When the workup goes beyond the 11 basic tests, an additional set maps precisely what is happening: ovarian reserve, anatomy (uterus and tubes), an in-depth hormone panel and, in specific cases, genetic tests. Without red flags, it moves forward gradually. Knowing each test helps you take part in the decisions and notice if something important was skipped.
| Test | What it is | What it shows, and when |
|---|---|---|
| Hysterosalpingogram (HSG) | An X-ray with contrast injected into the uterus and tubes. About 15 minutes; it can cause cramping, and a prophylactic antibiotic is often prescribed. | Whether the tubes are open, and changes in the uterine cavity. Done between day 7 and day 12 (after your period, before ovulation). |
| Saline infusion sonography (SIS) | Ultrasound with saline infused into the uterus. Less uncomfortable than the HSG. | An alternative to the HSG when the focus is the uterine cavity (polyps, submucosal fibroids). |
| Diagnostic hysteroscopy | A thin camera introduced into the uterus, with a biopsy if needed. | Indicated when earlier tests suggest a change in the endometrium or the uterine cavity. |
| Diagnostic laparoscopy | Minimally invasive surgery under general anesthesia. | Sees and treats endometriosis, adhesions and other pelvic changes. Not routine: only with strong clinical suspicion. |
The HSG is the key test for evaluating the tubes. And beyond the diagnosis, it can slightly boost fertility in the months that follow: the oil-based contrast “flushes out” small partial tubal blockages.
Each test has its own moment in the cycle:
| Test | When to draw | What it assesses |
|---|---|---|
| Progesterone | Day 21 (luteal phase) | Confirms ovulation |
| Prolactin | Morning, fasting | Hyperprolactinemia |
| Total and free testosterone | Any day | PCOS, hyperandrogenism |
| DHEA-S | Any day | Adrenal glands |
| Estradiol | Day 2 to 4 | Baseline ovarian function |
| 17-OH-progesterone | Morning, follicular phase | Adrenal hyperplasia |
| Anti-TPO and Anti-Tg | Any day | Thyroid autoimmunity |
Ovarian reserve has its own markers (AMH, antral follicle count and baseline FSH), explained on a separate page.
Immunological evaluation is a controversial area, with many tests of debatable usefulness. Some clinics offer very expensive immune panels with dozens of tests, and the vast majority have no solid evidence of clinical usefulness. Talk it through with your specialist before agreeing: some are useful, many are marketing.
In cases without red flags, the workup moves forward gradually:
This is Chapter 32 of Map to the Positive, in Station IV, Signs. Right after it, the book explains the 8 most common diagnoses these tests can lead to and lays out the available treatments on a rising scale of complexity, so every result has a place on the map and you know what the next step is.
Take 30 days. If it does not give you more clarity than everything you have read for free so far, ask for a refund and you get every cent back. We cannot promise you a pregnancy. We can promise you will not be guessing.
References: ESHRE. Guideline on Recurrent Pregnancy Loss, 2022.