Clinical Presentation
Women over 35 years old should have an expedited evaluation and treatment after 6 months of failed attempts to become pregnant. Women over 40 years old require immediate evaluation and treatment. Immediate evaluation is indicated in the presence of amenorrhea or oligomenorrhea; genetic or acquired conditions that may affect ovarian reserve; suspected or known uterine, tubal, or peritoneal disease; stage III-IV or severe endometriosis; and suspected or known male infertility.
History
A thorough medical, surgical, sexual, pregnancy, and contraceptive history must be undertaken. Key elements of the medical history include obstetric and pregnancy history, the duration of attempts to conceive, menstrual patterns, past medical and surgical history, gynecological history (including prior infertility evaluations or treatments), history STIs, sexual history (eg frequency and timing of intercourse and any sexual dysfunction), childhood and developmental history, family and occupational history (eg possible gonadotoxic exposures), as well as a review of systems, current health status, lifestyle factors (eg tobacco use, alcohol and other substances), and current medications. An inventory of medical treatments or intake of recreational drugs known for adverse effects on ovulation (eg steroids, neuroleptics, antidepressants) should be done. Environmental risk factors for infertility should be noted. Clinical history suggestive of ovulatory dysfunction includes the presence of premenstrual syndrome, abnormal cycle length, hot flushes, excessive physical exercise (eg athletes) and weight problems. History and physical signs of endocrine dysfunction must be elicited (eg thyroid disorders, diabetes mellitus [DM], galactorrhea).
Physical Examination
Calculate the body mass index (BMI). A thorough physical exam must be performed with emphasis on evaluation of secondary sex traits, external genitalia, and bimanual exam of the pelvic area.