Essential Tests For Assessing Female Fertility

Having worked with many couples wanting to get pregnant naturally, I know most couples do not understand what blood tests are essential for assessing female fertility. Even when couples have consulted an Obstetrician/Gynecologist, even a fertility specialist, few have benefitted from receiving a thorough evaluation with a complete set of blood tests, appropriately timed. So today I want to equip women who may be seeking an evaluation of the status of their fertility, with an understanding of the essential blood tests they should be receiving, and the timing of the those tests, based on my training and experience in functional medicine (also known as root cause medicine), NaProTECHNOLOGY, and FEMM (another form of Restorative Reproductive Medicine).

Cycle Day Two or Three:

• FSH Follicle Stimulating Hormone
• LH Luteinizing Hormone
• Estradiol
• AMH Anti-Mullerian Hormone

First Half of the Cycle:
Thyroid panel:

• TSH Thyroid Stimulating Hormone
• Free T4
• Free T3
• Total T3
• reverse T3
• anti-TPO thyroid peroxidase antibody
• anti-TG thyroglobulin antibody

Any Day of the Cycle, But Best Done in Early Morning:

• Prolactin
• DHEA-S
• testosterone
• free testosterone
• sex hormone binding globulin
• complete metabolic panel includes liver function test, kidney function tests, and fasting glucose
• fasting lipid panel
• 25-hydroxy-vitamin D level
• fasting insulin hs-CRP
• homocysteine
• ferritin
• 8am cortisol

Post Ovulation Labs

• Estradiol
• Progesterone

Best to repeat test of both hormones, every couple of days, post ovulation, to assess ovarian function

For clarity, Cycle Day 1 is defined as the first day of menstrual bleeding. However, for women who have three or more days of premenstrual spotting, Cycle Day 1 does not start until the first day of actual menstrual flow. For women who tend to have shorter cycles, like about 24-25 days, best to do those four labs on cycle day two, if possible

Most OB/GYNs are willing to order the four tests I recommend doing on cycle day two or three, as these are commonly ordered tests by fertility doctors. Having said that, it is also not uncommon for women who have been seeking fertility care for years to not even have had these four basic tests done by the time they see me.

While the post-ovulatory estradiol and progesterone would be done on alternate days in the luteal phase of the cycle, it is possible to have all the other tests drawn at the same time, if done on cycle day two or three, around 8am, while fasting (no food for 12 hours prior).

Research shows that when LH is twice as high as FSH, and/or when AMH > 5 ng/ml, the woman is more likely to have a hormonal condition known as polycystic ovarian syndrome (PCOS). PCOS is linked to poorer egg quality and recurrent pregnancy loss. Fortunately, with the use of functional medicine, there are many ways to improve fertility for women with PCOS.

When FSH and LH are both consistently quite elevated, for example well over 20, in a woman who has not had a period for many months or years, it is likely that the woman is heading into menopause. Her odds of getting pregnant would be quite challenging as this would be difficult to reverse.

 Optimal Levels for Cycle Day Two or Three Labs

FSH: 4-7 mIU/ml (7-10 is still considered decent)
LH: <7 mIU/ml, and best in 1:1 ratio with FSH
Estradiol: 30-50 pg/ml
AMH: best to be <4 ng/ml

However, if only FSH is elevated and LH is still close to optimal range, and the woman has a fairly regular cycle of about 25-42 days, it is still possible to improve her fertility with use of functional medicine, and without the use of assisted reproductive technology.

Knowing the Estradiol level is helpful when evaluating FSH. Estradiol is a hormone that is produced by the ovary, and when present in excess would cause the brain to decrease release of FSH. Thus, a woman with high estradiol level may mask a likely high FSH level. Thus the fertility prognosis is not as good when estradiol level is higher than optimal. However, with the use of functional medicine, it is still possible for these women to conceive naturally.

And while most IVF doctors think AMH level of <1 means poor prognosis for achieving pregnancy, the reality is that AMH is only a good prognostic marker for women who do IVF and not for women trying to get pregnant naturally. In my practice, I have helped women conceive with AMH as low as 0.17.

As for the thyroid panel, while typically TSH is considered normal if it is less than 4.5 mIU/L, there is research showing that it is best for preconception TSH to be < 2.5. Additionally antibodies against the thyroid have been linked to higher risks of miscarriage.

Regarding post ovulation labs, this does require the woman to know when she ovulates. One good way to determine the timing of ovulation is learning a fertility appreciation method such as Billings or the Creighton Model FertilityCare System. In NaProTECHNOLOGY, we like to see the estradiol and progesterone levels at seven days after ovulation to be close to 120 pg/ml and 15.7 ng/ml, respectively.

Based on research done by NaPro doctors, many couples seeking fertility care do have suboptimal post-ovulatory hormones. It is possible to correct these deficiencies by improving egg quality, and optimizing other hormones such as prolactin, DHEA-S, insulin, and thyroid. And if still needed, bioidentical estradiol and progesterone supplementation can be provided.

As for the labs that can be done any time of the cycle, these are definitely more nuanced. But in essence, it is good to make sure that these hormones and other markers of overall health are optimized to maximize female fertility potential.

In my clinic, in addition to the above tests, as appropriate, I also run specialized functional medicine tests to assess cellular nutrient status, gut health, and hormone breakdown pathways. These tests help me personalize the woman’s treatment and further increase her chance of success in achieving and maintaining a pregnancy.

While this article is about testing for female fertility, it is important that the husband is not neglected. It takes both a man and a woman to have a baby. Thus, in a complete fertility work-up, a semen analysis should also be done.

When couples encounter difficulty conceiving, the first step is to do a thorough work-up. It is always better to test, than to guess. This is the root-cause approach, instead of the typical cookie-cutter approach, to fertility evaluation and treatment.