Condition		History and physical examination	Laboratory and radiologic testing	Comments
Female
Endometriosis or pelvic adhesions		History of abdominal or pelvic surgery; history consistent with endometriosis	Rarely helpful	Generally diagnosed on laparoscopy; consider in women with otherwise unexplained infertility
Hypothalamic amenorrhea		Amenorrhea or oligomenorrhea; low body mass index	Low to normal FSH level; low estradiol level	Encourage weight gain
Ovarian failure/insufficiency		Amenorrhea or oligomenorrhea; menopausal symptoms; family history of early menopause; single ovary; chemotherapy or radiation therapy; previous ovarian surgery; history of autoimmune disease	Elevated FSH level; low estradiol level	Consider additional tests of ovarian reserve (antral follicle count, antimüllerian hormone level, clomiphene [Clomid] challenge test)
Ovulatory disorder		Irregular menses; hirsutism; obesity (polycystic ovary syndrome); galactorrhea (hyperprolactinemia); fatigue; hair loss (hypothyroidism)	Progesterone level < 5 ng per mL (15.9 nmol per L); elevated prolactin level; elevated TSH level [corrected]	Check TSH and prolactin levels based on clinical symptoms
Tubal blockage		History of pelvic infections or endometriosis	Abnormal hysterosalpingography result	Usually necessitates subspecialist referral for treatment
Uterine abnormalities		Dyspareunia; dysmenorrhea; history of anatomic developmental abnormalities; family history of uterine fibroids; abnormal palpation and inspection	Abnormal hysterosalpingography or ultrasonography result	May necessitate subspecialist referral for treatment
Male
Genetic etiology:			Both syndromes result in normal semen volume but low sperm count	Y deletions can be passed to offspring if intracytoplasmic sperm injection is used with in vitro fertilization; genetic counseling is indicated
	Y deletions	Y deletions: small testes	Y deletions may present as normal hormone levels or have an elevated FSH level
	XXY (Klinefelter syndrome)	Klinefelter phenotype: small testes, tall, gynecomastia, learning disabilities	Klinefelter syndrome typically results in low testosterone level and an elevated FSH level
Other genetics:		Absence of the vas deferens	Low volume semen analysis	Because of the inheritance pattern, genetic testing of the partner is warranted, and counseling is indicated if she is a carrier
	CFTR gene (cystic fibrosis)
	5T allele (cystic fibrosis)
Obstruction of the vas deferens or epididymis Ejaculatory dysfunction		History of infection, trauma, or vasectomy; normal testicular examination	Low volume semen analysis; transrectal ultrasonography can identify obstruction	Rare cause of infertility; evaluation reserved for fertility specialist
Systemic disease (not all-inclusive):		—	Low FSH level; low testosterone level; check prolactin level and, if elevated, perform imaging for pituitary tumor	Infiltrative processes that cause a small number of infertility cases; however, effective treatment is available
	Hemochromatosis
	Kallmann syndrome
	Pituitary tumor
	Sarcoidosis
Unclear etiology		Normal testicular examination	Normal FSH level; normal semen volume; low sperm count	Subspecialist may consider testicular biopsy to determine obstructive vs. nonobstructive azoospermia