**3. Diagnosis**

History taking and physical examination are paramount to understanding the etiology of the infertility, and should be undertaken in both partners after 1 year of trying to conceive. In certain cases, investigation is indicated after 6 months of unprotected intercourse, such as when the female partner is over 35 years old or has a history of oligomenorrhea or amenor‐ rhea, known or suspected endometriosis or tubal disorders, a past history of chemotherapy or radiation therapy, and in couples in which the male partner is known to be subfertile.

#### **3.1. History taking**

A menstrual history (menstrual interval and characteristics) should be elicited in all female patients in order to understand their ovulatory cycles. For instance, regular monthly cycles with premenstrual symptoms (breast tenderness, ovulatory pain, bloating) suggest that the patient is ovulating, whereas severe dysmenorrhea may indicate endometriosis.

A personal and lifestyle history should also be obtained from all infertile couples, including details about occupations; ages; stressors; levels of exercise; diets; and consumption of alco‐ hol, tobacco, and other substances which can influence fertility [33]. It is also important to take a sexual history, including an evaluation of the frequency of intercourse and of underlying problems such as sexual dysfunction. Infrequent or inappropriately timed sexual intercourse can result in infertility.

Clinicians should elicit a full medical, surgical, and obstetric history including information about the number of previous pregnancies, type and number of deliveries, and number of abortions (including spontaneous and induced) [32]. A gynecological history should evaluate any history of pelvic inflammatory disease, sexually transmitted infections, and treatment of abnormal pap smears, as well as uncover any history of procedures or medications, which could be related to infertility. In addition, a review of systems should be conducted in order to evaluate whether a patient has symptoms of dyspareunia, hypo‐/hyperthyroidism, pelvic or abdominal pain, galactorrhea, or hirsutism [34].

A family history of infertile couples should record in detail whether any family members have birth defects, mental retardation, genetic mutations, or fertility issues. The most com‐ mon inherited cause of infertility is fragile X syndrome, which presents as premature ovarian failure (POF) in women, and which can lead to developmental delay or learning problems in men [35].

#### **3.2. Physical examination**

**2.4. Tubal blockage and other tubal abnormalities**

90 Chinese Medical Therapies for Diabetes, Infertility, Silicosis and the Theoretical Basis

sulfate (DHEAS) secretion from the adrenal glands [32].

abdominal surgery [31].

**2.5. Hyperprolactinemia**

**3. Diagnosis**

**3.1. History taking**

can result in infertility.

or abdominal pain, galactorrhea, or hirsutism [34].

Tubal anomalies that contribute to infertility include congenital absence and major diver‐ ticula, duplication of the tubes, tubal occlusion, and hydrosalpinx [29, 30]. Other causes of tubal infertility include endometriosis, intrauterine contraceptive devices, infections (gonor‐ rhea, chlamydia trachomatis, and genital tuberculosis), and postoperative complications of

Symptoms of hyperprolactinemia include amenorrhea, oligomenorrhea, infertility, decreased sexual desire, and habitual abortion. Women may also have signs of chronic hyperandrogen‐ ism such as acne and hirsutism, which may be related to increasing dehydroepiandrosterone

History taking and physical examination are paramount to understanding the etiology of the infertility, and should be undertaken in both partners after 1 year of trying to conceive. In certain cases, investigation is indicated after 6 months of unprotected intercourse, such as when the female partner is over 35 years old or has a history of oligomenorrhea or amenor‐ rhea, known or suspected endometriosis or tubal disorders, a past history of chemotherapy or

A menstrual history (menstrual interval and characteristics) should be elicited in all female patients in order to understand their ovulatory cycles. For instance, regular monthly cycles with premenstrual symptoms (breast tenderness, ovulatory pain, bloating) suggest that the

A personal and lifestyle history should also be obtained from all infertile couples, including details about occupations; ages; stressors; levels of exercise; diets; and consumption of alco‐ hol, tobacco, and other substances which can influence fertility [33]. It is also important to take a sexual history, including an evaluation of the frequency of intercourse and of underlying problems such as sexual dysfunction. Infrequent or inappropriately timed sexual intercourse

Clinicians should elicit a full medical, surgical, and obstetric history including information about the number of previous pregnancies, type and number of deliveries, and number of abortions (including spontaneous and induced) [32]. A gynecological history should evaluate any history of pelvic inflammatory disease, sexually transmitted infections, and treatment of abnormal pap smears, as well as uncover any history of procedures or medications, which could be related to infertility. In addition, a review of systems should be conducted in order to evaluate whether a patient has symptoms of dyspareunia, hypo‐/hyperthyroidism, pelvic

radiation therapy, and in couples in which the male partner is known to be subfertile.

patient is ovulating, whereas severe dysmenorrhea may indicate endometriosis.

The physical examination can uncover signs indicative of latent causes of infertility. The patient's body mass index (BMI) and fat distribution should be measured and calculated, as an abnormally low BMI is related to infertility, whereas abdominal obesity is associated with insulin resistance [34].

In women, the presence of vaginal and cervical discharge or anatomic abnormalities may indicate an underlying infection or Müllerian anomaly, respectively. If the uterus is enlarged, irregular, or lacks mobility, this may suggest the presence of a uterine abnormality such as endometriosis, leiomyoma, or pelvic adhesions. Chronic pelvic inflammatory disease or endometriosis presents with tenderness, or with masses in the adnexa or posterior cul‐de‐sac (pouch of Douglas), while endometriosis also has palpable tender nodules at the rectovaginal septum or uterosacral ligaments [35].

Patients with Turner syndrome have absent periods, and distinctive morphological features including a squarely shaped chest, and a stocky, short body habitus. Those with hypogo‐ nadotropic hypogonadism have primary amenorrhea and unremarkable secondary sexual characteristics. The presence of galactorrhea, thyroid gland anomalies, or signs of androgen excess such as acne, hirsutism, virilization, and male pattern baldness indicate an endocri‐ nopathy (e.g., polycystic ovarian syndrome, adrenal disorders, hyper‐ or hypothyroidism, hyperprolactinemia) [33, 35].

In men, anatomic abnormalities or discharge from the penis, scrotum, and urethral meatus may indicate the presence of an inguinal/femoral/scrotal hernia, cryptorchidism, or infection. Varicoceles, usually noted on the left side, are associated with infertility, whereas small, hard testes (<2 cm long) are suggestive of Klinefelter's syndrome [36].

#### **3.3. Other diagnostic methods**

Additional essential infertility evaluations include semen analyses, assessment of ovula‐ tory function by laboratory tests, and a hysterosalpingogram to uncover underlying uterine abnormalities and evaluate tubal patency.

Diagnostic laparoscopy is recommended for women with suspected pelvic adhesions or endometriosis, during which chromotubation can assess tubal patency and hysteroscopy can assess the uterine cavity [29, 30].

Women older than 35 years and those younger but with risk factors for POF should measure estradiol and follicle‐stimulating hormone (FSH) levels on day 3 in order to evaluate the ovar‐ ian reserve. Other tests such as antral follicle count, level of anti‐Müllerian hormone (AMH), and the clomiphene citrate challenge test (CCCT) should be performed if necessary [35].
