Pre-IVF Tests: Ovarian Reserve, Tubal Patency and Semen

The essential pre-IVF tests assess three things in the woman (the uterus, the fallopian tubes and ovarian reserve) and one in the man (the semen). In practice that means a day two or three transvaginal ultrasound, FSH, oestradiol and AMH, a tubal patency test such as hysterosalpingography, and a semen analysis, supported by infectious disease screening and baseline blood tests.

Dr. Shelly Singh, Senior Director Obstetrics & Gynaecology, Fortis La Femme, New Delhi, India, described these as the bare essentials of an infertility evaluation: one test for the uterus, one for the tubes and one for ovulation, with the male partner tested alongside. The same tests decide whether a couple needs corrective surgery before IVF, which is why she encourages general practitioners to order them before referral. Where the workup sits in the wider pathway, from causes of infertility to cost and legal limits, is set out in the complete guide to pre-IVF workups and corrective surgeries.

Transvaginal ultrasound: the first test for the uterus and ovaries

A transvaginal ultrasound is one of the most important tests for any woman presenting with infertility. Dr. Singh prefers a three-dimensional transvaginal scan where it is available; where it is not, a conventional transvaginal scan with good resolution is adequate.

A single scan answers several questions at once:

• Uterine size and shape, including the outline that suggests a congenital anomaly.
• Endometrial thickness, the depth of the lining in which an embryo implants.
• Abnormalities of the cavity: a submucous fibroid, a polyp or intrauterine adhesions.
• Ovarian volume and antral follicle count, two direct markers of ovarian reserve.

The scan for ovarian reserve is done on day two or three of the period. The sonologist counts the antral follicles (small fluid-filled sacs, each containing an immature egg) in each ovary and estimates the volume of each ovary. A low count and a small ovarian volume both point to a reduced supply of eggs.

When MRI is used instead

MRI of the pelvis has a defined place in the workup. Dr. Singh orders it where three-dimensional ultrasound is not available, where a patient is not comfortable with a transvaginal scan, and for unmarried young women in whom a transvaginal examination is not appropriate. MRI also maps the uterus and ovaries in detail when a complex anomaly or deep endometriosis is suspected.

Ovarian reserve testing: FSH, oestradiol and AMH

Ovarian reserve describes the number of eggs a woman has left. Every woman is born with a finite number of eggs, and that number falls steadily with age: as Dr. Singh put it, the biological clock keeps ticking. The hormonal tests of ovarian reserve are:

• Follicle-stimulating hormone (FSH): the pituitary hormone that drives follicle growth. It is preferably measured on day two of the period; if periods are irregular, it can be measured at any time. Very high FSH levels may affect the results of IVF, because they indicate that the ovaries need a stronger signal to respond.
• Oestradiol: the main form of oestrogen produced by the ovaries, measured alongside FSH in the early follicular phase.
• Anti-Müllerian hormone (AMH): a hormone produced by the small follicles in the ovary, which reflects the number of eggs available. Unlike FSH, AMH varies little across the menstrual cycle and can be measured on any day.

Dr. Singh highlighted a pattern she now sees regularly. AMH levels are extremely low in many women, including younger women. At the same time, couples are marrying later and thinking about conception later, so that by the time they seek help, AMH has fallen substantially. For a couple considering IVF, a low AMH changes both the urgency of treatment and the counselling about likely egg numbers.

Tubal patency tests: HSG, sonosalpingography and chromopertubation

Blocked tubes are one of the commonest reasons for IVF, so confirming whether the fallopian tubes are open is part of every evaluation. Three tests are available.

Hysterosalpingography (HSG)

In a hysterosalpingogram, a water-soluble radiographic dye is pushed through the cervix into the uterus. If the tubes are open, the dye travels along them and spills out of their far ends. The procedure is watched on a fluoroscopic screen and X-ray images are taken, which provide documentary evidence of whether each tube is open.

Sonosalpingography

A sonosalpingogram uses ultrasound instead of X-rays. Saline is introduced through the cervix into the uterus, and the sonologist watches for fluid collecting in the pouch of Douglas, the space behind the uterus. Fluid there shows that at least one tube is patent.

Chromopertubation at laparoscopy

When a laparoscopy is being done for another reason, chromopertubation can be performed at the same time. A dye, methylene blue, is injected through the cervix while the surgeon watches the tubes through the laparoscope. If the dye spills from the ends of the tubes, they are open. Because the tubes are seen directly, this is the most definitive of the three tests.

When HSG shows both tubes blocked near the uterus

An HSG that shows both tubes blocked at their uterine ends, known as bilateral proximal tubal blockage, is often a false positive. HSG is frequently done without sedation, and a patient in pain tenses so much that the tubes go into spasm and appear blocked. Dr. Singh's approach is to give an antispasmodic before the procedure and, where possible, light sedation, since HSG is a painful test. Together these remove many of the false positives.

If both tubes still appear blocked proximally, she prefers to proceed directly to a diagnostic hysterolaparoscopy (hysteroscopy and laparoscopy performed together) with chromopertubation rather than repeat the HSG. The tubes are then visualised directly, and most patients find repeated HSG very painful. This question was raised by a doctor attending the masterclass, and Dr. Singh's full answer is in the Live Discussion from this masterclass. The operations that follow a confirmed blockage are described in Endometriosis and tubal surgery before IVF.

Semen analysis: why the male partner must be tested

About a third of infertility is due to the female partner, a third to the male partner and a third to both, so a semen analysis belongs in the first round of tests, not as an afterthought. Dr. Singh noted that some husbands refuse testing because they assume the problem lies with their wife; she urges clinicians to press for the test regardless.

How the sample is collected

The sample is collected after two to three days of abstinence. Most good hospitals and laboratories have a private collection room, and the sample goes to the laboratory immediately. If a man collects at home, he should bring the sample to the laboratory promptly; Dr. Singh's guidance is within about 15 minutes. A complete sample matters, because the result depends on the contribution of the accessory sex glands as well as on testicular function.

What a normal semen analysis looks like

The World Health Organization reference values were revised after the 2010 edition of its laboratory manual; the current, sixth edition was published in 2021. Its lower reference limits, the values below which a result is considered abnormal, include:

Dr. Singh also highlighted the other features a laboratory reports:

• Liquefaction, which should occur within 30 minutes.
• Viscosity: semen that is too viscous may indicate infection.
• Appearance, volume and pH of the ejaculate.
• Pus cells and immature germ cells, which again point towards infection.

One abnormal result is not a diagnosis

A single sample is not enough to label a man as having a low sperm count (oligozoospermia) or any other abnormality. Dr. Singh requires at least two to three samples, taken at different times, before calling a result abnormal. Any result outside the reference values warrants evaluation, and she refers such men to andrology colleagues who specialise in male infertility.

Infectious disease screening before IVF

Before IVF, and before any fertility surgery, patients are screened for blood-borne and sexually transmitted infections:

• Hepatitis B surface antigen (sometimes called the Australia antigen).
• HIV.
• Hepatitis C.
• VDRL, a screening test for syphilis.
• A complete sexually transmitted disease panel where indicated.

Baseline blood and urine tests before IVF

The final part of the workup is a general health assessment, and this, Dr. Singh said, is where the general practitioner's role comes in. Most of the couples she treats arrive having been fully evaluated by their own doctors, so that the specialist can move directly to treatment. The baseline set includes:

• A complete blood count, to exclude anaemia.
• Blood sugar and HbA1c, to detect diabetes or poorly controlled glucose.
• Thyroid function tests, before a pregnancy is attempted.
• Rubella status, so that a woman who is not immune can be vaccinated before she conceives.
• Thalassaemia and sickle cell status, usually by haemoglobin high-performance liquid chromatography (HPLC).
• Vitamin D levels.
• Iron studies.
• Urine tests.

Abnormal results here are often the ones a general practitioner can correct directly. Thyroid disease, PCOS and hyperprolactinaemia are common reasons for disrupted ovulation, and Dr. Singh relies on GP and physician colleagues to bring them under control before or alongside fertility treatment.

From pre-IVF test results to a treatment plan

Taken together, the tests sort couples into those who can proceed to treatment directly and those who need something corrected first. A submucous fibroid, a polyp or adhesions seen on ultrasound, a cyst suggesting endometriosis, or tubes that are blocked or swollen with fluid may each call for a specific operation, chosen because it improves the chances of the IVF cycle that follows. Those decisions are covered in Fibroids, polyps and uterine surgery before IVF and in the article on endometriosis and tubal surgery linked above. For the stepwise diagnostic workup of the infertile couple set out in the World Health Organization's 2025 infertility guideline, see Dr. Hrishikesh Pai's guide to the diagnosis and management of the infertile couple.