Female Fertility

Causes of Female Infertility

Female infertility can be associated with issues related to a variety of factors, including:

  • Egg quality
  • Ovulation
  • Cervical, tubal, or pelvic factors
  • Hormone imbalance
  • Weight
  • Illness and medications
  • Lifestyle (e.g., drug use, smoking, etc.) and environmental factors

There are several female fertility tests the providers our San Francisco Bay Area and Sacramento clinics can use to determine the potential causes of your infertility.

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Common Female Fertility Tests

There are various tests that may be performed to gain a better understanding of a woman’s fertility and hormonal baseline and to determine the appropriate treatment protocol.

Blood Tests

Follicle Stimulating Hormone (FSH)

FSH is a hormone that stimulates the development of the follicle (egg) in the ovaries. It is measured by taking a blood test usually on day 2 or day 3 of your menstrual cycle (day 1 is the first day of your full menstrual flow).

What do the test results mean?
FSH levels measure egg quality and ovarian reserve, or how well the ovaries are working. A normal FSH means the ovaries are working well. An elevated FSH (greater than 10) can be an early indication of decreased fertility.


Estradiol is made by the egg follicles as they grow in the ovaries. Estradiol, in addition to progesterone, prepares the uterine lining to receive the fertilized egg. The blood test to measure estradiol is taken at the same time as FSH level on day 2 or day 3 of your menstrual cycle.

What do the test results mean?
A normal estradiol level indicates that pregnancy is possible. A high estradiol level (greater than 80) may indicate that ovarian reserve is decreased.


Progesterone is a hormone made in the ovaries after ovulation and is responsible for maintaining the lining of the uterus, where the fertilized egg must attach to grow. Progesterone is measured with a blood test during the second part of your menstrual cycle, usually a week after ovulation (around day 21, day 22, or day 23).

What do the test results mean?
If ovulation has occurred, your provider should see a rise in your progesterone level (greater than or equal to 10 ng/mL).

Prolactin and Hyperprolactinemia

Prolactin is a hormone made in the pituitary gland, at the base of the brain, that stimulates milk production in women. Small amounts of prolactin normally circulate in the blood of nonpregnant, nonlactating (nursing) women. Too much prolactin (hyperprolactinemia) can cause irregular periods and trouble ovulating and/or getting pregnant. It can also cause nonpregnant women to have a milky secretion from their breasts. If the initial blood test results are high, a repeat test may be needed. Sexual intercourse and breast stimulation should be avoided the day before prolactin testing because these activities can cause an increase in prolactin levels.

What causes high prolactin?
High prolactin can be caused by medications, low levels of thyroid hormone (hypothyroidism), some types of surgery, or a small, non-cancerous growth in the pituitary gland (prolactin-secreting adenoma).

If prolactin is high, how is it treated?
Additional blood tests and an MRI of the pituitary gland (brain scan) may be needed to try to determine the cause of high prolactin. In most cases, there is simple oral medicine that can be taken to reduce prolactin. Once prolactin levels are in the normal range, menstrual periods will typically become more regular and egg release (ovulation) will become more normal. Once a pregnancy is established, the medications to lower prolactin are discontinued.

Fasting Blood Sugar

Fasting blood sugar is a common lab test that measures the level of your blood sugar after you have not eaten for at least 8 hours. It is used to determine if you have diabetes or high blood sugar levels.

It is important to have well-controlled blood sugar levels before starting infertility treatment.


Rubella is a viral infection also known as German measles. Exposure to rubella during pregnancy and lack of immunity to the disease could result in serious birth defects. Before attempting pregnancy, a blood test will be done to determine immunity to rubella.

What does rubella nonimmune mean?
Nonimmune indicates no protection against rubella disease. If you are not immune, speak to your provider to receive a vaccination prior to trying to get pregnant. You should not be pregnant when you receive the vaccine. You will be instructed to use birth control to avoid pregnancy for 30 days after you receive the rubella vaccination.

Medical Imaging

Hysterosalpingogram (HSG)

HSG is a procedure where a liquid, dye-like solution is injected through the cervix and tracked via X-ray as it flows up through the uterus and tubes. The procedure provides a view of the shape of the uterine cavity and fallopian tubes and can identify abnormalities or damage. An HSG is performed after all menstrual bleeding is over, but before ovulation. In women with a 28-day cycle, this is usually between day 6 and day 12.

Pelvic Ultrasound

An ultrasound is an instrument that uses high frequency sound waves to create a picture of the internal organs. A pelvic ultrasound captures an image of the uterus and ovaries. There are two types of pelvic ultrasounds:

Abdominal pelvic ultrasound. An external scan of the pelvis done by gliding the ultrasound transducer (imaging tool) over the surface of the abdomen.

Transvaginal ultrasound. An internal scan done in early pregnancy or infertility by inserting the ultrasound transducer into the vagina to produce sharp, clear images of the embryo or developing egg, and pelvic organs.

Ultrasound is often used in gynecology and pregnancy. It can help detect uterine fibroids and polyps, ovarian cysts, early pregnancy, and the thickness of the endometrial (uterine) lining. In infertility, it is used to monitor egg (follicle) growth and ovulation, and to guide egg retrieval during in vitro fertilization (IVF).

No radiation, dyes, drugs, or chemicals are used in ultrasound. An ultrasound may be uncomfortable for some women but is not painful.


A hysteroscopy is a way of looking at the inside of a uterus. A small lighted scope is placed through the vagina and cervix, up into the uterus. This view is helpful in diagnosing problems within the uterus such as polyps, scar tissue, abnormal shapes or membranes, and fibroids.



A pelvic laparoscopy is a surgical procedure that allows the provider to look inside the pelvis through small incisions in the belly using a lighted scope and other surgical tools. The provider may be able to see if scar tissue, ovarian cysts, tubal blockage, or endometriosis is present. These conditions may be treated during the same surgery.


Laparotomy is a surgical procedure that is done to remove fibroids or severe scarring in the pelvis. It is done through one incision in the belly. The incision may be small (2 to 3 inches) or larger, up to 4 to 5 inches.

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Common Female Fertility Treatment Options

Once the potential cause of infertility is determined your provider will be able to recommend the best path forward. The most common fertility treatment options include fertility medications, intrauterine insemination, or in vitro fertilization.

Fertility Medications

The use of fertility medication ranges from noninvasive oral medications with little or no side effects to injections with more significant side effects.

Clomiphene citrate (Clomid)

This is an effective oral medication that has been used for many years, especially for women with infrequent or no ovulation. Clomiphene citrate can promote ovulation by increasing the production of hormones that stimulate egg development. Your provider may suggest alternative medications that might work better for you.


These provide an extra supply of FSH and LH, helping to stimulate the development of eggs. Taking these medications is a more intense process that involves daily injections at home and frequent blood estrogen level and ultrasound evaluations.

Endocrine medications

These may improve fertility by addressing other underlying issues. Examples of these medications are cabergoline or bromocriptine for elevated prolactin, thyroid medication for an under-or overactive thyroid, insulin for diabetes, and metformin for selected women with polycystic ovarian syndrome (PCOS).

Intrauterine Insemination (IUI)

An IUI, sometimes also referred to as artificial insemination, is a procedure that involves inserting washed sperm into the uterus through the vagina. This procedure is less invasive than IVF and is often the first attempt for couples seeking help to conceive. If an IUI is unsuccessful, the next step may be IVF. Insemination can be done with sperm from a male partner, or sperm from a known or anonymous donor.

IUIs are only available to Kaiser Permanente members with coverage for fertility services. We recommend you speak with your Human Resources representative to understand whether your plan includes artificial insemination.

In Vitro Fertilization (IVF)

IVF is the process of combining eggs and sperm outside the body, in a controlled laboratory setting, to develop an embryo that can then be transferred back into a woman’s uterus. Once embryos are developed, patients can choose to have them genetically tested prior to transfer. The eggs and sperm used could be one’s own or from a known or anonymous donor. Donated embryos can also be used for IVF. If you’re interested in using donated embryos, please look into embryo adoption agencies, such as National Embryo Donation Center and ReproTech. Learn more about IVF.

IVF is largely a non-benefited service; however, certain employer groups do offer the IVF benefit. We recommend speaking with your Human Resources representative to understand whether your plan includes the IVF benefit.

Source:  The Art of Conception, Kaiser Permanente, The Permanente Medical Group