Evaluation of the infertile couple

The evaluation of the infertile couple is usually a lengthy investigation in which all possible etiologic factors in both partners have to be considered. Optimal and cost-effective investigation requires adequate recognition of significant historical data and physical findings. Males without stigmata of endocrinopathies or general medical illnesses require an analysis of their semen as the minimum initial step of evaluation. Those suspected of deficient androgen production and/or action and those with abnormal sperm counts, motility, and/or morphology need assessment of their serum concentrations of selected reproductive hormones. When these initial investigations are negative and there are no demonstrable etiologic female factors underlying the state of infertility, specialized sperm function and sperm allergy testing needs to be performed. The initial investigation of the female partner is best served by assessing the frequency of ovulation and adequacy of corpus luteum function. Women without ovulatory defects should be assessed for the presence of the hostile cervical mucus and structural anomalies of the reproductive tract. Investigations of patients with menstrual dysfunctions should be based upon the presence or absence of hirsutism, changes in body weight, and evidence of other endocrinopathies or medical illnesses. Following the identification and normalization of causes of anovulation, further work-up of patients who remain infertile is similar to those with regular menstrual cycles. The diagnosis of idiopathic infertility is essentially by exclusion of all other causes. Algorithms for the diagnostic evaluation of most infertile couples are provided.