Female factors approx. (40%):
ovulation disorders e.g. ovarian failure, PCOS
other causes amenorrhea or hypomenorrhea
tubal disease e.g. endometriosis
Male factors (approx. 40%):
Serious disorders not to be missed
Unreceptive cervical mucus
Anatomical congenital disorders e.g. uterine, Fallopian
Chromosomal abnormalities e.g. Klinefelter syndrome, Turner syndrome
Thyroid/other endocrine: several incl. hyper/hypothyroid, prolactinaemia
Is the patient trying to tell me something?
Consider psychosexual dysfunction incl. technique
In men: sexual function, past history incl. testicular problems e.g. mumps orchitis, undescended testes; medical problems e.g. diabetes, STIs, genitourinary surgery; occupational e.g. exposure to heat, pesticides; drugs e.g. chemotherapy, illicit agents, alcohol, smoking, antihypertensives. Frequency and timing of intercourse (both). In women: past history incl. previous fertility, obstetric, menstrual, STIs and PID, genitourinary surgery and abdominal surgery esp. appendicitis, peritonitis, abortion, IUCD use, body weight, drugs e.g. smoking, alcohol, OCP, anabolic steroids. Symptoms of ovulation and endometriosis
Both: body habitus, general health, secondary sex characteristics, urinalysis.
Men: external genitalia including testes (normal range 15–35 ml) and penis, PR.
Women: genitalia and breasts, thyroid status, vaginal and pelvic examination.