Fertility Testing for Couples: Semen, Hormones, Ultrasound and HSG

AI-assisted English educational illustration. Causes and proportions vary by population; the cards do not represent prevalence.

Fertility testing usually assesses both partners: sperm, ovulation, the uterus and the fallopian tubes. Some blood tests depend on cycle timing, while others do not. This guide explains what the tests measure, when they may be useful and why a fertility evaluation is tailored rather than a fixed checklist.

When should fertility testing begin?

For couples having regular unprotected intercourse, evaluation generally begins after 12 months if the female partner is under 35, or after six months from age 35. Earlier assessment is appropriate when a known fertility problem or irregular or absent periods are present; over 40, more immediate evaluation may be warranted. ASRM evaluation guidance.

The first appointment includes medical and reproductive history, current medicines and relevant symptoms. Both partners should be considered, because concentrating testing on only one partner can miss a contributor to infertility. Initial findings determine whether further blood tests, imaging or specialist assessment are useful. NHS fertility diagnosis.

Semen analysis and the male partner

A semen analysis evaluates sperm concentration or count, movement and shape. Follow the laboratory’s collection instructions, including the requested abstinence interval, and report collection difficulties. An unexpected result needs interpretation in context and may lead to repeat testing or a male-fertility assessment; a single number is not a complete fertility diagnosis. ASRM semen-analysis information.

Early-cycle blood tests and antral follicle count

Cycle day 1 is the first day of menstrual bleeding. Some ovarian-reserve tests are scheduled early in the cycle, but the entire infertility evaluation does not have to occur on day 2 or 3.

FSH and estradiol: When these basal tests are indicated, they are commonly measured together early in the cycle, around days 2–4. Values vary and should not be interpreted alone.
AMH: Anti-Müllerian hormone can usually be measured on any cycle day. It helps estimate ovarian response to stimulation; it does not directly measure egg quality or guarantee the chance of natural conception.
Antral follicle count (AFC): A transvaginal scan counts small visible follicles in both ovaries, commonly early in the cycle. This is an ovarian-reserve marker, not a count of all remaining eggs.
Other hormones: LH, thyroid tests, prolactin and other measurements are selected according to the history. Prolactin is not a routine test for everyone; it may be indicated with absent or infrequent periods or milk discharge.

AMH and AFC are useful for anticipating the response to ovarian stimulation, but age and the wider clinical picture remain important. ASRM ovarian-reserve guidance.

Uterine and tubal tests after menstruation

Imaging can answer different questions about the uterus and fallopian tubes. HSG is commonly arranged after bleeding ends and before ovulation; the clinic gives the exact timing and pregnancy-exclusion instructions. ASRM patient information on HSG.

Hysterosalpingography (HSG): X-ray images follow contrast through the uterine cavity and fallopian tubes. The test helps assess whether the tubes are open and can identify some cavity abnormalities. It does not diagnose every uterine or pelvic condition.
Hysteroscopy: A thin camera passes through the cervix to examine the uterine cavity. It can help investigate or treat problems such as polyps and adhesions when indicated.
Laparoscopy: Keyhole surgery can examine the pelvis, including suspected endometriosis or tubal disease. It is not a routine first test for everyone with infertility; the history and less invasive findings guide its use.

These procedures serve different purposes and are not automatically all required. NHS fertility diagnosis. NHS hysteroscopy information.

Around ovulation: scans, mucus and infection testing

Ultrasound: Monitoring can assess follicle development and the uterine lining, and look for structural findings such as fibroids. Ovulation is not fixed to days 12–14 in every cycle.
Cervical mucus and swabs: Mucus observations may help track fertile days. Infection testing is a separate assessment based on symptoms, history and local screening practice; a swab or urine test may check for chlamydia. A broad list of organisms is not automatically a required infertility panel.
Postcoital testing: This older test looked for moving sperm in cervical mucus after intercourse. ASRM no longer recommends it in the routine infertility evaluation because it is unreliable and does not usefully predict inability to conceive.

Luteal-phase testing: what progesterone can show

When ovulation confirmation is needed, progesterone is generally measured about one week before the expected next period, rather than on a fixed cycle day. A single result can support recent ovulation but cannot reliably establish the quality of the luteal phase; levels fluctuate markedly. Estradiol testing is not a universal check that the luteal phase is normal. ASRM evaluation guidance.

Before arranging a test, ask which clinical question it answers, whether the cycle day matters and how the result would change the next step. This makes the evaluation more useful than ordering every available test at once.