Female Infertility Diagnosis: A Complete Guide to Fertility Tests

In short: The diagnosis of female infertility includes hormone tests (FSH, LH, prolactin, testosterone, and progesterone to confirm ovulation), ultrasound on day 2 or 3 of the cycle and later to follow the growth of the egg, and an X-ray of the uterus and tubes (HSG) to look for blocked tubes. Laparoscopy or hysteroscopy and immune or genetic tests may also be needed. These tests are safe.

Diagnosis of Female Infertility

Understanding why pregnancy hasn’t happened yet can feel overwhelming, but a clear, step-by-step evaluation can help identify the cause and guide the right treatment plan. Below is an overview of the main diagnostic tools used to assess female fertility.

Diagnostic Procedures

1- Hormonal levels:

Importance of Hormonal tests

FSH, LH and estradiol (on day 2–3 of the cycle), AMH (to assess ovarian reserve), thyroid hormone (TSH), prolactin and testosterone levels can all be measured. The specific hormones tested depend on each patient’s situation — for example, checking progesterone after ovulation helps assess how well the corpus luteum is functioning.

2- Vaginal Cytology:

This is an older technique in which a swab is taken from the vagina to get a general idea of ovarian function. It is rarely used today, since more advanced and accurate tests are now available.

3- Testing Changes in the Cervix:

Cervical mucus goes through natural changes during each cycle and acts as a barrier that protects the uterus from bacteria. In the first half of the cycle, it is scanty and thick; about five days before ovulation, it becomes clear and watery so sperm can pass through more easily during intercourse. Any disruption to these changes may make it harder for sperm to reach the egg, which can affect fertilization.

Hormonal shifts throughout the month directly influence the quality and amount of cervical mucus. Just before ovulation, it becomes stretchy and watery — similar to raw egg whites. About 24 hours after ovulation, mucus production slows, then returns to a thicker, white-yellow consistency for the rest of the cycle.

4- Microbiological, laboratory and blood tests:

For example:

• Liver function test.
• Blood sugar level.
• Urine analysis.
• Other tests for contagious microorganisms.

5- Ultrasound examinations:

Ultrasound is used to visualize internal organs including the uterus, ovaries, testes, prostate, liver, kidneys, and gallbladder. It is generally preferred over x-ray because it does not use radiation and is safe for both men and women. There are two main types of ultrasound used in evaluating female fertility:

A- Trans-abdominal ultrasound:

Here, the probe is moved over different areas of the abdomen depending on what is being examined — mainly the uterus and ovaries in fertility assessments.

B- Trans-vaginal ultrasound:

This method gives a clearer, more detailed view of the ovaries, making it more accurate for tasks such as measuring follicle size during ovulation induction, diagnosing PCOS, monitoring ovulation, and assessing the pelvic organs, endometrium, uterine wall (myometrium), and fibroids.

How often should ultrasound be done to check for ovulation?

Typically, an initial scan is done on day 2 or 3 of the cycle to check the uterus and ovaries and screen for PCOS. A second scan around day 13 checks follicle size and ovarian activity, whether in a natural cycle or after ovulation induction. Without stimulation medication, the leading follicle grows roughly 1–2 mm per day and usually releases the egg when it reaches about 18–24 mm. If ovulation occurs, your doctor can usually identify specific signs on ultrasound.

The ideal follicle size for fertilization depends on the type of treatment being used for ovarian stimulation. Sometimes a follicle appears mature on ultrasound but isn’t quite ready, so your doctor may recommend repeated scans, since follicle growth can pause or continue without releasing an egg. In some cases, HCG hormone is given to trigger ovulation. If the follicle keeps growing without releasing the egg, a small ovarian cyst (called LUF) may form — this is not a serious condition and usually resolves on its own without treatment.

Ovarian Follicles as seen by Trans-vaginal ultrasound

Other conditions that may be diagnosed by ultrasound:

• Small, immature ovary in an adult woman (hypogonadotrophic hypogonadism).
• Infantile uterus (smaller-than-usual uterus).
• Endometrial thickness at different stages of the cycle.
• Multi-cystic ovaries: similar to PCOS but with fewer, larger follicles.
• Women recovering from anorexia nervosa.
• Uterine fibroids or ovarian masses.
• Early pregnancy.
• Congenital anomalies in the fetus.
• Multiple pregnancies (two or more embryos).
• Fetal presentation, placental location, and baby’s sex.
• Ectopic pregnancy.
• Pregnancy dating, estimated fetal weight, and amniotic fluid levels.

Color Doppler ultrasound:

This is a more advanced tool, and its role in fertility diagnosis is still being researched. It measures blood flow within blood vessels, allowing evaluation of blood flow between the ovaries and uterus.

Color Doppler ultrasound

Can this method affect the follicle or cause harm?

No harmful effects on follicles have been demonstrated so far.

6- Hysterosalpingogram (HSG)

In this test, a special dye is passed through a thin tube inserted into the cervix, and a series of x-ray images track its movement. If a fallopian tube is blocked, the dye will not pass through it. The amount and duration of dye used is considered safe.

Hysterosalpingogram (HSG)

This procedure generally causes only mild lower abdominal discomfort, takes just a few minutes, and does not require hospital admission.

It is helpful for diagnosing:

• Intrauterine lesions (fibroids, polyps).
• Tubal blockage or dilation (hydrosalpinx).
• Uterine anomalies.
• Intrauterine adhesions (Asherman’s syndrome).

HSG Showing patent tubes

Tubal blockage and dilation (hydrosalpinx).

7- Hysterosalpingo Contrast Sonography (HyCoSy):

Since fallopian tubes usually cannot be seen on standard ultrasound, this technique was developed specifically to check tubal patency, and it offers several benefits:

• It complements standard ultrasound imaging and is increasingly used in modern practice.
• It avoids x-ray exposure, unlike HSG.
• No iodine-based contrast is needed, reducing the risk of allergic reaction.
• Compared to other techniques, it is minimally invasive and generally not painful.
• No general anesthesia is required.
• It can be done as an outpatient office procedure.
• Results are available quickly and accurately.
• It provides detailed structural and functional information about the organs examined.

For example, when examining the endometrial cavity, it can help distinguish between a submucosal fibroid and an endometrial polyp.

This procedure can be performed using either abdominal or transvaginal ultrasound.

First, the genital area is cleaned, and the patient lies on her back with knees bent and slightly apart. The cervix is gently held in place, and a thin catheter is inserted through it. A special contrast fluid or foam (for example ExEm foam, a technique known as HyFoSy) is introduced through the catheter — the whole process takes about 10–15 minutes and does not require anesthesia. A small balloon at the tip of the catheter is inflated to keep it in place before the vaginal ultrasound probe is inserted. The doctor then follows the fluid as it passes through the uterus and fallopian tubes on screen. If a tube is blocked, the patient may feel some discomfort, and she is encouraged to mention this right away.

• About 2–3 ml of fluid is typically used to visualize the uterus and detect abnormalities such as a septum or fibroid.
• An additional 1–2 ml is used to visualize the fallopian tubes.
• At the end of the exam, the balloon is deflated before removing the probe so any area it may have covered can also be checked.
• Mild lower abdominal cramping, similar to period pain, may occur for up to an hour afterward and is easily managed with simple pain relief.

Hysterosalpingo Contrast Sonography

This procedure is:

• Quick.
• Easy to perform.
• Associated with no major side effects.
• Generally comfortable for the patient.

Some abnormal findings that may be noticed:

• A reflection zone in the endometrium, often related to a previous cesarean section.
• Intrauterine adhesions such as Asherman’s syndrome.
• Polyps.
• Fibroids
• Uterine anomalies such as arcuate uterus, bicornuate uterus, or uterus duplex.
• Tubal blockages.

If both tubes are blocked, the uterus may appear swollen on the ultrasound screen and mild pain may occur. If only one side is blocked, there is usually no swelling, and the location of the blockage is easier to identify.

Adhesions or tumors can slow the passage of the contrast fluid, so an experienced specialist is important to avoid misdiagnosis.

8- Diagnostic laparoscopy

9- Diagnostic hysteroscopy

10- Falloposcopy:

Performed either during laparoscopy or transcervically, with or without hysteroscopy.

11- Post-Coital Test (PCT):

Around ovulation, cervical mucus becomes watery, stretchy, clear, and abundant, helping sperm travel through and reach the egg. In this test, a sample of cervical mucus is collected 6–10 hours after intercourse and examined under a microscope to assess sperm activity and mucus quality.

Mucus-producing cells in the cervix respond to estrogen, which rises sharply around ovulation. At this time, about 98% of the mucus is water, giving it its stretchy quality. Increased salt and water content also interacts with mucus proteins, an indirect marker of rising estrogen. These changes help sperm survive in the cervix for up to 3–5 days, which is why intercourse in the days before ovulation can lead to pregnancy. As progesterone rises afterward, the mucus becomes thicker and less supportive of sperm survival.

The post-coital test is simple to perform, but it is no longer recommended as a routine test by international guidelines, because its results vary widely and do not change treatment decisions or pregnancy rates; a semen analysis and tubal and ovulation tests give more useful information.

It has also been observed that healthy cervical mucus can sometimes help compensate for mildly low semen counts.

While the post-coital test is easy to perform, it is not always fully reliable. It can occasionally give a falsely poor result — for example, if antibodies are present in the cervix, or if there is a cervical infection affecting the mucus — even when the semen analysis itself is normal.

Post coital test showing active motile sperm

Assessment in the Post-Coital Test includes:

1 - Mucus elasticity, since sperm cannot pass through mucus that is too thick.

2 - Presence of antibodies: The cervix has a strong capacity to produce antibodies (followed by the endometrium and fallopian tubes), which contributes to local immune activity. Sperm exposure can trigger antibody formation, both locally and in the bloodstream.

The cervix contains plasma cells and the proteins needed for antibody production. These levels vary throughout the cycle and are typically lowest around ovulation.

Sperm Antibodies

3 - Whether sperm are able to reach the cervix at all.

4 - Presence of vaginal or intrauterine infections — bacterial, fungal, or other pathogens.

12- Endometrial Biopsy:

This is performed around day 21–23 of the cycle. The cervix is gently dilated and a small endometrial tissue sample is collected and sent for histopathology. If ovulation occurred, progesterone levels and tissue findings typically align in a predictable pattern; if not, progesterone will be low and the tissue findings will differ.

This method is no longer recommended for assessing ovulation or fertility, since a mid-luteal progesterone blood test and vaginal ultrasound give the answer more simply; an endometrial biopsy is now reserved for specific situations, such as suspected chronic infection of the lining (endometritis) or abnormal bleeding.

13 - Basal Body Temperature Chart (BBT):

This method involves measuring body temperature every morning, starting on day one of the period, and recording it daily until the next cycle begins. If ovulation occurs, a small temperature rise (about 0.2–0.5°C) appears in the second half of the cycle due to increased progesterone, and stays elevated until just before the next period. If pregnancy occurs, the temperature remains elevated. Without ovulation, temperature stays fairly constant throughout the cycle.

This method has several limitations. Temperature readings can be inaccurate or inconsistent, illness or infection can raise body temperature independently, and some women show irregular temperature patterns even with normal ovulation. Hormonal variability can also mean the expected rise doesn’t always appear exactly around day 12–14.

Other factors, such as individual differences in how the body responds to progesterone, can also affect accuracy.

Because of these limitations, along with newer, more reliable tools, this method is used far less often today.

14- Immunological tests:

• Anti-sperm antibodies — these are no longer tested routinely in women; when needed, they are checked in the semen of the male partner.
• Adrenal (21-hydroxylase) and thyroid antibodies in cases of premature ovarian insufficiency (anti-ovarian antibody tests are not reliable and are no longer recommended).
• Other antibodies, such as anti-phospholipid antibodies, which are tested in women with recurrent miscarriage or a history of blood clots; their role in implantation failure after embryo transfer is not proven.

15- Genetic and chromosomal tests:

These may be recommended in cases such as:

1- Premature ovarian failure.

2- Primary amenorrhea (menstrual cycles that have never started).

3- Recurrent miscarriage.

16- Psychological evaluation:

Emotional wellbeing can have a meaningful effect on fertility. Learn more here: stress and infertility

If you have questions about fertility testing or would like to discuss your individual situation, the team at Dr. Najeeb Layyous’s clinic is here to help guide you through the right diagnostic steps for your case.

Dr Najeeb Layyous F.R.C.O.G

Consultant Obstetrician, Gynecologist and Infertility Specialist