Infertility Tests and Pre-IVF Evaluation

Infertility tests are all the investigations, such as examination, blood tests, imaging and semen analysis, that look into why pregnancy has not happened. The aim is not to measure everything, but to reveal the most common causes with as little intervention as possible and as quickly as possible. The information below draws a general framework; which tests are needed varies from person to person, and it does not replace a diagnosis or treatment recommendation specific to you.

When and how does the assessment start?

According to current guidelines, the assessment should be systematic, quick and kept low in cost. It starts with the least invasive tests for the most common causes. The assessment covers both you and your partner and runs at the same time: at least one semen analysis of your partner is done in the first stage, and your own investigation does not wait for the semen result. When to start and how fast to proceed are determined by your age, your history and how long you have been trying for pregnancy; the older you are, the earlier the assessment is started. Every assessment starts with a history and physical examination: your menstrual pattern, your previous pregnancies, the operations and infections you have had, the medicines you use and your lifestyle habits are asked about at this stage.

How are your ovulation and hormones assessed?

If your periods are regular, it is often not necessary to prove separately that you ovulate. If there is no regularity or there is doubt, ovulation is confirmed. For this, current guidelines recommend serum progesterone measured in the second half of the cycle rather than ultrasound. If an ovulation problem is suspected, hormones such as FSH and LH, and, depending on the clinical situation, thyroid-stimulating hormone (TSH) and prolactin are also assessed.

What are the limits of ovarian reserve tests (such as AMH)?

Ovarian reserve tests (AMH, antral follicle count, FSH) serve to predict the response of your ovary to stimulation; they are not an independent indicator of your chance of pregnancy and should not be used to refuse treatment. These tests should not be used as a general "fertility test".

How are your uterus and tubes assessed?

Whether your tubes are open is assessed with hysterosalpingography (HSG) or contrast ultrasound; the diagnostic power of the two methods is similar. The choice is determined by your doctor's and your preference, accessibility and the risk of allergy to the contrast material. For the uterine cavity, guidelines put forward different methods: some regard ultrasound as sufficient in unexplained infertility and do not recommend additional assessment if the ultrasound looks normal; others recommend saline infusion ultrasound where it is available if the uterine cavity is suspected. Your doctor decides which method will be chosen.

Which tests are done on your partner?

The basis of your partner's assessment is semen analysis. If the result is outside what is expected, the analysis is often requested again after a time; confirming the abnormal result with consecutive analyses is recommended. If the sperm is very low or absent, hormones such as FSH, LH and testosterone, in severe cases genetic investigation, and, if the examination requires it, scrotal ultrasound are added. Because reference values can vary with the laboratory, your doctor interprets the result.

Which tests are not recommended routinely?

The same broad package of tests is not applied to you and your partner. According to current guidelines, when there is no specific indication, the following investigations are not requested in the routine assessment:

• Taking a sample from the lining of the uterus, and the post-coital test
• Basal body temperature charting
• Tests for inherited clotting tendency (thrombophilia) and for the immune system
• Karyotype

In the recommendations prepared for unexplained infertility, the following are additionally not recommended routinely:

• Advanced sperm function tests and hormone measurements when the semen analysis is normal
• Hysteroscopy when the ultrasound is normal
• Routine diagnostic laparoscopy

Not doing an additional test does not mean the investigation is incomplete.

How are the results assessed before IVF?

Before the decision for IVF is made, the results above are brought together. The prediction of response guides your doctor in planning the stimulation medicines. The semen result influences whether conventional IVF or microinjection will be applied; according to current assessments, the routine use of microinjection outside a male factor is not recommended. Before IVF, depending on legislation and the centre's practice, some infectious disease and genetic screenings may also be requested; the doctor carrying out your treatment tells you which are needed.

How are test results interpreted?

A single test result is rarely enough for a decision; the result is read together with age, history and examination findings. Hormone measurements can vary from cycle to cycle, the antral follicle count depends on the person doing the ultrasound, and reference ranges differ with the laboratory; for this reason you should not compare your results with the range of another laboratory. Reserve tests should not be used as a "fertility test".

What should be paid attention to after tests that involve a procedure?

After contrast imaging and saline infusion ultrasound, it is normal to have mild cramp and light spotting. An allergy to the contrast material is possible, although rare; shortness of breath or swelling of the face and lips is an emergency. You need to tell your doctor about the possibility of pregnancy before the procedure.