Your First Fertility Workup: Tests to Expect and What Each One Looks For

Your first fertility workup can feel like walking into an exam you never signed up for, with your body, your relationship, and your future all on the line. One minute you’re tracking ovulation on your phone; the next you’re staring at a referral for “diagnostic testing” and wondering what that even means for you, but you did it! You finally asked for help! 

It’s completely understandable if you’re hoping for answers and dreading them at the same time. The good news is that the initial fertility evaluation is meant to answer a few key questions as efficiently and gently as possible, with an emphasis on least‑invasive first, not on grading your body. Overall, the metrics can be difficult to interpret and can feel like receiving a sort of “grade”. 

Medical societies generally suggest seeking a fertility evaluation if you are under 35 and have been trying for 12 months, 35 or older and have been trying for 6 months, or at any age if you have very irregular or absent periods, very painful cycles, known endometriosis, prior pelvic infection or surgery, or known sperm issues. The American Society for Reproductive Medicine (ASRM) defines infertility as not conceiving after 12 months of regular unprotected intercourse under age 35, and after 6 months at 35 or older, and notes that people with obvious risk factors may warrant earlier evaluation.

ASRM’s patient fact sheet on diagnostic testing for female infertility explains that the goal of the initial workup is to clarify a few core issues: whether you are ovulating, what your ovarian reserve looks like, whether the uterus and fallopian tubes appear normal, and whether semen parameters are adequate. This initial diagnostic workup aims to identify and address the primary contributors to infertility, including ovulation issues (like PCOS), sperm parameters, fallopian tube blockage, uterine factors (fibroids/polyps), endometriosis, and age-related egg quality changes. Infertility is rarely simple, and while diagnosing what may be the main cause is crucial, the reality is usually much more nuanced than just identifying and eliminating a single factor when possible.

It can be emotionally jarring to move from “let’s just try” to “we need testing,” and it’s completely understandable if part of you hopes for answers while another part fears them. A 2021 review on infertility and psychological distress found that fertility patients have anxiety and depression rates comparable to those seen in serious medical illnesses, which helps explain why even starting an evaluation can feel so intense. Oftentimes this may even be the first time you ask/receive help for your health in general. Some patients who have had little need to see a doctor in their lives can feel especially overwhelmed at the scope of this initial workup. The process will take more than one day and involve multiple tests.   

Q: Is my first fertility appointment just bloodwork and ultrasounds?

A: Usually, it starts with conversation. Most medical guidelines emphasize that a detailed history and physical exam come before any advanced testing.

Your clinician will typically ask about :

If you have a partner who produces sperm, they’ll also be asked about prior paternity, surgeries (such as hernia repair or testicular surgery), infections, testosterone or other medications, smoking, heat exposure (saunas, hot tubs), and any previous semen testing, as described in clinical reviews of female infertility that highlight the importance of evaluating both partners. 

A basic physical exam is also common and may include weight, blood pressure, thyroid or breast exam,  a pelvic exam, and an internal exam if you have a uterus/vagina.

Initial bloodwork often covers :

ASRM also encourages clinicians to use existing records and labs whenever possible, and its evidence‑based position statement on infertility urges patients and providers to “follow the science” to avoid unnecessary tests and costs. Although, repeat testing cannot always be avoided.

Q: Will I definitely need a “day 21” post ovulation blood test?

A: Not necessarily.  Clinicians may differ on their approach to this factor. If your provider does want to confirm ovulation, they may order a mid‑luteal progesterone level, often called a “day 21” test, although the key is that it’s drawn about seven days before your next expected period. Mid‑luteal serum progesterone is considered as a standard tool for documenting recent ovulation.

Evaluation guidance notes that in people with regular menstrual cycles between 21 and 35 days, additional testing to confirm ovulation is often not required unless there are signs of hormone imbalance. Regular cycles generally imply ovulatory cycles in the absence of hirsutism or other endocrine symptoms.

Depending on your story, your clinician may also check for PCOS, thyroid disease, or elevated prolactin, all of which can interfere with ovulation. Other scientific research  list thyroid disorders, hyperprolactinemia, and PCOS among the most common endocrine causes of anovulation. They might also review any tracking you’ve done at home with cycle apps, ovulation predictor kits, basal body temperature. The use of these at home tools have been noted to be helpful by major medical associations and are more widely accepted by clinicians as usable sources for accurate data.

Q: Are they going to tell me exactly how many eggs I have left?

A: Ovarian reserve testing doesn’t count eggs one by one, but it does give an estimate of your near‑term egg supply and insight on how your ovaries might respond to stimulation. These tests should be used to augment counseling, treatment planning and to help inform decision making, not as a universal screening tool or a definitive predictor of who can get pregnant naturally.

Common ovarian reserve tests include:

Lower AMH, higher FSH, and a low AFC  are associated with a lower response to ovarian stimulation and fewer eggs retrieved during IVF, but that these markers “do not reliably predict failure to conceive” on your own. 

In other words:

*Note: These tests will not provide insight on egg quality.

How do they check my uterus and fallopian tubes?

Q: What imaging tests should I expect, and what are they looking for?

A: The big questions here are whether your uterus looks like a healthy place for implantation and whether your fallopian tubes are open so the sperm and egg have a way to meet. Most standard evaluations include an assessment of uterine structure and tubal patency.

A transvaginal or abdominal ultrasound is often one of the first imaging tests you’ll encounter. It allows your clinician to look at your uterus and ovaries for fibroids, ovarian cysts, polycystic‑appearing ovaries, or structural differences like a septate or bicornuate uterus. A pelvic ultrasound is a core part of the infertility workup because it can quickly reveal anatomic issues that may affect cycles or implantation.

An HSG is an X‑ray test where contrast dye is gently passed through the cervix into the uterus and fallopian tubes to show whether the cavity looks normal and whether the tubes are open. The Cleveland Clinic explains that an HSG “involves the insertion of contrast dye into your uterus” to allow your doctor to see the shape of the uterine cavity and the flow of dye through the tubes, and notes that it’s commonly used to investigate infertility.

During the test, you usually lie on an X‑ray table while a speculum is placed and a thin catheter introduces dye into the uterus; many people experience cramping for a short time and may be advised to take an over‑the‑counter pain reliever beforehand if appropriate. 

Sometimes, your clinician may order a saline infusion sonogram (sonohysterogram) instead of or in addition to an HSG. SHG can be particularly useful for evaluating the uterine cavity with fewer X‑rays.

*Recent guidelines generally recommend SHG for assessing tubal patency and uterine abnormalities, as it is less invasive and provides more comprehensive insight with less risk for infection or exposure to radiation 

Q: If my partner produces sperm, what does their evaluation look like?

A: Male factor contributes to about a third of infertility cases, and guidelines emphasize that semen analysis should be part of the initial evaluation, not something added at the end.

A standard semen analysis usually looks at:

For sample collection, the person producing the sample is typically asked to abstain from ejaculation for 2–4  days and then provide a sample under specific conditions. If the results are abnormal, they are often repeated, and a urologist who specializes in male infertility may be involved for further evaluation and management. Your partner will also do preconception blood work.

At‑home screening kits such as YO Home Sperm Test, Bird & Be Sperm Test and ExSeed can make it easier to start a conversation about sperm health. A Cleveland Clinic study found that the YO device was a “user‑friendly, accurate way to screen samples at home” compared with lab analysis, while also warning that lab semen analysis is still the standard for diagnosis and treatment decisions.

Articles about ExSeed describe it as a reusable smartphone‑based testing system that estimates sperm count and motility at home and pairs results with lifestyle coaching, helping people track changes over time.

Q: Do most people end up with laparoscopy, hysteroscopy, or genetic work‑ups?

A: Not by default. More invasive tests are reserved for specific indications, rather than used routinely in every case.

Your team might discuss further testing if your history, exam, or first‑line imaging suggests something specific, such as:

These procedures are typically targeted based on symptoms and prior findings, rather than ordered “just to check everything.” A good clinician should be able to explain why a test is recommended, how it might change your options, and whether it’s urgent or something you can take time to consider.

Q: These tests make me feel like my body is being graded. How do I not spiral?

A: That reaction is very common, and very human. A large review in Human Reproduction Update found that people navigating infertility have levels of anxiety and depression similar to those in serious medical illnesses, which validates just how intense this can feel even before treatment starts. Recognizing its merited occurrence, be intentional with daily practices to lower your stress burden. This stage of care will challenge you to rethink your coping mechanisms and how to manage new stress on top of your current status quo to stay balanced

Taking time to rest is essential for managing health anxiety, as it allows the mind and body to recharge, helping to reduce stress and promote a clearer perspective on health concerns.

Several studies suggest that mind–body, mindfulness, and self‑compassion–based interventions can ease distress during fertility treatment. For example, a 2023 trial of a self‑compassion‑based program for infertility found that participants had lower anxiety and depression and greater confidence in their ability to cope with treatment compared with usual care, even though it wasn’t framed as a way to “fix” fertility.

A separate study of a mindfulness‑based program for fertility patients reported reductions in infertility‑related stress and improved wellbeing.

This doesn’t mean you need to meditate your way to a baby or “relax to get pregnant.” It does mean that your emotional experience is a real part of your care, worth attention on its own. Small, practical steps, like planning something comforting after appointments, writing down questions so you don’t feel blindsided, or quietly telling yourself, “Anyone in my position would find this hard”, can help your nervous system weather a taxing process These mechanisms will help you in each stage: pregnancy, labour and delivery, postpartum, and parenthood.

Q: Do I need apps or devices before I see a specialist?

A: You do not have to use any apps or devices to “earn” fertility care, but some digital tools can make it easier to gather information and show up to appointments prepared. Think of these as optional helpers, not prerequisites.

These tools do not replace medical evaluation, but they can help you feel more organized,  and more like an active participant in your own care.

How can I prepare and protect my peace before the appointment?

A few practical steps can help you feel more confident going into your first workup:

Waiting for fertility test results can feel like waiting to hear whether your dreams are still possible. Yet each test is a piece of information, not a final judgment on your worth, your body, or your future as a parent.

Reviews on infertility and psychological distress emphasize that when patients are given clear information, realistic expectations, and emotional support, they cope better with both evaluation and treatment, even when the outcomes are uncertain.

Your journey is uniquely yours, believe in your strength and your love that you have to offer as a parent.

Your first workup is about understanding your body now. Spotting what can be supported or treated, and helping you and your team choose next steps together. Whether you come in with a neat folder of labs, a MyStoria profile, three months of OTO Fertility data, a handful of Oova charts, or simply your story and your questions, you deserve to be met with respect, clear explanations, and room for your feelings.

This appointment is not a test you pass or fail. It’s the beginning of getting answers, and you do not have to navigate it alone.