My Fertility Journey explains the important steps to take when planning a pregnancy to give you the best chance of conceiving and having a healthy pregnancy and a healthy baby. It provides evidence-based information to help prepare your body in the important months before conception. Reliable scientific information underpins everything we do and helps you go forward with confidence as you lay the foundations for the future health of your baby.
Medical Investigations for Women
If you’re having problems conceiving, understanding the medical investigations you may need helps ensure you get the right tests and the right treatment and puts you firmly in control of your fertility journey. In this section we look at:
- Your medical assessment
- Your first check-up
- Sexual health screen
- Assessment of ovulation
- Ways to check for ovulation at home
- Testing for ovulation with your doctor
- Other hormone blood tests and ultrasound scan
- Testing ovarian reserve
- Antral follicle count (AFC) and anti-Müllerian hormone (AMH)
- Testing luteinising hormone (LH)
- Testing androgens
- Thyroid function
- Testing prolactin
- Testing oestrogen
- The pelvic ultrasound scan
- Other investigations
Your medical assessment
Your medical assessment will start with a series of basic investigations for both partners. These can include:
- a general health screening by your GP
- a sexual health screen
- assessments to check whether you are ovulating, including progesterone testing
- other hormone blood tests and an ultrasound scan
- a semen analysis
What happens next will depend on the results of your investigations and you can find out further information in The Fertility Book: Your Definitive Guide to Achieving a Healthy Pregnancy.
Your first check-up
If you haven’t conceived after a period of trying naturally, your GP should be your first port of call. They should provide general health screening and preconception counselling, including the appropriate use of preconception vitamin supplements for both you and your partner. It is also important to ensure that you are up to date with screening for cervical cancer and that you are immune to rubella (German measles), which can cause serious developmental problems for the baby if you catch it while pregnant and are important aspects of preconception care.
Sexual health screen
A sexual health screen, with either blood tests or swabs looking for infections such as chlamydia, is usually performed on both partners. Chlamydia trachomatis infection is the commonest sexually transmitted infection (STI) in the UK and the commonest cause of damaged or blocked fallopian tubes leading to infertility. It often goes undiagnosed, which may cause inflammation of the cervix, tubes and endometrium in women (cervicitis, salpingitis and endometritis respectively) and in the urinary tract and parts of the testes in men. Symptoms can be mild and the majority of people with infection are asymptomatic, and therefore are not treated.
The infection bacterial vaginosis (BV) is also picked up on a swab and causes up to 50 per cent of vaginal infections, yet often goes unrecognised. BV is associated with complications following gynaecological surgery, first and second trimester miscarriage and premature labour. There is also an increased risk of miscarriage after in vitro fertilisation (IVF) in women found to have BV. You may be tested for BV by your fertility clinic, though many doctors prescribe routine antibiotics during IVF treatment as a prophylaxis (preventive treatment) against infections, and this will also treat BV if present.
A blood test to assess hepatitis B and C and HIV status is also needed before having assisted conception treatments.
Assessment of Ovulation
If your menstrual cycle is regular (it doesn’t vary by more than a couple of days either side of a cycle length of between 23 and 35 days), it is likely that you are ovulating. The first part or follicular phase of the cycle is when the egg-containing follicle grows in readiness for the release of a mature egg (oocyte). This phase of the cycle can vary in length from about 9 to 21 days, and is only 14 days in a 28-day cycle. You can find out more detail in The Fertility Book: Your Definitive Guide to Achieving a Healthy Pregnancy.
Ways to check for ovulation at home
It is important to have an idea of your ‘fertile window’ – that is the time in your cycle when it is most likely that you can conceive. There are also ways of testing whether you are ovulating at home:
- Basal body temperature (BBT): some women like to check their BBT every morning at home with a sensitive thermometer. The rationale behind the use of BBT measurements is that progesterone, released after ovulation, will raise the BBT by 0.2–0.4ºC, although between 10 and 75 per cent of ovulatory cycles fail to show an adequate rise in BBT. A ‘flat’ chart therefore does not necessarily mean you haven’t ovulated, and we therefore don’t recommend their routine use. Furthermore, they can cause stress without telling you in advance when you are going to ovulate.
- Cervical mucus: you can monitor your cervical mucus to predict when it is receptive to sperm (the so-called ‘Billings method’). This can be used to determine the best time to get pregnant.
- Mid-cycle pain: you may be also aware of pelvic discomfort (mittelschmerz) around the time of ovulation and this can also be used as a guide to when to have sex. The discomfort is usually felt on the side of ovulation and is nothing to worry about – it is probably caused by a combination of the ovary being swollen by the egg-containing follicle and the release of fluid from the follicle at the time of ovulation. It is interesting that ovaries ovulate on alternate sides more often in young women, while those over 40 years of age are more likely to have successive ovulations from the same ovary.
- Home testing kits: you can also buy ovulation detection kits to use at home. These kits test for hormones in the urine. The simplest way to test is by measuring luteinising hormone (LH) in the urine to identify the pre-ovulatory surge and help predict when to have sex, so that sperm is waiting for the egg when it is released. We recommend that you calculate your anticipated ‘fertile window’ and start testing your urine the day before. Some advocate testing urine morning and evening, but this is probably more than is required and so a morning check on its own is fine. The most advanced monitors measure both oestradiol and LH in the urine and can be expensive. Women with polycystic ovary syndrome (PCOS) may produce a high level of LH and so can have false positive results when using kits.
- Menstrual cycle regularity: if your menstrual cycle is regular (frequency of 23–35 days, with no more than 2–3 days’ variation each month), there’s a greater than 95 per cent chance that you are ovulating, so the use of BBT charts or urinary testing kits has limited value. Up to 75 per cent of women with an erratic cycle are also found to be ovulating. Therefore, for most women, the most important thing is to have regular sex during their cycle. This is good for your relationship and also for the health of sperm – long gaps between ejaculations may lead to poorer quality sperm, which is produced daily and declines in function the longer it is stored. For the best-quality sperm, it’s best to have sex every two to three days in the follicular phase of the cycle and, if possible, daily for two to three days at the predicted time of ovulation. Try to avoid timed intercourse ‘to order’.
- Menstrual cycle length: the luteal phase (second half) of the cycle can last for between 10 and 17 days. Sometimes it is shorter, but usually this happens at random and is not due to a repeated problem with the secretion of progesterone.
Testing for ovulation with your doctor
To check whether you are ovulating, your doctor will test the level of progesterone in your blood. If it’s greater than 30nmol/L, this suggests you are ovulating, although the only real way to know for certain that an egg is released is if a pregnancy occurs. It is difficult to know when to take the blood if a woman has an erratic cycle – and impossible if she has no periods at all (amenorrhoeic) and you may need to check the timing of the blood test in relation to the date of your next period and repeat the test in the following cycle if the result is inconclusive.
Your GP should be able to arrange the measurement of progesterone. Sometimes a fertility clinic may also arrange a combination of serial ultrasound scans and hormone measurements (follicle-stimulating hormone (FSH) and LH) in the early follicular phase and progesterone in the luteal phase). The combination of a corpus luteum seen on ultrasound and an elevated serum progesterone concentration provides the best possible evidence of ovulation, although only a pregnancy will confirm that an egg was actually released from the follicle.
Other hormone blood tests and ultrasound scan
In addition to progesterone, your initial investigations will usually include a series of hormone (link to hormone section of female fertility), known as a baseline hormone (endocrine) profile, and an ultrasound scan. The hormone profile is best done during the first three days of your cycle and includes tests for FSH, LH and oestradiol (oestrogen). The assessment of anti-Müllerian hormone (AMH) as a measure of ovarian reserve, however, is not cycle-dependent. The normal reference range for a particular hormone may vary depending on the laboratory as the type of testing kit can differ between labs. This means the reference ranges may differ too, which makes it difficult to describe normal values.
If you are either not having periods (amenorrhea) or having infrequent periods (oligomenorrhea), a random blood sample has to be taken and is best repeated once or twice at intervals of at least a week in order to get an idea as to what’s going on. Hormone blood tests together with a pelvic ultrasound scan, to assess how your ovaries link to how your ovaries work of female fertility) are working and the thickness of your endometrium, will together usually be enough to make a diagnosis.
Testing ovarian reserve
It’s not possible to count the numbers of eggs within the ovaries without removing a whole ovary or taking a surgical biopsy – neither of which are practicable! We therefore have to estimate your ‘ovarian reserve’ by measuring hormones in the blood. For many years, FSH was measured to give an indication of how the ovary is working. An ovary that is functioning efficiently only needs a little FSH to keep it ticking over. An ageing or inefficient ovary, on the other hand, needs more FSH to stimulate the growth of follicles and so the level of FSH goes up as ovarian reserve goes down and age increases. In recent years we have had a more direct marker of ovarian reserve in the form of AMH, which declines with falling ovarian reserve. We therefore tend to measure AMH rather than FSH, when the test is available (see below).
Antral follicle count (AFC) and anti-Müllerian hormone (AMH)
As well as FSH, you may have other tests in order to get a clearer picture of your ovarian reserve. This includes measuring the volume of your ovaries (which goes down with age and ovarian reserve), counting the number of small antral follicles on an ultrasound scan (the AFC) and testing AMH in the blood.
The main thing that affects ovarian reserve is age, although the rate of ovarian ageing can vary significantly from person to person. The transition from normal fertility to subfertility, sterility and then menopause is individually based on your genetic predisposition, combined with lifestyle and environmental factors. How your ovaries respond to stimulation during fertility treatment is the ultimate test of how they are functioning, but you only find this out after the event. Predicting how your ovaries might respond to stimulation based on measurements of ovarian reserve is one of the most important aspects of your fertility treatment. We use these measurements to decide how much of a particular drug is needed to get the best possible result. This is part of what is known as your stimulation protocol. Women with a ‘normal’ ovarian reserve should ideally develop 8–15 follicles, with a corresponding number of oocytes, during routine stimulation for IVF.
When you have a pelvic ultrasound scan, the number of antral follicles in each ovary will be counted (see below). The total number of follicles in both ovaries visible on the scan is your AFC. AFC is a good predictor of poor ovarian response to stimulation for IVF and similar to a measurement of AMH because it is these visible follicles that produce AMH.
Testing luteinising hormone (LH)
Depending on your symptoms and results of other blood tests, LH is sometimes measured. LH is released from the same cells in the pituitary gland as FSH, under the influence of gonadotrophin-releasing hormone (GnRH) which is released in pulses from the hypothalamus at the base of the brain. LH secretion by the pituitary is very sensitive to the levels of oestrogen in the blood. When oestrogen levels are low, for example in a woman who is underweight, LH levels in the circulation are lower than FSH, while the surge of LH (and FSH) that happens before ovulation is primed by rising oestradiol secretion from the ovary.
Testing LH can tell us various things about what is going on in the body and this test can be helpful if you suspect you have PCOS. You can find out what your different results may mean in The Fertility Book: Your Definitive Guide to Achieving a Healthy Pregnancy.
Another test that you may have is for the androgen hormones – predominantly testosterone. Androgen hormones are secreted by both the testes and the ovaries. Androgens are steroid hormones and there are different ways in which one hormone is converted that can affect the normal balance of these vital substances in the blood. Oestrogen is made from testosterone, for instance, and so all women have some testosterone in their blood just as all men have some oestrogen. The blood test is looking for changes in the balance between the different hormones.
Androgen blood tests that fall outside the normal range can give us further information about your reproductive health, with the most usual cause of high testosterone being PCOS. Most women with PCOS, however, have a normal T level (about 70 per cent in our experience). If you also have your sex hormone binding globulin (SHBG) tested, your doctor can calculate your ‘free androgen index’ (FAI) [(T x 100)/SHBG]. Being overweight can often mean the FAI is high while the total testosterone is in the normal range.
Tests for other androgen hormones are not usually part of routine testing but include 17-hydroxyprogesterone, dehydroepiandrosterone sulfate (DHEA-S) and androstenedione. If levels are very high your doctor would then need to ensure you don’t have a tumour of the ovaries or adrenal glands. This is checked by ultrasound or computed tomography (CT) scans.
As well as testing sex hormones, a fertility clinic will test your thyroid hormones as thyroid disease is common in women, and even mild disturbances of thyroid function may have a profound effect on fertility and the health of a pregnancy. Women often have no symptoms with thyroid disease; ‘biochemical hypothyroidism’ is when the hormone levels are outside of the normal range in the absence of any symptoms.
The thyroid gland, situated in the neck, secretes thyroxine (T4), which is a hormone needed for the health of most bodily functions. It is especially important for the normal growth and development of the fetus, including, most significantly, the fetal brain. You need sufficient iodine in your diet to produce thyroxine and getting enough before you conceive is especially important and you can find out more about this in The Fertility Book: Your Definitive Guide to Achieving a Healthy Pregnancy. The production of thyroxine is stimulated by thyroid-stimulating hormone (TSH) which is produced by the pituitary gland. If the thyroid becomes underactive, the pituitary secretes greater amounts of TSH to ensure that enough thyroxine is made.
These tests are important to ensure your thyroid isn’t underactive or overactive, both of which can cause problems for fertility and pregnancy and impact your periods. If your initial test results are abnormal, you may also be tested for thyroid antibodies (thyroid peroxidase – TPO) and free tri-iodothyronine (T3). It is essential that thyroid disease is treated and thyroid function stabilised prior to conception. Hypothyroidism in particular is very bad for the developing baby. You can find out more about these tests and what your results mean in The Fertility Book: Your Definitive Guide to Achieving a Healthy Pregnancy.
You may have your levels of prolactin tested as part of your fertility investigations, particularly if you have irregular periods. The hormone prolactin causes the breasts to make milk and increases during pregnancy and breastfeeding. Mild elevations in prolactin levels may be associated with stress and may occur simply as a result of having blood taken. Prolactin levels vary day to day and, if elevated to more than 1,000mU/L, the test should be repeated. If levels are still high, you will need further investigations, including magnetic resonance imaging (MRI) of the pituitary gland. If you have slightly raised prolactin levels, this can indicate PCOS or hypothyroidism.
While oestrogen is an extremely important hormone for female health and for the normal development of the endometrium, measuring it isn’t that helpful when investigating infertility. The main form of oestrogen is oestradiol and levels tend to be at their lowest during days 1–3 of the cycle. Levels then start to rise with follicular growth and increase at the time of ovulation, but can vary quite widely.
If you have absent or irregular periods, it’s often more helpful to have an ultrasound scan, both to look at the appearance of your ovaries and to assess the thickness of your endometrium. If you have low levels of oestrogen, your endometrium will be thin and it will only thicken in the presence of oestrogen. The number of follicles in the ovaries also gives more of a clue as to what is going on.
The Pelvic Ultrasound Scan
A pelvic ultrasound scan is an extremely important part of your initial investigations to look at both the uterus and ovaries. Most GPs can order this test at the start of investigations, although sometimes it isn’t done until after the first hospital visit.
You may initially have a transabdominal scan, where the ultrasound probe is placed on the abdomen together with ultrasound jelly, which helps the person scanning to see the internal organs, including, if necessary, the kidneys and other structures in the abdomen. You will need to have a full bladder when you have a transabdominal scan. This helps to ensure the images are clear. This can be quite uncomfortable and so in the fertility clinic a transvaginal scan is usually performed, with a probe placed within the vagina to look at the pelvic organs. A transvaginal scan also provides clearer images of the pelvic structures.
Not all women will need further assessment after a pelvic ultrasound scan, but it’s helpful to understand exactly what your specialist is looking for so that you have confidence that you’re having everything you need in terms of investigations and are able to recognise the relevance of any symptoms. This includes an assessment of your endometrium, ovaries and antral follicle count. You can find out more about what your scan may show in The Fertility Book: Your Definitive Guide to Achieving a Healthy Pregnancy.
As well as these initial tests, you may have further investigations depending on symptoms, underlying medical conditions and family history. This may happen at the same time as your initial tests or after your doctor has seen your initial test results. This may include glucose tolerance tests to assess your body’s ability to control blood sugar, chromosomal analysis to check for any genetic problems in the sperm or eggs, and autoantibodies to check for autoimmune disease. You can find out more about these tests in The Fertility Book: Your Definitive Guide to Achieving a Healthy Pregnancy.
- Adam Balen and Grace Dugdale. The Fertility Book: Your Definitive Guide to Achieving a Healthy Pregnancy. Penguin Random House (Vermilion) 2021
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