Recommended Blood Work for Female Fertility Testing
For a comprehensive female fertility evaluation, obtain the following blood tests: anti-Müllerian hormone (AMH) on any cycle day, day 3 FSH and LH, mid-luteal progesterone (day 21), TSH, prolactin if menstrual irregularities exist, and a complete blood count. 1, 2
Core Hormonal Panel
Ovarian Reserve Assessment
- AMH (Anti-Müllerian Hormone): This is the most reliable marker of ovarian reserve and can be measured on any cycle day, making it the most convenient test 1
- Day 3 FSH and LH: Measure between cycle days 2-3 to assess ovarian reserve and pituitary function; an LH/FSH ratio >2 suggests polycystic ovary syndrome (PCOS) 3, 1, 2
- Day 3 Estradiol: Obtain simultaneously with FSH and LH to provide complete baseline hormonal assessment 2
Note that AMH levels may fluctuate in women under 25 years, requiring cautious interpretation in younger patients 1
Ovulation Confirmation
- Mid-luteal progesterone: Measure on day 21 of a 28-day cycle (or 7 days before expected menses); levels >6 nmol/L confirm ovulation, while levels >30 nmol/L strongly support ovulation 3, 1, 2
Low progesterone indicates anovulation, with common causes including PCOS, hypothalamic amenorrhea, or hyperprolactinemia 3
Thyroid and Prolactin Assessment
- TSH (Thyroid-Stimulating Hormone): Essential screening to rule out thyroid disorders that can impair fertility 3, 1, 2
- Prolactin: Measure morning resting serum levels if galactorrhea or menstrual irregularities are present; levels >20 μg/L are abnormal and may indicate pituitary tumors or hypothyroidism 3, 2
Critical pitfall: Never measure prolactin immediately post-seizure or post-stress, as this will falsely elevate results 3
Androgen Assessment (When Indicated)
Obtain the following on cycle days 3-6 if irregular cycles or PCOS is suspected:
- Testosterone: Levels >2.5 nmol/L suggest PCOS or valproate effect 3
- Androstenedione: Levels >10.0 nmol/l warrant evaluation for adrenal or ovarian tumors 3
- DHEAS (Dehydroepiandrosterone Sulfate): Age-specific cutoffs apply; elevated levels suggest non-classical congenital adrenal hyperplasia 3
Metabolic Screening (For PCOS Suspicion)
- Fasting glucose and insulin: Obtain if obesity, irregular cycles, or PCOS features present; fasting glucose >7.8 mmol/L suggests diabetes, and glucose/insulin ratio >4 indicates reduced insulin sensitivity 3
Hematologic Assessment
- Complete Blood Count (CBC): Identify anemia or other hematologic abnormalities that could impact fertility 3, 1
Infectious Disease Screening
- Chlamydia and gonorrhea: Essential screening as these can cause tubal factor infertility 1
- Rubella serology: Vaccinate if seronegative before conception 1
- HIV, syphilis, hepatitis B surface antigen: Recommended by CDC for comprehensive preconception care 1
Timing Considerations
Initiate fertility evaluation after 12 months of unprotected intercourse for women under 35 years, or after 6 months for women aged 35-40 years. 2 Women over 40 years or with known risk factors (history of pelvic inflammatory disease, endometriosis, irregular cycles, prior chemotherapy/radiation) warrant immediate evaluation 3, 2
Integration with Imaging
Blood work should be complemented by transvaginal ultrasound to evaluate ovarian morphology, measure antral follicle count, and assess for structural abnormalities; ovarian volume <3 cm³ with <5 antral follicles indicates diminished ovarian reserve 1 Hysterosalpingography may be needed to assess tubal patency if initial evaluation suggests tubal factor infertility 3, 1
Common Pitfalls to Avoid
- Do not order FSH alone without concurrent estradiol, as elevated estradiol can artificially suppress FSH and mask diminished ovarian reserve 2
- Do not assume normal fertility based solely on regular menstrual cycles; women can have regular cycles with diminished ovarian reserve or anovulation 3, 4
- Do not delay evaluation in women over 35 years, as ovarian reserve declines rapidly after this age 2, 4