The most common forms of fertility testing for women and trans and gender diverse people presumed female at birth1 are:
- blood hormone tests to check you are ovulating normally,
- pelvic ultrasounds to check the ovaries, uterus and uterine (fallopian) tubes, and
- procedures to check for blockages to the uterine (fallopian) tubes.
Other investigations include tests for sexually transmitted infections (particularly for chlamydia which can cause infertility), simply monitoring the menstrual cycle (e.g., via temperature checks and monitoring mucus and ovulation pain) to check when ovulation is occurring, and diagnostic laparoscopies or hysteroscopies (forms of keyhole surgery) to check for endometriosis or other pelvic conditions.
For men and trans and gender diverse people presumed male at birth, sperm analysis is the main form of fertility testing2. For people of any gender, preconception testing for genetic causes of infertility or conditions that may be passed on to a child is recommended to be offered for spinal muscular atrophy, cystic fibrosis and Fragile X syndrome (however, these are costly). Genetic testing may also be recommended if there is a family history of inherited conditions. If genetic testing of embryos follows, this can only occur once fertility treatment has started – see Pre-implantation genetic testing and fertility preservation.
Finally, if a person or couple has commenced IVF but are not conceiving, their doctor may at some point suggest pre-implantation genetic testing of the embryo for genetic abnormalities.
1 As well as trans and gender diverse people presumed female at birth who have not had gender affirming medical treatment.
Experiences of fertility testing among the people we spoke to reflected the stage of their journey they were at (before, during or after fertility treatment), their age, the nature of their fertility problems and how quickly their fertility specialist had been able to identify a cause, and whether they were in a relationship and if so what kind.
Some people underwent extensive testing over a period of years without a clear diagnosis, others were given an explanation relatively quickly, while a few had to advocate for themselves to be able to access testing. A few women underwent initial testing only, either because their male partner was infertile, they had previously undergone fertility preservation, or they were in a same-sex relationship.
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Georgia, who is about to start ovulation induction, describes the fertility tests she underwent. Hormone imbalances and polycystic ovaries* may be making it hard for Georgia to conceive.
Georgia: So I went back to the GP again, and I said, “Look, it’s not happening. We’ve been trying for about a year now, and I’m just wondering if there’s anything else that I can do.” So she sent me to have a blood test done through every cycle. So I had the blood tests starting from day five, and then they would let me know when to come back, and do all that sort of stuff. Then they would phone me to say, “You’re going to ovulate or you’re just about to ovulate; come back in seven days and we will check your progesterone.” So that was fine.
I did that for three or four months, I think; and thought, “Okay, things still aren’t progressing. I know that I’m ovulating.” We’d try and get the right times. “What’s going on?” basically. So I went back to my GP, who didn’t really have any answers for me. She just said, “Look, these things happen.”
So I ended up contacting a previous employer of mine who is actually an obstetrician gynaecologist, and she works at a fertility clinic. So I went to her, and I said, “Look, I’m just really confused. I need some answers.”
So within five minutes, clicking through all of my different results, said, “You’re not close to ovulating, and your progesterone isn’t where it should be.” So that was a bit of a kick to the stomach, to think that I’ve been doing this for so long, and things really weren’t the way that they should be, even though I was being told differently. So she said, “I don’t have any concerns whatsoever that you are completely infertile; I don’t think that at all. But we should get some tests done, just in case.”
After I’d seen the specialist, went for the pelvic ultrasound. So they had a look at both ovaries, and they just have a look to see if the uterus is the right shape. They make sure that the shape is fine, that your ovaries are okay, and that they haven’t got any cysts. Then my husband went for his sperm test. That was simple enough; and then we had the HyCoSy [Hysterosalpingo Contrast Sonography] done.
It starts off like a pap smear; so they put the speculum in, and then the really tiny, tiny… I think it was 2mm catheter is introduced, into the uterus, and into the cervix… Through the cervix; and then a balloon is inflated. Then what they do is they inject a fluid that should travel down the fallopian [uterine] tubes, and if it is going outside of the fallopian [uterine] tubes, you think that there’s something going on; or if it can’t get through them, it means that they’re occluded. So the eggs aren’t going to get through. So, that wasn’t a nice procedure; it was not very nice at all. But I’m so glad that I’ve done it.
Interviewer: So… And that was all clear.
Georgia: Yes. Just the scan, they found a lot of cysts on my ovaries. So from the scan, they said that they found… I think it was 30 on each ovary, which, in comparison to a few people that I’d spoken to, isn’t that many; but for me, it is a lot. I have no symptoms at all; nothing. It was a complete surprise when they told me, yep.
* Polycystic ovaries (PCO) and Polycystic Ovary Syndrome (PCOS) are not the same thing. A significant proportion of women of reproductive age may have polycystic ovaries on ultrasound but no other symptoms of PCOS and this is particularly common in young women. In fact, in women less than 8 years from their first ever period, ultrasound is not recommended for diagnosis of PCOS for this reason. To learn more, please see ‘Four myths about polycystic ovary syndrome – and why they’re wrong’ by Tessa Copp and colleagues (The Conversation, 2020).
Belle shares her experience of how doctors gradually learned more about why she and her husband were having trouble conceiving once they had started IVF.
We were then referred to a fertility specialist because it had probably been about 14 months since we had naturally fallen pregnant the first time.
The fertility specialist initially organised for a dye test to be undertaken where they inject dye into your fallopian [uterine] tubes to make sure that they’re not blocked. There was an indication that one of my fallopian [uterine] tubes was blocked and that the other one wasn’t, and so with that, he recommended IVF as something that we probably should consider.
We continued to try naturally for a few more months, I suppose, and then went back and saw the IVF fertility specialist to say that we were ready to commence IVF, and that was in late 2018.
In October 2018, we had my eggs collected. We received 23 eggs, and from those 23 eggs, we had eight embryos that we sent off for genetic testing. We had four of those embryos come back as genetically healthy and able to be implanted. And one of those embryos was what they call mosaic and the other three were genetically abnormal, so were disposed of.
We effectively implanted one of the healthy embryos in December 2018, it wasn’t successful. We implanted another embryo in January 2019, and that wasn’t successful either. And in January on thawing of the embryos, we also lost one of the genetic embryos that we tested when it had thawed. Then in February 2019, we put the last healthy, genetically tested embryo in, and that was unsuccessful as well.
The fertility specialist was… I guess we weren’t expecting that result that three from three wouldn’t have worked when they had been genetically tested and thought to be healthy embryos. So with that, the fertility specialist undertook a hysteroscopy and laparoscopy on me in March 2019 to make sure that there was no signs of endometriosis. And basically, the results that came back from that indicated that everything was looking good in my uterus and that was when it was deemed to be unexplained infertility.
We were then referred to a fertility professor.
The professor went through obviously all the information, my file, documentation, asked a lot of questions. And basically, one of the questions that he asked was, after the embryo had been implanted those three times, was I getting my period when I was on the progesterone medication? To which I said, yes, I was. So then he said that my progesterone levels, instead of increasing, after embryo implantation, were potentially decreasing quite significantly. And that that would indicate that I needed more progesterone medication to maintain the pregnancy.
We then went in for another egg collection round and got 23 eggs again, ironically and from this batch, we only ended up with three embryos. This time we didn’t genetically test them because we couldn’t afford to and the first of those embryos we implanted was also unsuccessful, despite having had an increase in my progesterone medication. For that round, they had increased the dosage of my progesterone orally and had also increased the compound makeup of the pessaries I was using. But that, unfortunately, at round four was unsuccessful. So we went again round five, and this time they included progesterone injections on top of the oral progesterone and the pessary progesterone, and that, at round five, was successful.
Tallace and her partner chose a fertility specialist who worked with LGBTQI+ clients for their first baby. She explains why they changed specialists for their second baby.
So, my son was born and then we just enjoyed being parents for four and a half years; at which point I realised that my window was closing, if we wanted to have another child. Which I did. I did, and always have wanted two. And so we returned to the same IVF place, because we wanted to access the same donor, a clinic-recruited donor.
I chose a different fertility specialist this time, because I felt that something that had perhaps been happening with my previous specialist was that she specialised in seeing LGBT clients, and I think that there was an assumption that my ‘social infertility’ was the issue, and that maybe that had precluded other investigations. I just felt like I had had to really drive investigations.
So I saw someone else, who was incredibly… I felt like she really knew her stuff, so that was very encouraging; but she was really full-on. I went to the appointment, and said, “I think maybe I’d like to try by December”, and it would have been… I’m not sure, maybe August, then. And she just said, “Well, you’ve been diagnosed with low egg reserves; you shouldn’t wait.” And I was 38, or I was about to be 38. So, she thought that we were fools for even waiting an extra month. So we didn’t; we just rushed right in. I had thought that I should do some kind of super-duper cleanse, and get really healthy; and she just thought that was rubbish, and I was reasonably healthy, and we should just go for it.
Chelsey has always had irregular periods, so she found it ‘frustrating’ that their doctor didn’t seem to think it was necessary to further investigate her fertility* after her husband had an abnormal semen analysis.
So we’d been trying naturally, obviously, and we weren’t having much success, and we happened to go and visit my mother-in-law, who is in another country, and she told me that my hubby had mumps as a teenager. So that did set off some alarm bells, so I did a little bit of research on my own.
So we kept trying. Hubby was resisting to go and get tested.
Finally, he agreed to go and we found out that, yes, we did have problems on his side, and on my side the doctor said that there was no point in investigating me because we’d have to have IVF and ICSI, which was a bit frustrating, ‘cause I would have liked to have known if I had contributed.
Firstly we went to the GP and just did some preliminary tests there. That showed that he did have sperm, but even so, we continued on to a specialist because I was over the age of 30 and we had been trying for several years without success.
I went and had a full screen health test and to see whether or not my hormones were in balance, like the oestrogen and the progesterone and what else do they look up. But basically my screening of things seemed to be okay.
So when we went to the fertility specialist, we actually had to go into the facility and provide the samples there and then so that there was no waiting time for them to be sitting in a lab somewhere. And then we then went back and had another appointment where the specialist did say he had conditions that will actually affect sperm health, so he went through all of that and what it meant for us, and he was very clear in that we wouldn’t conceive naturally without IVF and without ICSI. So unless we had those two procedures done, we could be trying forever.
He was very clear in saying, “Look we test the males first because if there is something wrong with the male, then we’re always going to have to look at IVF,” regardless of what the female situation is. If the male’s sperms are not healthy, we will have to have IVF to start with. So his take on it was that I didn’t really need too much investigating, that I’m okay and at least are producing an egg a month, or releasing rather, an egg a month, and that we could work with that. So because I’d have to be injected with the hormones anyway, we’ll take that on the chin as it comes.