Preconception Fertility Blood Work Recommendations
For women, obtain blood pressure screening, diabetes screening if indicated, and STI testing; for men, obtain testosterone and FSH levels if sperm analysis is abnormal, along with STI testing for both partners.
Women's Laboratory Testing
The AAFP preconception care guidelines 1 provide a framework that emphasizes routine screening rather than extensive fertility-specific blood work for most women:
Essential Blood Work:
- Blood pressure measurement during routine care to identify hypertension
- Diabetes screening for women with risk factors (obesity, family history, prior gestational diabetes)
- STI testing based on risk assessment for both partners
- Rubella and varicella immunity status (if immunization history unclear)
Condition-Specific Testing:
- Thyroid function tests if symptoms of thyroid disease are present
- Hemoglobin A1c for women with known diabetes to assess glycemic control
- Depression screening (though not blood work, this is emphasized as critical)
Important caveat: The AAFP guidelines notably do not recommend routine hormonal panels (FSH, LH, AMH, progesterone) for all women seeking preconception care. These are typically reserved for women with specific fertility concerns like irregular cycles, suspected ovulation disorders, or advanced maternal age.
Men's Laboratory Testing
For male partners, the approach is more targeted 1, 2:
Initial Assessment:
- Semen analysis first (two samples if first is abnormal) - this is the cornerstone, not blood work 2, 3
- Blood work is secondary and conditional based on semen analysis results
Hormonal Blood Work Indicated When:
- Testosterone and FSH if sperm concentration is abnormally low 2, 3
- LH assay if testosterone is low (to differentiate central vs. peripheral hypogonadism) 2
- When sexual dysfunction is present
- When clinical findings suggest endocrinopathy 3
Additional Testing:
- STI screening based on risk assessment 1
- Karyotype if sperm concentration ≤10 million/mL 2
- Y chromosome microdeletion analysis if concentration ≤1 million/mL 2
- CFTR gene testing if bilateral or unilateral vas deferens agenesis suspected 2
Clinical Algorithm
Step 1: Both partners undergo STI risk assessment and testing as indicated
Step 2: Women receive blood pressure check and diabetes screening if risk factors present
Step 3: Men provide semen analysis (the primary male fertility test)
Step 4: Only if male semen analysis is abnormal, proceed with testosterone/FSH testing
Step 5: Additional genetic testing only for severe male factor infertility (as outlined above)
Common Pitfalls to Avoid
- Don't order extensive hormonal panels reflexively - the guidelines emphasize targeted testing based on clinical findings, not shotgun approaches 1
- Don't skip the male partner - approximately 50% of infertility has a male component 2, 4, yet evaluation often focuses disproportionately on women
- Don't order blood work before semen analysis in men - this is inefficient and not evidence-based 3, 5
- Don't forget non-laboratory assessments - folic acid supplementation, immunization status, BMI assessment, and substance use screening are equally critical 1
The evidence consistently shows that preconception care is more about risk assessment, counseling, and optimization of existing conditions rather than extensive laboratory screening in asymptomatic couples 1, 6. Blood work should be targeted based on individual risk factors, symptoms, and initial findings rather than applied universally.