. Semen samples are collected for analysis after two to seven days without ejaculating.

After a semen analysis, a doctor may recommend endocrine testing that can detect conditions that cause male infertility. Endocrine testing may involve several tests:

 

Endocrine Testing in Men
Test Name Test Sample What It Measures
Testosterone test Blood sample The level of testosterone in the blood
Luteinizing hormone test Blood or urine sample The level of luteinizing hormone in the blood
Follicle-stimulating hormone (FSH) test Blood sample A hormone associated with reproduction and the development of eggs in women and sperm in men

Other laboratory tests may be ordered as needed to assess whether other conditions may be affecting fertility. In addition to laboratory testing, doctors may suggest ultrasounds of the scrotum and rectum can help doctors diagnose an obstruction in the ejaculatory duct, the pair of tubes through which semen is ejaculated into the urethra.

Genetic testing can determine potential genetic causes of infertility in men. Several types of genetic tests may be used, depending on the situation:

 

Genetic Tests Related to Infertility in Men
Test Name Test Sample What It Measures
Chromosome analysis Blood sample Chromosome abnormalities
Y-chromosome microdeletion testing Blood sample Loss of genetic material needed for normal sperm cell development
Cystic fibrosis (CF) gene mutations testing Blood sample or scraping of the inner cheek Cystic fibrosis gene mutations

Getting Tested for Fertility

Working with a doctor can help you determine the most appropriate fertility tests for your situation and can ensure that you understand fertility testing, that your sample is collected properly, and that the analysis is conducted by a certified laboratory. Insurance may cover fertility testing when it is prescribed by a physician.

While primary care physicians can perform fertility testing, patients dealing with infertility concerns may also find it helpful to locate a fertility specialist or obstetrician-gynecologist (OB-GYN) who is experienced in the evaluation and treatment of infertility.

At-home testing

Many types of at-home fertility tests are available. Doctors may recommend at-home urine testing of luteinizing hormone (LH) as a quick and helpful way to track ovulation. At-home LH testing involves testing a sample of urine to detect an increase in LH that occurs prior to ovulation.

At-home fertility monitors are digital devices that predict ovulation based on electrolyte levels in saliva, LH levels in urine, or a woman’s basal body temperature. At-home fertility monitors can store information over multiple menstrual cycles to help women better predict ovulation timing and plan for pregnancy.

For women seeking to understand potential causes of infertility, at-home fertility testing kits are available that analyze samples of blood, saliva, or urine. Many at-home fertility tests attempt to give a broad picture of fertility by including multiple tests such as estradiol, LH, follicle-stimulating hormone, testosterone, and thyroid stimulating hormone.

For men, an at-home semen analysis involves collecting a sample of semen and mailing it to a laboratory for analysis. Some at-home sperm tests give men the option of storing their sperm for an additional fee.

Although at-home fertility tests can help couples plan for pregnancy, they are not a replacement for fertility testing prescribed by a doctor. Fertility testing performed by a physician may give more accurate results.

Sources and Resources

These resources provide additional information about infertility and reproductive health:

Sources

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A.D.A.M. Medical Encyclopedia. Infertility. Updated March 28, 2019. Accessed April 15, 2021. https://medlineplus.gov/ency/article/001191.htm

A.D.A.M. Medical Encyclopedia. Semen analysis. Updated January 15, 2020. Accessed April 15, 2021. https://medlineplus.gov/ency/article/003627.htm

A.D.A.M. Medical Encyclopedia. Prolactin blood test. Updated August 29, 2020. Accessed April 15, 2021. https://medlineplus.gov/ency/article/003718.htm

AHFS Patient Medication Information. Clomiphene. American Society of Health-System Pharmacists, Inc. Updated September 15, 2017. Accessed April 16, 2021. https://medlineplus.gov/druginfo/meds/a682704.html

American College of Obstetricians and Gynecologists. Evaluating infertility. Updated January 2020. Accessed April 15, 2021. https://www.acog.org/womens-health/faqs/evaluating-infertility

American College of Obstetricians and Gynecologists. How your fetus grows during pregnancy. Updated August 2020. Accessed April 15, 2021. https://www.acog.org/womens-health/faqs/how-your-fetus-grows-during-pregnancy

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Anawalt BD, Page ST. Causes of male infertility. In: Matsumoto AM, ed. UpToDate. Updated September 30, 2020. Accessed April 15, 2021. https://www.uptodate.com/contents/causes-of-male-infertility

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Hornstein MD, Gibbons WE, Schenken RS. Optimizing natural fertility in couples planning pregnancy. In: Barbieri RL, ed. UpToDate. Updated April 6, 2021. Accessed April 15, 2021. https://www.uptodate.com/contents/optimizing-natural-fertility-in-couples-planning-pregnancy

Jennings V. Fertility awareness-based methods of pregnancy prevention. In: Schreiber CA, ed. UpToDate. Updated April 24, 2020. Accessed April 15, 2021. https://www.uptodate.com/contents/fertility-awareness-based-methods-of-pregnancy-prevention

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