History, examination and investigation of female and male subfertility
| Female | Male | Both | |
| History | |||
|
Ovulatory cycles:
Average menstrual cycle length (usually within ±2 days for most women), number of menses per year, contraception history Hypothalamic amenorrhoea: Weight loss, excessive exercise, psychological stress, family history PCOS/CAH: Hirsutism, acne, oligomenorrhoea Endometriosis: Dyspareunia, dysmenorrhoea, cyclical pelvic pain PID Pelvic pain, discharge, STIs |
Testosterone deficiency:
Libido, potency/erectile dysfunction, shaving frequency, gynaecomastia. Risk factors for testicular dysfunction: History of mumps/orchitis History of STIs Trauma Previous oncological treatments |
General questions:
Duration of trying to conceive Fecundity, frequency of sexual intercourse, pubertal milestones Medical history, medications, alcohol, smoking, illicit drug use Prolactinoma: Headaches, galactorrhoea, visual field impairment Kallmann syndrome: Anosmia, incomplete pubertal development. Can be associated with other features depending on specific mutation, for example, hearing impairment, renal agenesis, synkinesia | |
| Examination | |||
|
Signs of hyperandrogenism:
Ferriman-Gallwey score for hirsutism. Acne. Pelvic examination | Testicular volume with Prader orchidometer. Epididymal hardness/thickening Presence of vas deferens | Secondary sexual characteristics BMI | |
| Investigations | |||
| Male factor | Semen analysis | ||
| Microbiology | Rubella serology | Chlamydia swab/urine test | |
| Bloods | Mid-luteal progesterone level Oligomenorrhoeic/anovulatory: FSH, LH, oestradiol, SHBG, testosterone, prolactin, follicular phase 17-OHP, serum AMH. | Pre-10 am fasting testosterone FSH, LH, SHBG, albumin Iron studies for haemochromatosis |
If undergoing ART:
HIV, hepatitis B and C Thalassaemia/sickle cell |
| Imaging | TVUS, HyCoSy, HSG to assess tubal patency and uterine cavity | Scrotal US/Doppler for varicocele or obstructive causes | |
AMH, anti-Müllerian hormone; ART, assisted reproductive treatment; BMI, body mass index; CAH, congenital adrenal hyperplasia; FSH, follicle stimulating hormone; HA, hypothalamic amenorrhoea; HIV, human immunodeficiency virus; HSG, hysterosalpingography; HyCoSy, hystero-contrast sonography; LH, luteinising hormone; 17-OHP 17, hydroxyprogesterone; PCOS, polycystic ovary syndrome; PID, pelvic inflammatory disease; SHBG, sex hormone binding globulin; STIs, sexually transmitted infections; TVUS, transvaginal ultrasound; US, ultrasound.