Infertility testing typically begins with blood work and a semen analysis, then moves to imaging tests that check for structural problems. The standard threshold for starting an evaluation is 12 months of unprotected sex without pregnancy if you’re under 35, or 6 months if you’re 35 or older. For women over 40, most specialists recommend starting even sooner. Both partners should be evaluated at the same time, since male and female factors contribute roughly equally to fertility problems.
When Testing Should Start
The timeline depends on your age and medical history. The American Society for Reproductive Medicine recommends evaluation after 12 months of trying for women under 35, and after 6 months for women 35 and older. But certain conditions warrant testing right away, regardless of how long you’ve been trying. These include irregular or absent periods, a known history of endometriosis or pelvic disease, prior chemotherapy or radiation, sexual dysfunction, or a suspected male factor like a history of undescended testicles or prior surgery.
If any of those apply, there’s no reason to wait out the clock. Bring them up at your first appointment so testing can begin immediately.
What Happens at the First Appointment
Your fertility specialist will start with a detailed medical history for both you and your partner. Expect questions about menstrual cycle regularity, previous pregnancies, sexual history, surgeries, medications, lifestyle factors like smoking or alcohol use, and any family history of reproductive problems. A physical exam is standard, along with blood and urine samples to screen for sexually transmitted infections.
From there, your provider will order a first round of fertility tests. Some may happen that same day, others will be scheduled for specific points in your menstrual cycle. Don’t expect a definitive answer at the end of visit one. It often takes several weeks and multiple tests before a diagnosis comes together, and in some cases, no clear cause is ever identified.
Testing for Male Fertility
A semen analysis is the cornerstone of male fertility testing and one of the first tests ordered. You’ll provide a sample, usually through masturbation, either at the clinic or at home with a collection kit. The lab evaluates several characteristics of the sperm against reference values established by the World Health Organization: a concentration of at least 15 million sperm per milliliter, total motility (the percentage of sperm that are moving) of at least 40%, and normal shape in at least 4% of sperm. Those numbers represent the lower end of fertile range, meaning men who successfully conceived had values at or above those thresholds.
If the first semen analysis is abnormal, your provider will usually repeat it. Sperm quality fluctuates based on illness, stress, heat exposure, and other temporary factors, so a single abnormal result doesn’t necessarily mean a permanent problem.
Physical Exam and Additional Tests
A urologist may perform a physical exam to check for a varicocele, an enlarged vein in the scrotum that feels like a “bag of worms” on examination. Varicoceles are a common, treatable cause of male infertility. The exam is done while standing, sometimes while bearing down, because varicoceles can shrink when lying flat. If the physical exam is inconclusive, a scrotal ultrasound can clarify.
Sperm DNA fragmentation testing is not part of a routine workup. It may be recommended in specific situations, such as recurrent pregnancy losses, where standard semen analysis results look normal but something else may be affecting the sperm’s ability to support a healthy pregnancy.
Blood Tests for Female Fertility
Hormonal blood tests assess two main things: whether you’re ovulating and how many eggs you have left (your ovarian reserve).
Ovulation Confirmation
A regular, predictable menstrual cycle occurring every 21 to 35 days is often sufficient evidence that you’re ovulating. If there’s any doubt, a blood test measuring progesterone can confirm it. The test is drawn about 7 days before your expected period (day 21 in a typical 28-day cycle). A progesterone level above 3 ng/mL provides strong evidence that ovulation recently occurred. If your periods are irregular, absent, or unpredictable, that alone is enough to establish an ovulation problem, and your provider will investigate the underlying cause.
Ovarian Reserve Testing
Ovarian reserve tests estimate the quantity of eggs remaining. They don’t measure egg quality, which is primarily a function of age. Two blood tests are used together. FSH (follicle-stimulating hormone) is drawn on day 2, 3, or 4 of your menstrual cycle, along with estradiol. Elevated FSH in the early cycle suggests the ovaries are working harder to recruit eggs, a sign of diminished reserve.
AMH (anti-Müllerian hormone) can be drawn at any point in your cycle, which makes it more convenient. Average AMH falls between 1.0 and 3.0 ng/mL, with levels below 1.0 considered low. To give a sense of how AMH changes with age: a 30-year-old might expect a level around 2.5 ng/mL, while a 40-year-old is closer to 1.0 ng/mL. By 45, the average drops to about 0.5 ng/mL. These are estimates on the lower side of normal for each age, not hard cutoffs.
Ultrasound and Imaging Tests
Transvaginal Ultrasound
A pelvic ultrasound, usually performed transvaginally, gives your provider a direct look at your uterus and ovaries. It’s used to check for fibroids, cysts, polyps, or structural abnormalities. When done in the first few days of your cycle, the ultrasound also includes an antral follicle count: a tally of the small, fluid-filled sacs visible on each ovary. The number of antral follicles correlates with your remaining egg supply and declines with age. Combined with AMH and FSH results, this gives a more complete picture of ovarian reserve than any single test alone.
Hysterosalpingogram (HSG)
The HSG is an X-ray test that checks whether your fallopian tubes are open and whether your uterine cavity has a normal shape. During the procedure, you lie on a table as you would for a pelvic exam. A speculum is placed, and a thin catheter is threaded through your cervix. Contrast dye is injected through the catheter while X-ray images are taken in real time. If the dye flows freely through both tubes and spills out the ends, the tubes are open. If the dye stops at a blockage, that tells your provider exactly where the problem is.
The procedure takes about 15 to 30 minutes. Many women experience cramping similar to period pain during and shortly after the test. Your body absorbs the dye on its own. An alternative to the HSG is a saline sonogram (sonohysterography), which uses saline and ultrasound instead of dye and X-rays. It’s particularly good at detecting problems inside the uterine cavity, with accuracy above 90% for identifying issues like polyps or fibroids.
Typical Costs Without Insurance
If you’re paying out of pocket, the initial workup adds up across several tests. A pelvic ultrasound runs roughly $150 to $500. Fertility-related blood work (hormones, STI screening) typically falls between $200 and $400. The HSG is the most expensive diagnostic test, ranging from $800 to $3,000 depending on the facility. Semen analysis is generally on the lower end, often $100 to $300. Insurance coverage for fertility testing varies widely by state and plan, so it’s worth calling your insurer before scheduling to understand what’s covered.
How Long the Full Workup Takes
Because several tests need to be timed to specific days of your menstrual cycle, the full evaluation usually spans one to two menstrual cycles. FSH and the antral follicle count happen early in your cycle. The progesterone test happens about a week before your period. The HSG is typically scheduled in the first half of your cycle, after bleeding stops but before ovulation, to avoid disrupting a potential early pregnancy. A semen analysis can be done at any time, so it’s often one of the first results back.
By the end of this process, your provider will have a clear picture of whether ovulation is occurring, how your egg supply looks, whether your tubes are open, and whether sperm quantity and quality are adequate. From there, the conversation shifts to treatment options tailored to whatever the testing reveals.