Estradiol (the component of estrogen related to reproduction)A BLOOD TEST THAT MEASURES HORMONE VALUES is vitally important for diagnosing causes of fertility challenges. The following are checked to evaluate a person’s likelihood of becoming pregnant and having a healthy child:
Estradiol (the component of estrogen related to reproduction)
FSH (follicle stimulating hormone)
LH (luteinizing hormone)
TSH (thyroid stimulating hormone)
AMH (anti-Müllerian hormone)
Progesterone
Prolactin
In addition to these levels, testosterone and other “male” hormones may be evaluated, along with a glucose/metabolic panel if PCOS is suspected.
Estradiol (E2) 
E2 is the component of estrogen produced by the follicles in your ovaries. The level of E2 in your blood is the lowest at the onset of your period (because the eggs are just barely beginning to develop and secrete estradiol), and this is when it must be checked to be diagnostically meaningful (day 2 or 3 at the latest).
Estradiol levels naturally rise as your body selects a “lead” follicle for that cycle and continues to rise as the follicle progresses toward maturity and ovulation around day 14.
On cycle day 2 or 3, the range for E2 is roughly 20 to 70 pg/ml. Because of the relationship between E2 and FSH, abnormally high levels on cycle day 2 could be suppressing the true FSH value. Generally, high day 2 estradiol values are caused by a functional cyst (a follicle from the previous cycle that didn’t ovulate properly), polycystic ovary syndrome (PCOS), or pregnancy.
Follicle Stimulating Hormone (FSH) FSH is a hormone released by the pituitary when the hypothalamus tells it that it’s time to recruit a new lead follicle for the cycle that’s just starting. Because FSH is lowest on cycle day 2 or 3, it must be checked at this time to have any clinical relevance.
As we age, FSH levels will start to rise earlier, even before the period starts, leading to an early lead follicle. This may be due to decreasing egg quality and quantity (which means they aren’t releasing as much estradiol as they once were).
Up until recently, FSH was the primary predictor of ovarian reserve, which is one of the indicators for the likelihood of achieving a healthy pregnancy. Today, AMH (see below) is also used to diagnose ovarian reserve.
FSH ranges are as follows (ranges can vary from lab to lab; this is a generalization):
Ideal: 4 to 9
Okay: 9 to 11
Less than ideal: 11 to 13
Poor prognosis: 14 and higher
It is important to understand that these numbers are primarily used to determine whether or not a woman is likely to respond to the medications used in fertility treatments because those medications mimic the same actions as FSH on the developing follicles. Basically, they are synthetic FSH. So, if a woman’s follicles are not responding to her own intrinsic FSH, then she is likely to be a poor responder to fertility drugs. It’s also important to note that FSH levels can vary from month to month, so don’t be too discouraged if your numbers are slightly elevated—they may very well come down.
High FSH does not mean that you cannot become pregnant naturally, especially when lifestyle and dietary modifications are practiced for several months. There are countless cases of women becoming pregnant with high FSH levels, so don’t get discouraged if this is your situation. Lowering FSH levels is an area where herbs and acupuncture really shine. If high FSH levels are standing between you and an IVF cycle, think about finding yourself a fertility acupuncturist right away.
AMH (Anti-Müllerian Hormone) AMH is secreted by the granulosa cells in the ovary. This hormone is what holds back potential follicles from ovulation so that humans do not naturally breed litters of children. Thus, as ovarian reserve declines, AMH levels go down correspondingly.
AMH numbers decline with age and are used to predict ovarian reserve along with FSH. Low AMH does not necessarily indicate poor egg quality, especially if it is low in a younger woman. Unlike FSH, AMH levels do not predict an individual’s probable response to IVF medications; AMH predicts ovarian potential. AMH levels can be checked at any point in the cycle.
Luteinizing Hormone (LH) LH is secreted by the pituitary gland when the growing egg signals the brain that it is mature and ready to ovulate. At this point in the cycle, an LH surge occurs, sending a significant amount of LH down to the ovaries, leading to ovulation.
Typically, this hormone is tested on day 2 and is usually in about a 1:1 ratio with FSH. A 2:1 ratio is one indicator of possible PCOS, but it’s not diagnostic without considering other factors.
LH also plays a role in the conversion of the follicle to a corpus luteum, the outer shell of the follicle which produces progesterone during the second half of the menstrual cycle and into the first trimester, should pregnancy occur.
Thyroid Stimulating Hormone (TSH) TSH is secreted by the pituitary in order to stimulate the thyroid to produce T4 and T3. The thyroid helps to manage the body’s metabolism, blood calcium levels, and hormones, and an imbalanced thyroid will often contribute to fertility issues.
The normal reference ranges for thyroid disease are too broad for pregnancy. While the “normal” range for thyroid is measured by a TSH of 1 to 5, most functional medical doctors and fertility specialists prefer to see the level below 2.5.
If you are symptomatic for a thyroid condition and your TSH is normal, it is important to request further testing, including a complete thyroid panel that measures all the components of T3 and T4 as well as checking for thyroid antibodies that could indicate an autoimmune condition such as Graves’ disease or Hashimoto’s thyroiditis. See page 174 for a detailed summary of thyroid function.
Progesterone Progesterone is a hormone mainly secreted by the corpus luteum during the second half of the menstrual cycle. During this time, progesterone thickens the uterine lining, called the endometrium, in preparation for possible implantation.
Progesterone causes a slight rise in body temperature and is the reason for the rise in temperature seen on BBT charts just after ovulation has occurred, as well as maintaining these higher temperatures throughout the second half of the cycle (luteal phase) and throughout pregnancy. If progesterone levels are too low following ovulation, an otherwise healthy pregnancy could result in miscarriage.
Progesterone levels are typically checked about five days following ovulation. Ideally, the value will be above 10 ng/ml, an indication that ovulation has occurred and the corpus luteum is doing its job. Progesterone levels generally decline with age, and low progesterone can be a sign of improper ovulation.
Low levels are often supplemented with synthetic progesterone—usually in the form of vaginal suppositories or injections—to ensure that a potentially healthy pregnancy isn’t derailed by a lackluster corpus luteum.
Prolactin Prolactin is a hormone secreted by the pituitary. Its primary function is to promote lactation after a baby is born. Prolactin is not cycle day dependent and can thus be checked at any point.
High levels of prolactin (over 25 ng/ml) inhibit estrogen production, which is why a lactating woman often won’t ovulate or menstruate until she stops or dramatically reduces her breastfeeding.
While uncommon, it is possible to have high prolactin levels in the absence of lactation. This is typically caused by a benign tumor on the pituitary, called a prolactinoma, which wreaks havoc on normal hormone secretion and can interfere with ovulation and estrogen levels (among other things). Elevated prolactin can also be caused by stress, hypothyroid, kidney disease, and some medications.
Prolactin levels will naturally fluctuate throughout the day and rise after eating or sexual activity. If your prolactin levels are high, it’s important to recheck them in the morning while fasting and with no sex the day before.
Depending on the severity, this condition may be treated with a drug called bromocriptine, or in a worst-case scenario, with surgery to remove the benign tumor.
Day 2/3 Ultrasound Each month, our ovaries mature hundreds (and up to a thousand or so) eggs, only one of which will become the “lead” follicle, set on the road to ovulation. When planning an IVF or medicated IUI cycle, your doctor will likely perform an ultrasound on the second day of your cycle to see how many follicles (called antral follicles) are visible.
The importance of the ultrasound happening on day 2 resides in the likelihood that a lead follicle won’t have been recruited yet, providing a level playing field for all of the visible antral follicles to respond to ovarian stimulation medications. “Synchronized” follicles on day 2 offer the best chance for a successful IVF cycle.
A high antral follicle count (12 to 15 or more) is a good indication that you will respond well to IVF medications, whereas a low count (less than 5) is a signal that your eggs might not respond very well. An intermediate response (6 to 12) is less predictable. Keep in mind that age plays a huge role in follicle health, so lower numbers in a younger woman still may bode well.
Ultrasounds can also be used on any day of the cycle to observe ovarian health, make a preliminary assessment of the uterine cavity, and check ovarian reserve.
The HSG Test: Are the Pipes Clear and the Walls Smooth? The hysterosalpingogram (HSG) is a baseline test given to women experiencing fertility challenges in order to assess the inner walls of the uterus and the patency (openness) of the fallopian tubes.
The test is performed through the insertion of a catheter through the cervix and into the uterus. Radiopaque dye, similar to that used in an angiogram (or other such procedure), is then squirted into the uterus and through the fallopian tubes. If the tubes are open, it will be apparent to the radiologist, as the dye goes into the tubes via the uterus and cascades out the other end.
The HSG also looks at the inner walls of the uterus, in order to rule out certain abnormalities that could potentially impede or prevent implantation or compete for blood supply with a developing fetus. These include things such as fibroids, polyps, and uterine septum. On occasion, this test can be curative as well as diagnostic, as it may actually clear a fallopian obstruction, thus allowing for easier progression of a fertilized embryo down the tube toward its uterine destination.
Most women report this test to be uncomfortable, and the use of some type of relaxant such as valium may be recommended.
The Semen Analysis Thirty percent or more of couples experiencing infertility have male factor issues. Either the quantity (volume, concentration, or count), quality (morphology or DNA issues), or motility (strength and directionality) are compromised. Sometimes, all three are an issue. Rarely, there are no sperm at all, a condition called azoospermia.
In 2010 the WHO updated its parameters for a normal sperm analysis. Based on those changes, a healthy sperm profile will look like this:
Volume |
1.5 ml |
Concentration |
20 million/ml |
Progressive motility |
60% |
Normal forms (morphology) |
>4% |
Remember: Today’s sperm started its road to maturation roughly 90 days ago. Anything significant, including a high fever, extreme stress, excessive hot tub use, wearing snug pants frequently, or physical activity that could hinder sperm health (such as long-distance biking) should be considered and modified if the numbers are unfavorable. It’s a good idea to recheck sperm a few times before arriving at a diagnosis.
Postcoital Testing Throughout a woman’s cycle, her cervix produces fluid, which changes based on where she is in relation to ovulation. In the days just after the period, there is a slow increase in cervical mucus, which culminates in a slippery, egg white–like substance around the time of ovulation.
This fluid makes vaginal pH more hospitable to sperm making it easier for the sperm to swim through the cervix.
Occasionally, cervical mucus doesn’t lend itself to assisting the sperm during ovulation and can even prevent it from getting past the gate at all.
Postcoital testing is done by instructing a couple to have intercourse during the window of ovulation and then having them come in to the doctor within 12 hours. A sample is taken from the woman’s vagina and looked at under a microscope. If viable sperm are visualized, all is well. If all of the sperm are dead, it indicates a cervical factor.
Some of the reasons for cervical factor infertility include a history of HPV or surgery such as a cone biopsy. Also, an overactive immune system may create antisperm antibodies; essentially her body thinks the sperm is a harmful pathogen rather than a friendly invader.