What are the signs of female infertility, and when should I get tested?
Infertility is generally defined as the inability to conceive after 12 months of trying, or after six months for women over 35, at which point fertility testing is typically recommended. However, earlier evaluation may be appropriate if you experience irregular, absent, or unusually painful menstrual cycles, have had recurrent miscarriages, or have noticed other changes related to your reproductive health. Early fertility testing can also be helpful for women considering egg freezing or those who want a better understanding of how age and other medical factors may affect future fertility.
Possible Causes of Female Infertility
Female infertility can be linked to a wide range of issues, including ovulation disorders, hormonal imbalances, anatomical abnormalities, and underlying medical conditions. Common causes of female infertility include:
- Polyendocrine Metabolic Ovarian Syndrome (PMOS, formerly known as PCOS)
- Endometriosis
- Uterine fibroids or polyps
- Blocked fallopian tubes (tubal factor infertility)
- Primary ovarian insufficiency (POI)
- Hormonal imbalances
- Low ovarian reserve
- Irregular or absent ovulation
- Pelvic adhesions or scarring
- Genetic or chromosomal conditions
- Recurrent pregnancy loss
- Unexplained infertility
In some cases, fertility challenges may stem from several overlapping issues rather than a single cause.
What is AMH testing and why does it matter?
An AMH test measures the level of anti-Müllerian hormone (AMH) in the blood. AMH is produced by small follicles within the ovaries and is commonly used as an indicator of ovarian reserve, which refers to the number of eggs remaining in the ovaries.
Higher AMH levels are generally associated with a larger egg supply, while lower levels may suggest diminished ovarian reserve. As a woman ages, egg supply naturally declines, resulting in lower levels of AMH. However, the rate at which egg supply decreases varies from person to person, which is why AMH testing can be a valuable tool for understanding your individual fertility potential. That said, AMH results are only one part of a larger fertility evaluation and do not predict whether someone can or cannot conceive naturally.
AMH testing can also help fertility specialists estimate how the ovaries may respond to medications used during IVF or egg freezing cycles, allowing them to adjust treatment protocols accordingly.
What other female fertility testing is part of an overall evaluation?
No single test tells the entire story of a woman's fertility, which is why a thorough evaluation involves a combination of bloodwork, imaging, and other minimally invasive diagnostics to fully evaluate reproductive health. Here is an overview of what may be included:
Medical History and Physical Examination
A complete fertility evaluation begins with a detailed discussion of your medical and reproductive history. This may include questions about menstrual cycles, prior pregnancies, previous surgeries, medications, family history, and lifestyle factors that could affect fertility.
After this discussion, your provider will perform a physical exam to identify any visible concerns that may warrant further evaluation.
Ovulation Assessment
Conception cannot occur without ovulation. If ovulation is inconsistent or absent, pregnancy may be more difficult to achieve naturally. To evaluate ovulation, your provider may recommend cycle tracking, progesterone level testing, ultrasound monitoring, or a combination of all three.
Hormonal Testing
Female reproduction is largely regulated by a delicate balance of hormones, including follicle-stimulating hormone (FSH), luteinizing hormone (LH), estrogen, and progesterone. If hormone levels are disrupted, core reproductive functions such as ovulation and egg development may be negatively impacted. Through blood testing, fertility specialists can evaluate whether these hormone levels fall within expected ranges.
Ovarian Reserve Testing
Ovarian reserve refers to the quantity of eggs remaining in the ovaries. Beyond AMH hormone testing, ovarian reserve is often evaluated through an antral follicle count (AFC), which is an ultrasound-based assessment that helps providers count the number of developing follicles at the start of a cycle. Together, AMH and AFC give a more complete picture of egg supply and help guide treatment planning.
Hysterosalpingography (HSG)
A hysterosalpingography, or HSG, is a specialized X-ray procedure used to examine the uterus and fallopian tubes. During the test, contrast dye is introduced through the cervix and tracked as it moves through the reproductive tract. This imaging allows specialists to identify blocked fallopian tubes or uterine abnormalities that may interfere with fertilization or implantation.
Transvaginal Ultrasound Testing
During a transvaginal ultrasound, a small ultrasound probe is inserted into the vagina to provide detailed imaging of the reproductive organs. This exam may be used to monitor follicle development, assess the uterine lining, and identify concerns such as fibroids, cysts, or polyps.
Laparoscopy
When standard testing doesn't fully account for a patient's fertility challenges, laparoscopy may be recommended. During this minimally invasive surgical procedure, a small camera is inserted through a tiny incision to directly visualize the pelvic organs. It's often the most reliable way to diagnose conditions like endometriosis or pelvic adhesions, which are not always identifiable using standard imaging.
Genetic Testing
If personal or family history suggests the possibility of an inherited condition, or if other evaluation findings raise concern, your provider may recommend genetic testing. This can help identify genetic factors that may affect fertility, pregnancy outcomes, or the health of future children, and can be used to inform treatment planning accordingly.
Saline Infusion Sonogram (SIS)
A saline infusion sonogram uses a small amount of saline solution and ultrasound imaging to create a detailed view of the uterine cavity. The saline gently expands the cavity, making it easier to detect subtle abnormalities such as polyps, fibroids, or scar tissue that may not be visible on a standard ultrasound.
