What laboratory tests are typically included in a fertility evaluation?

Fertility Testing Laboratory Evaluation

For fertility testing, the essential laboratory tests include semen analysis (at least two samples, one month apart) for males, and follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, and prolactin levels for females, with both partners evaluated simultaneously from the outset. 1, 2

Male Partner Laboratory Testing

Core Initial Tests

• Semen analysis is the fundamental screening test and should be performed at least twice, one month apart, with 2-3 days of sexual abstinence before collection 1
• The semen analysis evaluates seven key parameters: ejaculate volume (1.5-5.0 mL), pH (>7.2), sperm concentration (>20 million/mL), total sperm number (>40 million/ejaculate), motility (>50%), forward progression (>2 on 0-4 scale), and morphology 1

Endocrine Evaluation (When Indicated)

• Perform endocrine testing if sperm concentration is less than 10 million per mL or if semen analysis shows other abnormalities 1
• Measure FSH and LH levels, as these have significant negative correlation with sperm count, motility, morphology, and vitality 1, 3
• Check prolactin levels, particularly when LH is low or low-normal 4
• Measure testosterone levels if clinical signs suggest hypogonadism 4
• Consider estradiol measurement if gynecomastia or breast symptoms are present 4

Important caveat: Thyroid hormone evaluation is not mandatory in male fertility workup, as studies show no significant associations between thyroid hormones and sperm parameters 5

Female Partner Laboratory Testing

Essential Hormonal Assessment

• Measure FSH levels to assess ovarian reserve 2
• Check LH levels as part of the comprehensive hormonal evaluation 2
• Measure prolactin, as hyperprolactinemia is characteristic of female infertility 6
• Assess estradiol levels, particularly since elevated levels correlate with infertility 6

Additional Diagnostic Testing

• Transvaginal ultrasound to evaluate uterine anatomy and assess tubal patency 2
• Anti-Müllerian hormone (AMH) may be considered for ovarian reserve assessment, though not yet universally included in standard guidelines 1

Timing and Approach

When to Initiate Testing

• Begin evaluation after 12 months of unprotected intercourse for women under 35 years 2
• Initiate testing after only 6 months for women over 35 years 2
• Start earlier if risk factors exist: oligomenorrhea, known uterine/tubal disease, endometriosis, or subfertile male partner 2

Critical Practice Point

Both partners must be evaluated simultaneously from the beginning to avoid delays in diagnosis and treatment 2. The ASRM and AUA emphasize that at minimum, male evaluation should include reproductive history and semen analysis, while female evaluation should include hormonal assessment and anatomical evaluation 1, 2

Common Pitfalls to Avoid

• Do not rely solely on reproductive history and single semen analysis, as 0.16% of men have significant medical conditions despite normal semen parameters 1
• Do not delay male partner evaluation while focusing exclusively on female factors 1
• Do not perform thyroid function tests routinely in males unless other clinical indicators suggest thyroid dysfunction 5
• Ensure semen specimens are examined within one hour of collection at room or body temperature 1