Female Assessment Before an IVF Cycle

Before starting an IVF cycle, female hormone assessment serves two main purposes: to estimate ovarian reserve and to understand how the hypothalamic–pituitary–ovarian axis is functioning at baseline. This information helps anticipate how the ovaries are likely to respond to stimulation and whether there are correctable endocrine issues.

In initial testing, AMH is one of the cornerstones of pre-IVF assessment. It is produced by granulosa cells of small antral and pre-antral follicles and reflects the size of the remaining follicular pool. Because AMH shows relatively little variation throughout the menstrual cycle, it provides a stable estimate of ovarian reserve and is particularly useful for predicting quantitative response to stimulation, such as the expected number of oocytes. It does not directly predict embryo quality or pregnancy potential, but it is invaluable for counseling patients on expected response and cycle planning.

FSH and LH are typically measured on cycle day 2 or 3 and give insight into pituitary drive to the ovaries. Basal FSH rises as ovarian reserve declines, reflecting reduced negative feedback from inhibin B and estradiol. An elevated FSH suggests diminished reserve and often correlates with a poorer response to stimulation. LH, while more variable and less predictive on its own, helps complete the picture of pituitary function and is particularly relevant in patients with suspected ovulatory dysfunction or PCOS-like patterns, where an altered LH:FSH ratio may be seen.

Estradiol, also measured early in the follicular phase, is important for context. A normal or low estradiol level alongside FSH gives a more reliable interpretation of ovarian reserve. An inappropriately elevated estradiol early in the cycle may artificially suppress FSH and mask underlying diminished reserve, which can lead to overly optimistic expectations if interpreted in isolation.

Prolactin and thyroid function tests, specifically TSH and free T4, are part of baseline screening because disturbances in these axes can interfere with ovulation, implantation, and early pregnancy maintenance. Mild hyperprolactinemia can disrupt gonadotropin secretion, while both overt and subclinical thyroid dysfunction have been associated with poorer reproductive outcomes. Identifying and correcting these issues before stimulation is a straightforward way to remove potentially reversible barriers to success.

Transvaginal ultrasound assessment of antral follicle count adds a crucial anatomical and functional dimension to hormonal testing. AFC reflects the number of recruitable follicles visible at the beginning of the cycle and correlates well with both AMH and ovarian response. Importantly, it allows direct visualization of the ovaries, helping identify asymmetry, cysts, or other findings that may influence cycle timing or protocol choice. When AMH and AFC are concordant, confidence in ovarian reserve estimation is high; when they are discordant, ultrasound findings often help guide interpretation.

For women who have experienced negative IVF cycles or who are in older age brackets, typically 35 years and above, extended hormonal testing can provide additional nuance. At this stage, the question is not only how many follicles remain, but also whether the intra-ovarian hormonal environment is optimal for follicular development.

DHEA-S is of interest because it serves as a precursor for ovarian androgen production. Adequate androgen levels within the ovary appear to support early follicular growth and FSH receptor expression. Low DHEA-S levels have been associated in some studies with poorer ovarian response, and identifying deficiency can help explain suboptimal outcomes in selected patients, particularly poor responders.

Total testosterone and SHBG together allow assessment of bioavailable androgen levels. Testosterone, in physiological female ranges, plays a permissive role in folliculogenesis, while SHBG regulates how much of that testosterone is free and biologically active. High SHBG can result in functionally low free androgen levels even when total testosterone appears normal, which may be relevant in women with repeated low oocyte yield or poor response despite acceptable AMH. Conversely, excessive androgens can be detrimental, so the goal is balance rather than indiscriminate supplementation.

Taken together, initial hormone testing combined with AFC provides a solid framework for most first IVF cycles, allowing realistic counseling and rational protocol selection. In women with prior failures or advanced reproductive age, extending the assessment to include adrenal and androgen parameters can uncover subtler contributors to ovarian response and help individualize subsequent treatment strategies. The key teaching point is that no single test should be interpreted in isolation; it is the integration of biochemical and ultrasound data that leads to the most clinically meaningful conclusions.

Non-Hormonal Assessment

Alongside hormonal evaluation, there is a group of non-hormonal parameters that have a meaningful impact on fertility potential and the ability to carry a pregnancy, yet they are often under-emphasized during initial work-ups. These factors do not directly alter ovarian reserve or stimulation response, but they shape the biological environment in which implantation, placentation, and early embryonic development occur. Ignoring them can lead to technically well-executed IVF cycles that still fail to result in a healthy ongoing pregnancy.

One of the most commonly overlooked areas is metabolic health. Fasting glucose, HbA1c, fasting insulin, and basic lipid parameters provide insight into insulin sensitivity and cardiometabolic status. Even mild insulin resistance, well below the threshold of overt diabetes, can negatively affect oocyte competence, endometrial receptivity, and early placentation. Hyperinsulinemia alters ovarian steroidogenesis and increases oxidative stress, while impaired glucose handling during early pregnancy increases miscarriage risk. These abnormalities are frequently present in women who are not obese and may have “normal” routine labs unless specifically looked for.

Inflammatory and iron-related markers are another quiet but important domain. Chronic low-grade inflammation, reflected in markers such as hs-CRP, ferritin, or subtle leukocyte pattern shifts, has been associated with poorer implantation and higher pregnancy loss rates. Ferritin deserves special mention because both deficiency and excess can be problematic. Iron deficiency may impair oxygen delivery and placental development, while elevated ferritin, particularly in the absence of iron overload, often reflects inflammatory or metabolic stress that can impair reproductive outcomes.

Vitamin and micronutrient status also plays a role that is frequently underestimated. Vitamin D is the most discussed, but not the only relevant factor. Adequate vitamin D levels are associated with improved implantation and pregnancy rates in some studies, likely via immune modulation and endometrial effects. Magnesium, B12, folate, and iodine status can influence energy metabolism, DNA synthesis, and thyroid function, even when overt deficiency syndromes are absent. These deficiencies may not prevent conception outright but can reduce resilience during early pregnancy.

Additional Tests for 40+ Patients with Repeated IVF Failures

In women over 40 with prior failed IVF cycles, this expanded assessment shifts the focus from isolated hormone concentrations to dynamic hormone metabolism and stress physiology. At this stage, ovarian reserve is often already constrained, so outcomes are disproportionately influenced by the quality of the endocrine and metabolic environment in which follicles develop and embryos implant. Traditional serum testing captures static hormone levels, but it does not explain how hormones are being metabolized, cleared, or interacting with other systems such as the adrenal axis, liver detoxification pathways, and the central stress response.

DUTCH testing is requested to evaluate urinary hormone metabolites because it provides insight into estrogen, progesterone, and androgen metabolism rather than just circulating levels. In advanced reproductive age, unfavorable estrogen metabolite patterns, impaired methylation, or excessive conversion toward more proliferative or inflammatory pathways may contribute to poor endometrial receptivity or early pregnancy loss despite “normal” serum estradiol. Similarly, progesterone metabolite patterns can help explain luteal phase inadequacy that is not obvious on single serum measurements. From an IVF perspective, this information helps contextualize repeated implantation failure and supports more individualized decisions regarding luteal support, timing, and broader metabolic optimization.

Five-point salivary cortisol testing complements this by mapping the diurnal rhythm of the hypothalamic–pituitary–adrenal axis. Chronic stress, sleep disruption, and long-term inflammatory load are common in women who have undergone multiple unsuccessful cycles and can result in flattened or dysregulated cortisol curves. Cortisol interacts directly with gonadotropin signaling, immune tolerance, and glucose metabolism, all of which are critical during implantation and early placentation. Identifying abnormal cortisol patterns allows targeted interventions aimed at restoring circadian rhythm and stress resilience, which in turn may improve endometrial receptivity and early pregnancy stability.

Taken together, these tests are not intended as routine screening for all IVF patients, nor as substitutes for conventional reproductive endocrinology work-up. Their value lies in complex, high-stakes scenarios where standard testing has failed to explain poor outcomes. In this subgroup, especially women over 40, understanding hormone metabolism and stress physiology can help refine treatment strategies and address modifiable factors that may otherwise continue to undermine IVF success.

Patients with Recurrent Miscarriages

In women with recurrent pregnancy loss, additional testing goes beyond assessing the ability to achieve implantation and focuses on identifying factors that interfere with early embryonic development, placentation, and immune tolerance. By definition, these patients have already demonstrated the capacity to conceive, so the clinical question shifts from “can implantation occur?” to “why is pregnancy not being sustained?” This distinction is critical, because the diagnostic priorities differ from those in primary infertility or poor ovarian response.

From a conventional standpoint, the core evaluation includes uterine cavity assessment to exclude structural abnormalities such as septa, submucosal fibroids, adhesions, or significant adenomyosis that may disrupt implantation or placental attachment. Genetic factors are also central. Parental karyotyping is considered when losses are unexplained, particularly if they occur early and repeatedly, as balanced chromosomal rearrangements can lead to recurrent aneuploid conceptions. In parallel, embryonic aneuploidy remains the most common cause of miscarriage, especially with advancing maternal age, and this context is essential when counseling patients about prognosis and the potential role of PGT-A.

Endocrine and metabolic contributors are another cornerstone of recurrent pregnancy loss assessment. Thyroid dysfunction, even at subclinical levels, has been consistently associated with increased miscarriage risk, and prolactin abnormalities can interfere with luteal function. Glycemic control and insulin sensitivity are equally important, as impaired glucose handling and hyperinsulinemia can adversely affect early placentation and embryonic development. These factors may be subtle and easily overlooked if testing is limited to basic screening. These are listed in our routine tests. Therefore, these would be included in the initial work-up.

Evaluation of coagulation and immune-related factors is more selective but highly relevant in women with characteristic histories, such as losses occurring after detection of fetal cardiac activity or placental complications in prior pregnancies. Screening for antiphospholipid syndrome remains a standard component, as it is one of the few clearly defined and treatable causes of recurrent miscarriage. From an immune standpoint, antiphospholipid syndrome represents the most clearly defined and evidence-based condition linked to recurrent pregnancy loss. Testing typically includes lupus anticoagulant, anticardiolipin antibodies, and anti-β2 glycoprotein I antibodies, measured on two occasions at least twelve weeks apart. Antiphospholipid antibodies interfere with trophoblast function, promote microthrombus formation at the maternal–fetal interface, and impair placental development. Importantly, this is one of the few immune-mediated causes of miscarriage for which treatment with low-dose aspirin and heparin has consistently been shown to improve outcomes, which is why it remains a standard component of evaluation.

Beyond antiphospholipid syndrome, immune testing becomes more nuanced and controversial. Abnormal natural killer cell activity, altered Th1/Th2 cytokine balance, or excessive inflammatory signaling have been proposed as contributors to pregnancy loss, particularly in women with implantation failure or losses occurring after documented fetal cardiac activity. While these findings may reflect a hostile endometrial immune environment, their interpretation requires caution. In many cases, serum levels do not correlate with endometrial levels. Many immune markers fluctuate and lack standardized thresholds, and abnormal results do not automatically imply causation. 

Thrombophilia assessment overlaps with immune testing but addresses a different mechanism: impaired placental perfusion due to abnormal coagulation. Inherited thrombophilias such as MTHFR, Factor V Leiden, prothrombin gene mutations, or deficiencies of protein C, protein S, and antithrombin have been associated with pregnancy complications rather than early miscarriage per se, including late fetal loss, placental abruption, and preeclampsia.  Broader thrombophilia and immune testing require careful clinical judgment to avoid over-interpretation but can be informative in selected cases when guided by history rather than used indiscriminately.

In patients with persistent unexplained losses, particularly those who are older or who have undergone multiple assisted reproduction attempts, assessment of hormone metabolism and stress physiology can add a deeper layer of understanding. DUTCH testing allows evaluation of estrogen and progesterone metabolites rather than relying solely on serum levels. This can reveal imbalances in estrogen metabolism or inadequate progesterone activity at the tissue level, even when circulating concentrations appear acceptable. Such patterns may help explain luteal phase vulnerability, altered endometrial signaling, or inflammatory tendencies that contribute to early pregnancy loss.

When integrated thoughtfully, this expanded testing framework helps move recurrent pregnancy loss evaluation away from a purely checklist-based approach and toward a more individualized understanding of why pregnancies fail to progress. In these patients, especially those in advanced reproductive age brackets, identifying and addressing modifiable systemic factors may improve not only the chance of conception, but the likelihood of achieving and sustaining a healthy ongoing pregnancy.

Hormone Tests and Their Normal Ranges

Test	Typical Reference Range (Reproductive-Age Female)	Alternative Units / Notes
AMH (Anti-Müllerian Hormone)	~1.0–4.0 ng/mL Differs across labs, so use references from labs.	≈7–28 pmol/L (1 ng/mL ≈ 7.14 pmol/L); values decline with age
FSH (Day 2–3)	~3–10 IU/L	Mildly higher values (10–12 IU/L) may still be acceptable; >12–15 IU/L suggests reduced reserve
LH (Day 2–3)	~2–10 IU/L	Interpretation depends on cycle phase and FSH relationship
Estradiol (E2, Day 2–3)	~25–75 pg/mL	≈90–275 pmol/L (1 pg/mL ≈ 3.67 pmol/L)
Prolactin	~5–25 ng/mL	≈100–500 mIU/L (lab-dependent conversion); stress and timing affect results
TSH	~0.5–2.5 mIU/L (pre-conception target)	Many IVF programs aim for <2.5 mIU/L
Free T4 (fT4)	~0.8–1.8 ng/dL	≈10–23 pmol/L
AFC (Antral Follicle Count)	~8–20 total (both ovaries)	Age-dependent; <5 low, >20 high response risk
DHEA-S	~35–430 µg/dL	≈0.9–11.6 µmol/L; declines with age
Total Testosterone	~15–70 ng/dL	≈0.5–2.4 nmol/L
SHBG	~30–120 nmol/L	Higher levels reduce free (bioavailable) testosterone

As a list, this is what an ideal female testing should look like:

1- Transvaginal USG for assessment of AFC on day 2 or day 3 of the menstrual period.

2- AMH, FSH, LH, Estradiol, Prolactin, TSH and fT4 on the same day as USG.

3- CBC, Vitamin D, Vitamin B12, Folate, Fasting glucose, Fasting insulin, Homa-IR, HbA1c, Apo B, Total cholesterol, LDL, HDL, Triglycerides.

For patients with previous failed cycles, PCOS and/or patients over the age of 35:

Standard list above + SHBG, Total testosterone, DHEAs.

For patients 40+ undergoing treatment with Cytoplasmic Transfer/ MRT:

All the tests above +

Dutch testing for urine metabolites

5-point salivary cortisol testing.

For patients with Recurrent Pregnancy Losses

Standard list + Antiphospholipid Testing, Thrombophilia Testing, NK, Th1/Th2, DUTCH.

At the end of the day, every test that is ordered should lead to a clear, actionable decision. Testing for the sake of completeness, without a realistic plan to act on the results, does not improve IVF outcomes and often adds confusion, cost, and emotional burden. A result is only valuable if it meaningfully influences clinical decisions such as protocol selection, medication choice, timing, or supportive interventions.

When broad panels are ordered “just to check everything,” they frequently identify borderline or poorly validated abnormalities that have no proven treatment or unclear relevance to pregnancy success. In these situations, testing can create more uncertainty rather than clarity, shifting focus away from the factors that truly matter. In contrast, a targeted approach prioritizes investigations that either explain prior failures or open the door to specific, evidence-informed interventions.

The goal of pre-IVF assessment is therefore not to test everything that can be measured, but to measure what can be acted upon. Thoughtful, purpose-driven testing ensures that each result adds value to the treatment strategy, supports individualized decision-making, and ultimately improves the likelihood of a successful and sustainable pregnancy.