What lab work is recommended to check fertility in a patient?

Laboratory Work for Fertility Evaluation

Order two semen analyses at least one month apart as the initial and most essential laboratory test for male fertility evaluation, combined with selective hormonal testing only when specific abnormalities are identified. 1, 2

Male Partner Laboratory Evaluation

First-Line Essential Testing

Semen Analysis (Two Specimens Required)

• Collect two separate semen analyses at minimum one month apart, as semen parameters show high biological variability and single tests are unreliable for diagnosis 3, 1, 2
• Instruct patients to abstain from sexual activity for 2-3 days before collection, as inadequate abstinence significantly affects volume and concentration, invalidating results 1, 2
• Examine specimens within one hour of collection at room or body temperature 3, 1
• Interpret using WHO-based reference limits: volume ≥1.4 mL, pH >7.2, sperm concentration ≥16 million/mL, progressive motility ≥30% 1

Selective Hormonal Testing (Not Routine)

Order endocrine evaluation ONLY when:

• Sperm concentration is <10 million/mL 3, 1, 4
• Azoospermia is confirmed 4, 5
• Sexual function is impaired 1, 4
• Physical examination reveals findings suggesting endocrinopathy 1, 4

When indicated, measure:

• Serum testosterone 1, 2
• Follicle-stimulating hormone (FSH) 1, 2, 5
• Luteinizing hormone (LH) 5

Additional Selective Testing Based on Findings

Post-ejaculatory urinalysis:

• Order only if ejaculate volume <1 mL to evaluate for retrograde ejaculation 1, 2
• Exception: Do not order in bilateral vasal agenesis or hypogonadism 1

Genetic testing:

• Order karyotype and Y-chromosome microdeletion testing if severe oligospermia (<5 million/mL) or azoospermia 1, 2
• Offer before intracytoplasmic sperm injection procedures 2

Female Partner Laboratory Evaluation

Ovulation Assessment

Mid-luteal phase serum progesterone:

• Measure on cycle day 21 to confirm ovulation 2, 6
• Value >30 nmol/L supports ovulation 2

Ovarian Reserve Testing

Baseline hormonal evaluation on cycle day 3:

• Follicle-stimulating hormone (FSH) 2
• Luteinizing hormone (LH) 2
• Estradiol 2

Anti-Müllerian hormone (AMH):

• Can be measured on any cycle day for ovarian reserve information 2

Selective Hormonal Testing

Thyroid function tests:

• Order only if symptoms of thyroid disease are present 2

Prolactin levels:

• Measure only if galactorrhea or menstrual irregularities exist 2

Critical Pitfalls to Avoid

Laboratory quality matters significantly:

• Many laboratories do not adhere to WHO standardized methods, leading to high variability and unreliable results 1
• Ensure specimens are processed by quality-controlled laboratories 1

Avoid routine hormonal testing in males:

• Hormonal evaluation is not recommended as primary first-line investigation for all infertile men 4
• Use a stepwise approach: history, physical exam, and semen analysis first, then selective hormonal testing based on abnormalities 4, 5

Single parameter assessment is insufficient:

• Evaluation of the entire semen analysis profile is necessary, not just concentration 1
• Normal semen analysis does not equal fertility, as 25% of infertility cases remain unexplained despite normal conventional parameters 1

Improper collection technique invalidates all results:

• Inadequate abstinence period, delayed analysis beyond one hour, or improper temperature control during transport renders results unreliable 1, 2