What are the signs of female infertility, and when should I get tested?
For some, certain signs, such as irregular periods, extremely painful periods, or a history of miscarriage, may suggest an underlying fertility issue. However, female infertility does not always cause obvious symptoms. Many women often have regular menstrual cycles and otherwise feel healthy, yet still experience difficulty conceiving.
In general, women under 35 should consider an evaluation after one year of regular, unprotected intercourse without pregnancy. Women over 35 are typically advised to seek testing after six months of trying to conceive without success.
That said, fertility testing is not limited to those actively trying to become pregnant. Women who are considering delaying pregnancy, exploring fertility preservation, or simply seeking a better understanding of their reproductive health may also benefit from an evaluation. Proactive testing can also be helpful for those with risk factors or conditions known to impact fertility.
Possible Causes of Female Infertility
Female infertility can develop from a variety of factors affecting ovulation, hormone production, ovarian function, reproductive anatomy, or implantation. 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
What is AMH testing and why does it matter?
Anti-Müllerian Hormone (AMH) is one of the most commonly ordered fertility tests for women. Because AMH is produced by the ovarian follicles, which are the small structures that contain and support a woman’s eggs, providers can use AMH levels to estimate ovarian reserve (the number of eggs remaining in the ovaries).
High levels of AMH tend to indicate a larger egg supply, while lower levels of AMH may suggest a smaller egg supply. Since the number of remaining eggs naturally declines with age, it is normal to see lower AMH levels over time.
Your provider will review your results against the normal range for your age. AMH levels that are either too high or too low for your age can provide important insight into ovarian function that can help guide further evaluation or future treatment decisions.
While AMH testing is highly informative, it does not account for other factors critical to conception, such as egg quality. It’s helpful to remember that AMH testing is just one part of a broader evaluation, and its results alone are not predictive of a woman’s reproductive potential.
What other female fertility testing is part of an overall evaluation?
Since female fertility hinges on multiple interconnected processes, a thorough evaluation often extends beyond a single test. Typically, fertility specialists use a combination of bloodwork, imaging, and, when necessary, minimally invasive diagnostic procedures to develop a full picture of your reproductive health. At the Reproductive Medicine Group, a comprehensive fertility evaluation may include:
Medical History and Physical Examination
Every fertility evaluation begins with a detailed review of your medical history. Your provider will ask about your menstrual cycle, previous pregnancies, medical conditions, medications, surgeries, and family history. This discussion is typically followed by a physical examination to identify any observable abnormalities.
Ovulation Assessment
For conception to occur, the ovaries must release at least one mature egg every month. To determine whether ovulation is occurring regularly, a fertility specialist may measure progesterone levels, recommend cycle tracking, or monitor follicle development via ultrasound.
Hormonal Testing
Hormonal imbalances are a common contributor to fertility challenges. Therefore, fertility specialists often order bloodwork to evaluate levels of key reproductive hormones such as FSH, LH, estradiol, prolactin, and TSH.
Ovarian Reserve Testing
Ovarian reserve refers to the quantity of eggs remaining in the ovaries. In addition to AMH testing, ovarian reserve may be determined using ultrasound-based follicle counts.
Hysterosalpingography (HSG)
A hysterosalpingogram (HSG) is a specialized X-ray procedure used to evaluate the fallopian tubes and uterine cavity. During the procedure, contrast dye is introduced into the cervix and tracked as it flows through the reproductive tract. This allows specialists to determine whether or not the fallopian tubes are obstructed and if there are any uterine abnormalities that may require further imaging.
Transvaginal Ultrasound Testing
A transvaginal ultrasound uses a small ultrasound probe inserted into the vagina to obtain detailed images of the reproductive organs. This allows fertility specialists to evaluate the uterus, ovaries, and surrounding pelvic organs.
Genetic Testing
Genetic carrier screening is recommended for all patients, regardless of personal or family history. Carrier screening helps identify whether you carry inherited genetic conditions that could be passed on to future children. Depending on your medical history and fertility evaluation, additional genetic testing, such as karyotype analysis to evaluate for chromosomal abnormalities or thrombophilia gene testing, may also be recommended when clinically appropriate.
Saline Infusion Sonogram (SIS)
A saline infusion sonogram (SIS) is an ultrasound procedure that uses sterile saline to gently expand the uterine cavity during imaging. This provides a more detailed view of the inside of the uterus and can help identify abnormalities such as polyps, fibroids, scar tissue, or other structural concerns. An SIS may also be recommended to further evaluate or clarify findings from a previous HSG.
