History and examination in infertility

In addition to taking a general medical, surgical and family history for both partners, assess factors specific to female fertility and male fertility. Also assess factors affecting sexual activity.

In assessing female factors, determine whether the individual has:

• irregular cycles (less than 24 days or longer than 38 days) or oligomenorrhoea (fewer than 9 cycles in 1 year), which can suggest polycystic ovarian syndrome (PCOS)
• amenorrhoea (absent bleeding for more than 3 months for a female with regular cycles, or more than 6 months for a female with irregular cycles), which can suggest:
  • functional hypothalamic amenorrhoea (caused by conditions such as stress, excessive exercise, systemic illness, eating disorders and very low body weight)
  • pituitary disorders (including prolactinoma and premature ovarian insufficiency or premature menopause)
  • other endocrine causes of secondary amenorrhoea, which are rarer
• symptoms of endometriosis (eg dysmenorrhoea, spotting, deep dyspareunia)
• other factors likely to block the fallopian tubes, such as previous pelvic inflammatory disease or surgery.

In assessing male factors, determine whether the individual has:

• testicular problems (eg cryptorchidism, injury, torsion, hernia, mumps orchitis, varicocele)
• symptoms of androgen deficiency
• exogenous anabolic steroid use
• difficulties with erections and ejaculation.

In assessing the timing and frequency of sexual activity:

• ask what the couple understand about the fertile window
• establish the frequency of sexual activity and whether symptoms of sexual difficulties, such as altered libido, pain or erectile or ejaculatory difficulties, are present.

A full physical examination of both partners should include body mass index (BMI), signs of normal secondary sexual characteristics and, if indicated, pelvic examination. See Examination of the vulva and vagina and Examination of the penis and testes for advice on reducing distress related to examination. Examine for signs of PCOS, including acne and hirsutism; note that weight is not always increased. Pelvic examination may detect tenderness suggestive of endometriosis or pelvic inflammatory disease. Testicular examination looks for small volume and lack of virilisation (which could indicate Klinefelter syndrome¹), masses (eg tumours, hernias, varicoceles) or palpable absence of the vas deferens (which may be a sign of cystic fibrosis).