Why the Workup Phase Exists

Before any clinic will move forward with egg stimulation, an embryo transfer, or a surrogate matching process, they need a complete picture of everyone's reproductive health. For heterosexual couples, same-sex couples using donor sperm or eggs, single intended parents, and surrogate carriers alike — the workup phase is your clinic's due diligence. It's also yours. This is the stage where you learn what you're working with, and where good clinics catch issues before they become expensive surprises down the line.

The tests fall into a few broad categories: ovarian reserve and hormone testing, uterine evaluation, infectious disease screening, genetic carrier testing, and (where applicable) sperm analysis. Not every person will need every test — your protocol depends on your specific path. But understanding what each one is for puts you in a much stronger position to have real conversations with your medical team.

A note on who this applies to: The ovarian reserve and uterine tests apply to anyone with ovaries — whether you're an egg-provider (intended parent or gestational egg-provider) or a surrogate carrier preparing your uterus for transfer. Sperm analysis applies if a male partner or known donor is contributing sperm. Gay male couples using donor eggs and a surrogate will focus more on the sperm side and less on the ovarian tests. We'll flag who each test is most relevant to throughout.

Hormone & Ovarian Reserve Tests

These bloodwork tests are usually ordered together, often on Day 2 or 3 of your menstrual cycle (though AMH can be drawn any day). Together, they give your clinic a picture of how your ovaries are likely to respond to stimulation medication.

AMH — Anti-Müllerian Hormone

What it measures: AMH is produced by the small follicles in your ovaries and is the closest thing fertility medicine has to a count of your remaining egg supply. Higher AMH generally suggests a stronger response to stim medications; lower AMH suggests a more limited reserve.

Typical range: 1.0–3.5 ng/mL is considered normal for most reproductive-age patients, though labs and reference ranges vary. AMH naturally declines with age.

What happens if it's low: A low AMH doesn't mean IVF won't work — it means your clinic will likely adjust your stim protocol to try to optimize your response, and they'll set realistic expectations around how many eggs you might retrieve. Some patients with low AMH have successful retrievals; others may consider donor eggs. This is a conversation worth having early.

What happens if it's high: Very high AMH can indicate polycystic ovary syndrome (PCOS) and a higher risk of ovarian hyperstimulation syndrome (OHSS) during stim. Your clinic will likely use a gentler protocol and monitor you closely.

Relevant to: Anyone providing eggs — intended mothers, egg donors, or surrogate carriers who will also be providing eggs (rare but possible). Not applicable to gestational surrogates who won't be stimulated.

FSH — Follicle-Stimulating Hormone

What it measures: FSH is the hormone your brain releases to stimulate your ovaries each cycle. A high baseline FSH can indicate that your body is working harder than normal to recruit follicles — a sign that ovarian reserve may be declining.

Typical range: Less than 10 mIU/mL on Day 3 is generally considered normal. Results above 10–12 may prompt your doctor to discuss prognosis more directly.

What happens if it's elevated: Your doctor will almost always look at FSH alongside AMH and estradiol together — no single number tells the whole story. An elevated FSH with a normal AMH and AFC might prompt a repeat test rather than immediate protocol changes.

Estradiol (E2) — Day 3 Baseline

What it measures: Estradiol is your main estrogen. A Day 3 baseline reading is used primarily to validate your FSH result. If estradiol is elevated on Day 3, it can artificially suppress FSH — making your ovarian reserve look better than it is. Context matters.

What happens if it's elevated: Your clinic may repeat the test on a different cycle, or it may prompt further investigation for a cyst or other hormone-disrupting factor.

Antral Follicle Count (AFC)

What it measures: This is a transvaginal ultrasound — usually done on Day 2–5 of your cycle — where your sonographer counts the small resting follicles visible in both ovaries. Each follicle has the potential to contain an egg, so the AFC gives a visual corroboration of the AMH result.

Typical range: A combined count of 10 or more across both ovaries is generally considered good. Some guidelines put ≥ 7 as sufficient. Under 5 suggests diminished reserve.

What happens if it's low: Same conversation as low AMH — protocol adjustments, expectations management, and potentially a discussion about donor eggs. If AFC is high, OHSS protocols apply.

Relevant to: Anyone being stimulated. Gestational surrogates won't typically have an AFC done since they won't be stimulated.

Uterine Evaluation Tests

Before any embryo transfer happens — whether that's an intended mother transferring her own embryo or a surrogate carrier receiving one — the uterus gets evaluated. Clinics need to confirm the cavity is clear, the lining is healthy, and the anatomy is going to give that embryo the best possible chance of implanting.

Saline Sonogram (SHG — Saline Infusion Sonohysterography)

What it measures: A small amount of saline is introduced into the uterine cavity while an ultrasound is performed. The fluid creates contrast, making it easier to spot polyps, fibroids, or abnormalities in the cavity shape that a standard ultrasound might miss.

What to expect: It's done in the clinic and takes about 15–20 minutes. Most patients describe it as similar to a Pap smear in terms of discomfort — some cramping, very manageable. You'll typically schedule it after your period ends but before ovulation.

What happens if something is found: Small polyps or a submucosal fibroid (one that protrudes into the cavity) will usually need to be removed before transfer. This might mean a hysteroscopic polypectomy — a minor outpatient procedure. It's extremely common and very treatable.

Relevant to: Anyone carrying an embryo — intended mothers doing their own transfers, and surrogate carriers. This is a standard part of surrogacy screening.

Hysteroscopy (if indicated)

What it measures: If the saline sonogram raises a question mark, a hysteroscopy lets the doctor look directly into the uterus with a small camera. It can also be used to treat what's found in the same procedure.

Not everyone will need a hysteroscopy — it's ordered when there's a specific concern to investigate or treat. Some clinics include a diagnostic hysteroscopy as standard protocol before any first transfer.

Mock Embryo Transfer

What it measures: This is a dry run of the actual embryo transfer. A soft catheter is guided through the cervix and into the uterus, mapping the exact angle and distance — so that on transfer day, the real thing goes smoothly. It sounds intimidating but it's very low-intervention.

Think of it as your clinic measuring your uterus for the procedure. It also lets them flag any cervical anatomy that might require a different catheter type on the day.

ERA — Endometrial Receptivity Analysis

What it measures: The ERA is a biopsy of the uterine lining performed during a mock (medicated) cycle — one designed to replicate the hormonal environment of a real frozen embryo transfer. A small tissue sample is sent to a lab, which analyzes gene expression to determine whether your endometrium is "receptive" at the standard progesterone timing, or whether it's slightly pre- or post-receptive (meaning the transfer window needs to be shifted).

Is it necessary? Not always. The ERA is most commonly recommended after a failed transfer with a high-quality embryo, or for patients with a history of implantation failure. Some clinics include it routinely; others use it selectively. It's worth asking your doctor where they stand on it — and reviewing the current research on ERA efficacy before deciding.

Relevant to: Intended mothers and surrogate carriers. Very much part of the surrogacy workup conversation.

Infectious Disease Panel & Blood Type

This is the standard pre-treatment screening required by the FDA for any fertility treatment involving a third party (donor sperm, donor eggs, or a surrogate). Even in non-third-party cases, most clinics require it as baseline safety screening.

The panel typically includes:

• HIV-1 and HIV-2
• Hepatitis B surface antigen and hepatitis B core antibody
• Hepatitis C antibody
• Syphilis (RPR or VDRL)
• HTLV-I and HTLV-II (in many protocols)
• Chlamydia and gonorrhea (via urine or swab)
• Blood type and Rh factor
• Rubella immunity (if not previously confirmed)
• CMV status (cytomegalovirus — relevant for matching with donors)

If anything comes back positive, it doesn't automatically disqualify you from proceeding — but it does require additional protocols, specialist consultations, or donor/recipient matching considerations. Your clinic and reproductive attorney (if you're in a surrogacy arrangement) will walk you through the implications.

Sperm Analysis (SA)

Relevant to: Any cycle using a male partner's or known donor's sperm.

A semen analysis evaluates sperm count (concentration), motility (how many are moving and how well), and morphology (what percentage are normally shaped). These three parameters together give a picture of whether the sperm is likely to fertilize eggs effectively through conventional insemination or whether ICSI (intracytoplasmic sperm injection — where a single sperm is injected directly into the egg) is recommended.

The WHO 2021 reference values are the current standard: a normal count is ≥ 16 million/mL, motility ≥ 42%, and normal morphology ≥ 4% (Kruger strict criteria). If results are outside these ranges, a urologist specializing in male fertility may be brought in — and this is worth taking seriously. Male factor infertility accounts for roughly half of all fertility challenges.

For gay male couples or single men using donor eggs and a surrogate: you'll still do a full sperm analysis. The protocols for preparing and testing sperm before transfer are the same regardless of family structure. If you're using a sperm donor, your donor's sperm has already been tested and quarantined per FDA banking requirements.

Genetic Carrier Screening

Carrier screening tests your DNA for recessive genetic conditions — meaning conditions where a child would only be affected if they inherited two copies of the variant (one from each biological contributor). Most people who are carriers have no symptoms and no family history.

Common conditions included in expanded carrier screening panels:

• Cystic fibrosis
• Spinal muscular atrophy (SMA)
• Fragile X syndrome
• Sickle cell disease
• Thalassemia
• Gaucher disease, Tay-Sachs, and others depending on the panel

If both biological contributors are carriers for the same condition, that's when the conversation about preimplantation genetic testing for monogenic disorders (PGT-M) comes in. This is a type of embryo testing that screens embryos before transfer. It doesn't eliminate the possibility of having an affected child, but it dramatically reduces the risk.

For LGBTQ+ intended parents using donor gametes: your reproductive endocrinologist and genetic counselor will help you match your carrier status with what's been tested in your donor. Most reputable sperm and egg banks include expanded carrier screening in their donor profiles.

Frequently Asked Questions

How long does the IVF workup phase take?

Most workup testing takes 2–6 weeks to complete, depending on where you are in your cycle when you start, how quickly results come back, and whether any follow-up tests are needed. If a hysteroscopy or polyp removal is required, that can add 4–6 weeks before you can proceed to stimulation. Some clinics move faster than others — ask your coordinator for a realistic timeline.

Do surrogates have to do all these tests too?

Yes — surrogate carriers go through an extensive medical screening as part of their evaluation. This includes the uterine evaluation (SHG, mock transfer, potentially ERA), infectious disease panel, blood typing, and a full physical and psychological evaluation. The surrogate's workup is typically managed by the intended parents' clinic and is a requirement before matching is finalized. Many agencies require surrogates to already have completed an initial screening before being listed.

What if I'm a single intended parent — does anything change?

The medical workup itself is essentially the same. You'll go through ovarian reserve testing (if you're the egg provider), uterine evaluation (if you're the carrier), or sperm analysis (if you're using your own sperm). The main difference is on the legal and donor coordination side, not the clinical side.

Do same-sex female couples both need to be tested?

Typically yes — even if only one partner is the egg provider and the other is the carrier (reciprocal IVF), both will go through their respective workups. The egg provider does ovarian reserve testing; the carrier does the uterine evaluation and infectious disease screening. If you haven't decided yet who is doing what, completing workups for both can give you more information to make that call.

What if my AMH or AFC comes back low?

A low result is not the end of the road — but it is important information. It affects your stimulation protocol, your retrieval expectations, and possibly your overall treatment plan. Some patients with low ovarian reserve have successful retrievals; others pursue donor eggs. Your reproductive endocrinologist can walk you through the data for your specific numbers. Getting a second opinion from another RE is also completely reasonable if you want another perspective.

Is the ERA test worth doing?

This is one of the more debated tests in reproductive medicine right now. Some studies show ERA-guided transfers improve outcomes; others show no significant benefit in unselected patients. The American Society for Reproductive Medicine (ASRM) does not currently endorse ERA as a routine test. It's most likely to be useful if you've had a failed transfer with a good embryo. Ask your doctor specifically about the evidence, not just their protocol.

Track Your Workup with Zygi

Going through the workup phase means keeping track of a lot of moving pieces — bloodwork results, ultrasound dates, test names you've never heard before, and a to-do list that seems to grow with every appointment. Zygi is a free, patient-side tracker built specifically for IVF and surrogacy journeys — no clinic data sharing, no premium tiers, no upsells. Just a clear checklist of where you are and what's next.

Use Zygi's workup checklist to track your results, mark tests complete, and stay oriented through Phase 1. Start for free at zygihealth.org.

Sources & Further Reading

ASRM — Ovarian Reserve Testing Practice Committee Guidelines

WHO Laboratory Manual for the Examination and Processing of Human Semen (6th ed., 2021)

ERA test — BMJ evidence review (2023)

CDC — Assisted Reproductive Technology Data

SART — Society for Assisted Reproductive Technology

FDA — Third-party reproductive tissue requirements

This post is for informational purposes only and is not medical, legal, or financial advice.