Fertility Testing Explained: What to Order, What to Skip, and Why

In this episode of the Love & Science podcast, Dr. Erica Bove walks through her complete framework for evaluating fertility — including which tests she routinely orders, what each one actually tells her, and which expensive panels are often unnecessary.

From AMH and hormone testing to semen analysis, uterine cavity evaluation, and fallopian tube testing, this episode explains how reproductive endocrinologists think through infertility workups in a practical, evidence-based way.

We cover:
 • What AMH really means (and what it doesn’t)
 • Why Day 3 labs matter: FSH, estradiol, and LH
 • How ultrasound and antral follicle count guide fertility treatment
 • Sonohistogram vs HSG: what each test is best for
 • When to evaluate fallopian tubes more closely
 • The role of prolactin, thyroid testing, vitamin D, A1C, and PCOS labs
 • Expanded carrier screening and preconception testing
 • Why semen analysis is essential — and often delayed too long
 • Which fertility tests are evidence-based
 • Common tests that may be overordered or unnecessary

This episode is designed to help you better understand your fertility workup, ask informed questions, and feel more empowered navigating next steps.

Because fertility testing should not feel random or confusing — it should tell a clear story about what your body is doing and how to move forward strategically.

Transcript

Hello, my loves, and welcome back to the Love and Science podcast. Today, we're going to talk about
how I think about fertility testing, what to order, what to skip, my framework when I see a new
patient. So when I first see an individual or a couple, I always take a thorough history,
right? That's where I start. And again, I was taught in medical school that most of the things I
need to know, I could learn from the patient themselves. And I really do stand by that in fertility
medicine because there's so much we can truly clean by taking careful history. So I want to know
menstrual history. I want to know menstrual patterns. I want to know if the menses are heavy,
if they're painful, if there's intermittent, intermental spotting, I want to understand if there's,
you know, significantly pain outside of the time of periods. I want to understand all these things.
I need to know if somebody's been pregnant before or maybe in a different relationship. Maybe they
were successful with a different partner, another in a second marriage and things aren't connecting
as easily, right? There's the full gamut of all the testing that we get. That's really, really
important. I want to know if anybody has any sexually transmitted infections. I want to understand
if people have had significant abdominal surgery. I want to understand if people gain some weight
and all of a sudden their cycle is spaced out, right? So there's so many different... you know,
questions that we ask that try to get at the question of like, what is the state of this person's
reproductive system in general that are really important. That having been said, I will say pretty
routinely, I always check an anti-mullerian hormone. What is an AMH? That is that serum test that
can be drawn at any point in the cycle that helps us understand. basically how many eggs somebody
has relative to their age. And so it is a very useful test for us. And you can't say you're
infertile or not based on the AMH, but you can say, at least quantitatively speaking, you have an
expected number of eggs for your age. I will usually check a follicle-stimulating hormone in an
estrogen. Now, if somebody has transportation issues or Um, they're, they really want answers now
and they're going away for their day three labs. Sometimes I'll forgo that, but I will tell you, I
learned so much from the follicle stimulating hormone and the estrogen. I learn, you know, how hard
the brain is working to keep the cycles going. I understand if maybe the day three estrogen is
elevated, maybe somebody has recruited a follicle on the sooner side. And I really am worried about
diminished ovarian reserve. I will often also check a baseline LH because I, especially in female
physicians, I see a lot of sort of lean PCOS or hypothalamic amenorrhea. So that also helps me
understand somebody's diagnosis. So day three labs are really important from my perspective because
they help me understand the physiological picture about the communication between the brain and the
ovaries. I will also generally get an antral follicle count because that helps me understand how
many eggs somebody goes through in a given month. So say, you know, somebody goes through 10 eggs
in a given month, but ovulates one. or somebody goes through 25 eggs in a given month and ovulates
only one, the person with the 25 group size will probably have more eggs to work with in an IVF
setting. It also helps you with response to medication. So not only is an internal ultrasound
helpful to understand the pelvis and the myometrium, and if there's any polyps or fibroids,
I usually throw a little fluid in there just for a solid histogram. But I think that it's also
really useful for me to understand the antropoccal count. as I help the council people, especially
in terms of their response to meds. It can also be really helpful if there's discordance, right?
Say the AMH is really high, but the antifolical count is really low or vice versa. Sometimes it can
help me understand if somebody might have like a DOR slash PCOS phenotype. Sometimes those two tend
to cancel each other out. Sometimes if the AMH is unexpectedly low, it can tip me off to
endometriosis. Not always, but sometimes. And so I would say, you know, for most people in the
fertility realm, I get AMH. day three FSH, estradiol, LH, and then an internal ultrasound for
endofalcal count. Bonus points if we can get the sonohistogram and the hycose, that fluid through
the tubes to make sure that the tubes are patent. If somebody has true risk factors for fallopian
tube disease, such as like significant abnormal surgery or STI history, or let's see,
you know, maybe they have a previous ectopic pregnancy, any of those things, I will generally get a
hysterosalpingogram as well to make sure we're truly understanding. the patency of the fallopian
tubes. Endometriosis is another one. If somebody has a history of endometriosis, I really want to
understand the nature of the tubes. And along with that, if they've had previous abdominal surgery,
that's really helpful as well. Okay. So I think about eggs. We talked about ovarian reserve
testing. I think about uterine cavity, fallopian tube structure. I think about preconception
testing as well. So that's sort of the third category. And that is to make sure that you are
optimized to be a pregnant person. So within that, I think about the complete blood count, making
sure that somebody is optimized from an anemia standpoint, that they're not anemic going into a
pregnancy. Also, especially if I'm going to do IVF and I'm going to put a needle in the pelvis, I
really want to know what their baseline CBC is. So it kind of is twofold in that way. I get a type
in screen, make sure that there's no antibodies that we need to worry about. I get a rubella.
chickenpox, measles, antibodies to really understand somebody's immunity. We give a booster if
somebody is not immune. And then we will, you know, I'll usually offer people STI labs.
If somebody is doing IVF, we're going to need them anyway, in terms of like HIV, hep B, hep C,
syphilis. But at least at our clinic, we have a policy that if somebody is going to do an IUI, they
need a gonorrhea chlamydia on file. And so again, I always say not because I think you have it, but
because we test everybody for it. I usually try to get a urine as well. Let's see vitamin D.
I check vitamin D pretty much in everybody as long as our interns will cover it because the studies
have shown better outcomes when vitamin D is repleted. And if somebody also has like PCO type
phenotype, I will get a testosterone level and a 17-hydroxyprogesterone. I typically don't get a
DHEAS, even though that was part of my training when I studied for my boards. I looked through the
data and if somebody's testosterone is elevated, then I'll get it. But usually I try to save money
for the healthcare system and don't get that off the bat. And if somebody's an ovulatory or oligo
-ovulatory, I will typically get a prolactin and a TSH. I have a whole other episode about TSH.
It's kind of controversial, but I am trying to roll back my TSH testing based on the guidelines. I
do still feel like there's a number of people who do meet criteria for thyroid screening. And so I
will often get that from my people. But that is sort of part of my initial testing if somebody is
symptomatic or if they have a strong family history or recurrent pregnancy loss, et cetera. Okay.
Um, expanded carrier screening. Now, you know, it's, it's interesting because it's not a fertility
test per se, but when I was in training, I was taught to order cystic fibrosis and spinal muscular
atrophy on everybody, or at least to offer it. And now we, we actually have these panels where you
can get tested for hundreds of mutations at a time. And if you have a partner, they can get
screened to, um, to make sure that you're not sort of sharing any, um, similar mutations that might
give you a child with a recessive gene mutation. I even have same-sex couples who actually like to
both check their status so that they can get a sperm donor, especially if they're going to use the
same sperm donor, who is going to be compatible with both of them and not just one or the other.
And so I think it can serve a lot of purposes. Sometimes it's out of pocket, but it's usually just
a few hundred dollars to get it done. I'm not minimizing that. But again, thinking about having a
kid with a lifelong disease that can be screened with IVF versus understanding this ahead of time,
preconception. And going that route for me, it's worth the money personally. And so, you know,
these are sort of the preconception labs, like I said, like optimizing your CBC, your TSH,
your vitamin D, getting those ancillary tests. If I'm worried about. also an a1c i will usually get
an a1c if i'm worried about obesity or um strong family history of diabetes or current pregnancy
loss as well um or pcos i get it you know even people with lean pcos can have an elevated
hemoglobin a1c so i checked it as well and so those are the tests that i really try to get on my
new patient appointment, at least from the female perspective. Now, the fourth category is the
sperm. So the sperm, often overlooked, many people say in the beginning, they just want to focus on
themselves. For some reason, it is crazy hard to get men to come in and produce sperm into a cup.
I know it's awkward. Thankfully, after COVID, we now have people produce at home and bring it in,
especially if they're within an hour of the clinic. But it really is 40% of heterosexual
infertility. And if we're not paying attention to that, we might subject a female to like months
and months of testing and finally get an answer that we've wasted time and somebody's older now and
they're still. at where they were before. And so getting a semen analysis is really important. We
look at numbers, shape, movement. If the analysis is abnormal, we would generally repeat it a
second time. We have a reproductive urologist we can work with to do further lab testing for the
male side of things if that is needed. So what I would say is there's egg reserve testing,
there's uterine cavity testing and fallopian tube testing, there's preconception testing,
and there's semen analysis testing. There's a whole slew of things I don't recommend screening for.
For instance, like all the reproductive immunology labs, generally speaking, those are very
expensive and they have not, the data has not borne out for those. Any sort of expanded,
you know, hypercoagulability panel that has not borne out. Even recurrent pregnancy loss,
even still the only thing that's evidence-based from a coagulation, you know, perspective is the
antiphosphate antibodies. And so I think, you know, people do spend a lot of money on Testing,
I'm all for leaving no stone unturned, but I think we have to know what's evidence-based, what's
not evidence-based, when to get the PCOS labs, when to double check the sperm test,
when to do a recurrent pregnancy loss evaluation. That can be really important, but especially at a
new patient infertility visit, these are the staples. These are the things I'm really looking for
that when I see somebody again at their next visit, I'm going to have all the data that I need to
help people out. Now, you know, I will say there are some nuances, like people will say,
what's the best cavity evaluation for me? Anything where you can see. and see if there's any
pathology or not. So for most people, a sonohistorium is going to be beautiful because it allows
for a comprehensive evaluation of a pelvis. You can get the antropoccal count at the same time. You
can typically put some bubbles through the fallopian tubes and confirm tubal patency. So it's a
very comprehensive test, but we can get fooled, right? Especially if a patient's on the heavier
side and it's harder to see those bubbles, especially if somebody really does have risk factors for
tubal disease. And you can see the bubbles go into the fallopian tubes, but you don't necessarily
see them come out of the fallopian tube. And so, you know, my general rule of thumb is if I'm
really worried about somebody's fallopian tubes, I'm going to get an HSG, right? If I'm really
worried about somebody's cavity in their pelvis and I'm going to get a sonal histogram, I don't
think it's wrong to get both tests. I know it's kind of annoying to go as a patient, but they give
me different information. And so, you know, even recently I... I did a sonohistogram on somebody
who had a normal HSG just a couple of months ago. And she had a big, huge pulp in there because
sometimes HSGs miss polyps and filling defects in the cavity. So again, sonohistogram better for
the cavity, HSG better for the tubes. You know, again, why not get both if I'm worried about both?
Again, for most people, a sonohistogram with a high COC is going to be very acceptable, but these
are the questions to ask your REI to say like, why am I getting this test and not this test? When
would a hysteroscopy be warranted, especially if somebody is not getting pregnant after several IVF
cycles? I really want to look at the tissue health, which, you know, sonohistogram and
hysteroscopy, basically very similar test characteristics as to understanding if there's filling
defects present. But if I can look directly with a camera and see the tissue and understand,
does it look healthy? Does it look gray? Does it look yellow? Does it have micropolyps? Am I
concerned for chronic anometritis? all those different things, I'm going to be able to see a little
bit better, actually a lot better with the office hysteroscopy compared to the sonohistogram. So
again, these are the things I think about as I'm thinking about how to take very good care of
patients. It is not a one size fits all, as I think you can see. Every single person deserved a
personalized, tailored approach to their particular situation and their story. But again,
these are evidence-based. There are many things, many panels that you can read about that are not
evidence-based. I think that there, unfortunately, are people who will run those tests and spend a
lot of money, a lot of the micronutrient stuff especially as well. So just be aware. If you ever
have a question, send me a DM. I'm happy to help you sort out what tests are right or even do a
more in-depth consult to help put you in the right direction. Okay, my loves. You know how much I
love you. Until the next time. Bye.