What are the signs of female infertility, and when should I get tested?
Female infertility can present in very different ways, and in many cases, it presents with no symptoms at all. Some women have clear indicators that warrant early evaluation: irregular or absent menstrual periods, very heavy or painful periods, a history of pelvic inflammatory disease or sexually transmitted infections, recurrent miscarriage, or a prior diagnosis of endometriosis, PMOS, or uterine fibroids. These findings do not confirm infertility, but they do indicate that an earlier, more proactive evaluation is appropriate.
For many women, however, infertility is entirely silent. Normal cycles, normal physical exams, and no symptoms do not rule out conditions such as diminished ovarian reserve, blocked fallopian tubes, or subtle hormonal disruptions that may be making conception more difficult. This is why waiting for a clear symptom before seeking evaluation is not always the most effective approach.
The standard clinical threshold for seeking a fertility evaluation is 12 months of regular, unprotected intercourse without conception, or 6 months for women 35 and older, given the accelerated decline in ovarian reserve after that age. That said, any woman with known risk factors, a relevant medical history, or concerns about her fertility is encouraged to pursue an evaluation earlier. Proactive testing is a reasonable and increasingly common choice, and there is no disadvantage to knowing more about your reproductive health sooner.
Possible Causes of Female Infertility
Fertility testing is designed to identify the specific conditions or factors that may be contributing to difficulty conceiving. Common causes of female infertility include:
- Polyendocrine Metabolic Ovarian Syndrome (PMOS): A hormonal disorder characterized by irregular ovulation or anovulation, elevated androgens, and often polycystic ovaries on ultrasound.
- Endometriosis: A condition in which tissue similar to the uterine lining grows outside the uterus, causing inflammation, scarring, and potential damage to the fallopian tubes and ovaries. It is frequently underdiagnosed due to variable and often silent symptoms.
- Uterine fibroids or polyps: Noncancerous uterine growths that, depending on size and location, can interfere with implantation or obstruct the fallopian tubes.
- Blocked fallopian tubes (tubal factor infertility): Damage or obstruction in one or both fallopian tubes – most commonly caused by prior infection, endometriosis, or surgery – that prevents normal fertilization or embryo transport.
- Primary ovarian insufficiency (POI): A condition in which the ovaries lose normal function before age 40, resulting in reduced egg supply and irregular or absent menstrual cycles.
- Hormonal imbalances: Disruptions to the reproductive hormone axis, including elevated prolactin, thyroid dysfunction, abnormal FSH or LH levels, or elevated androgens, can interfere with ovulation and overall cycle regulation.
- Low ovarian reserve: A reduced quantity of remaining eggs, which affects both the likelihood of natural conception and the expected response to ovarian stimulation during fertility treatment.
- Irregular or absent ovulation: Ovulatory dysfunction is among the most prevalent causes of female infertility. Without consistent ovulation, natural conception is not possible.
- Pelvic adhesions or scarring: Scar tissue within the pelvic cavity – often from prior surgery, infection, or endometriosis – can distort reproductive anatomy and impair fertility.
- Genetic or chromosomal conditions: Certain inherited or spontaneous genetic abnormalities can affect ovarian function, egg quality, or the capacity to sustain a pregnancy.
- Recurrent pregnancy loss: Two or more consecutive miscarriages may indicate an underlying uterine, hormonal, chromosomal, or immunological cause that warrants dedicated investigation.
- Unexplained infertility: In some cases, comprehensive evaluation does not identify a clear cause. Advanced testing and individualized treatment approaches remain available and effective.
What is AMH testing and why does it matter?
Anti-Müllerian Hormone (AMH) testing has become one of the most clinically valuable tools in female fertility evaluation. AMH is a hormone secreted by the granulosa cells of small antral and preantral follicles in the ovaries. Because its concentration in the bloodstream directly reflects the number of actively developing follicles, it serves as a reliable, real-time indicator of ovarian reserve, or the remaining egg supply.
One of the practical advantages of AMH testing is that it does not need to be timed to a specific point in the menstrual cycle. It can be drawn on any day, making it a convenient component of an initial evaluation. A single blood draw is all that is required.
Interpreting AMH results requires understanding both the value itself and the patient’s age, since ovarian reserve naturally declines over time:
- Higher AMH levels: Generally indicate a larger remaining follicle pool and a stronger predicted response to ovarian stimulation medications during treatments such as IVF. Very high AMH may also be a feature of PMOS, in which large numbers of small follicles are present but ovulation is irregular.
- Lower AMH levels: Suggest diminished ovarian reserve, meaning fewer eggs remain. This has implications for natural conception probability and for the ovarian response to fertility medications. It does not mean conception is impossible, but it is an important factor in clinical planning, particularly regarding treatment urgency and medication dosing.
It is equally important to understand what AMH does not measure: egg quality. Quality is influenced by age and other biological factors and is not captured by AMH. A woman with a lower AMH who is younger may still have good egg quality and achieve a successful pregnancy. Results are always interpreted alongside other markers, including Day 3 FSH, estradiol, and antral follicle count on ultrasound, to build a complete picture of ovarian reserve.
What other female fertility testing is part of an overall evaluation?
AMH is a key starting point, but a complete female fertility evaluation typically incorporates several additional assessments. The specific combination of tests recommended will depend on your age, health history, cycle patterns, and the clinical picture that emerges from your initial consultation. Here’s what you can expect:
Medical History and Physical Examination
Every fertility evaluation at NYU Langone Fertility Center begins with a comprehensive medical history. Your provider will ask about your menstrual cycle, any prior pregnancies or losses, past surgeries or procedures, infections, current and prior medications, and family health history. This review helps identify risk factors and inform decisions about which diagnostics are most likely to be relevant.
A physical examination, including a pelvic exam, provides direct clinical information about reproductive anatomy and looks for evidence of uterine irregularities, adnexal tenderness, ovarian cysts, or other findings that may suggest an underlying condition. The medical history and physical exam together establish the clinical context in which all subsequent test results are interpreted.
Ovulation Assessment
Regular, well-timed ovulation is a prerequisite for natural conception. Confirming that ovulation is occurring is a standard part of the female fertility workup.
Ovulatory function is assessed through several methods depending on clinical need. A mid-luteal progesterone blood test (typically drawn around day 21 of a 28-day cycle) is used to confirm that ovulation has occurred. Basal body temperature tracking and urinary LH monitoring with ovulation predictor kits can help identify the LH surge preceding ovulation. Serial transvaginal ultrasounds allow real-time observation of follicle development and confirmation of ovulation. For women with irregular or absent periods, ovulation assessment is particularly important, as anovulation is one of the most common, and most treatable, causes of female infertility.
Hormonal Testing
Reproductive hormones function as a coordinated system, and disruptions anywhere within that system can affect ovulation, cycle regularity, and fertility. A hormone blood panel is a routine component of the female fertility evaluation. Key hormones assessed include:
- Follicle-Stimulating Hormone (FSH): Drawn on day 3 of the menstrual cycle, an elevated FSH is a marker of diminished ovarian reserve, indicating that the pituitary is working harder to stimulate the ovaries.
- Luteinizing Hormone (LH): Works with FSH to trigger ovulation. Elevated or dysregulated LH patterns are associated with PMOS and other ovulatory disorders.
- Estradiol (E2): Also drawn on day 3 alongside FSH to provide context for interpreting FSH levels and to assess baseline ovarian activity.
- Prolactin: Elevated prolactin can suppress ovulation and is associated with menstrual irregularity.
- Thyroid-Stimulating Hormone (TSH): Both hypothyroidism and hyperthyroidism can disrupt the menstrual cycle and interfere with conception. Thyroid function screening is standard in a fertility workup.
- Androgens (e.g., testosterone, DHEA-S): Elevated androgen levels may suggest PMOS or adrenal dysfunction and can contribute to ovulatory irregularity.
Hormone results are interpreted collectively rather than in isolation. Your specialist will explain what each finding means in the context of your individual fertility profile.
Ovarian Reserve Testing
Ovarian reserve refers to the quantity of a woman’s remaining egg supply, an important determinant of both natural fertility and treatment response. It is assessed through a combination of tests that together provide a more complete picture than any single marker alone.
AMH (Anti-Müllerian Hormone) is the primary hormonal marker of ovarian reserve and can be drawn on any cycle day. Day 3 FSH and estradiol offer complementary hormonal data. Antral follicle count (AFC), performed via transvaginal ultrasound, counts the small resting follicles visible in the ovaries at the beginning of a cycle, each representing a potentially recruitable egg. The combination of AMH, Day 3 FSH, and AFC gives your care team a reliable and multidimensional view of ovarian reserve that informs treatment planning, medication protocols, and, where relevant, the urgency of proceeding with treatment or preservation.
Hysterosalpingography (HSG)
A hysterosalpingogram (HSG) is an X-ray-based imaging procedure used to evaluate the condition of the fallopian tubes and the shape of the uterine cavity. During the procedure, a small amount of contrast dye is introduced through the cervix into the uterine cavity under fluoroscopic guidance. As the dye fills and flows through the uterus and into the fallopian tubes, X-ray images capture the anatomy in real time. Open tubes allow the dye to spill freely into the pelvic cavity; blockages appear as points where dye flow stops. The HSG can also reveal intrauterine abnormalities such as polyps, fibroids, uterine septum, or adhesions. The procedure is performed on an outpatient basis, typically takes 15 to 30 minutes, and involves mild to moderate cramping that usually resolves shortly afterward.
Transvaginal Ultrasound Testing
Transvaginal ultrasound is a diagnostic tool in reproductive medicine. Using a small probe introduced into the vaginal canal, it produces high-resolution images of the uterus, ovaries, and surrounding pelvic structures, with significantly greater anatomical detail than abdominal ultrasound for fertility-related assessment.
In a fertility evaluation, transvaginal ultrasound is used to assess uterine size and morphology, detect fibroids, polyps, and endometrial abnormalities, evaluate the ovaries for cysts or signs of PMOS, perform the antral follicle count, and monitor follicular development during treatment cycles. It is a quick, well-tolerated procedure performed in the clinic without sedation and is a routine component of both initial evaluation and ongoing monitoring throughout fertility treatment.
Laparoscopy
Laparoscopy is a minimally invasive surgical procedure that provides direct visualization of the pelvic organs. A thin, lighted camera (laparoscope) is introduced through a small incision near the navel, allowing the surgeon to inspect the uterus, fallopian tubes, ovaries, and surrounding pelvic structures in real time. It is typically reserved for cases where a structural cause of infertility is suspected but cannot be adequately assessed through non-invasive imaging.
Laparoscopy is particularly valuable for diagnosing endometriosis – which can be invisible on ultrasound in mild or early-stage disease – as well as pelvic adhesions, peritubal adhesions, and some cases of ovarian pathology. When a diagnosis is made at the time of laparoscopy, the surgeon can often treat the identified condition during the same procedure, removing adhesions, excising endometrial implants, or addressing other findings. Laparoscopy is performed under general anesthesia and is not part of every fertility workup, but it can be a decisive step in cases of unexplained infertility or a clinical history strongly suggestive of hidden pelvic pathology.
Genetic Testing
Genetic testing may be recommended as part of a female fertility evaluation in specific clinical contexts. Carrier screening, which tests whether a woman carries gene variants for heritable conditions such as cystic fibrosis, spinal muscular atrophy, or fragile X syndrome. is increasingly offered to all patients as part of a standard fertility workup, regardless of family history, because most carriers have no personal symptoms or known family members with the condition.
Additional genetic evaluation may be recommended for women with primary ovarian insufficiency (POI), to screen for the fragile X premutation or other genetic contributors to early ovarian aging; for those with a history of recurrent pregnancy loss, where analysis of both partners may identify a chromosomal rearrangement; or for patients whose IVF embryos have repeatedly failed to implant or resulted in miscarriage.
Saline Infusion Sonogram (SIS)
A saline infusion sonogram (SIS), also referred to as a sonohysterogram, is a specialized ultrasound procedure used to evaluate the uterine cavity in detail. During the procedure, a small amount of sterile saline is introduced into the uterus through a thin catheter, temporarily distending the cavity and creating a fluid contrast that allows the ultrasound to produce clear, high-resolution images of the endometrial surface and any intrauterine structures.
SIS is particularly effective for identifying uterine polyps, submucosal fibroids, intrauterine adhesions (Asherman’s syndrome), and uterine septum, all of which can affect implantation and increase the risk of miscarriage. When SIS identifies an abnormality that requires intervention, operative hysteroscopy is usually the recommended next step. SIS may be performed as part of the initial evaluation or in preparation for an IVF cycle.
