2. Train Providers to do a physical exam. The physical examination of the woman and her partner can reveal abnormal findings which may point to the cause of infertility. Providers should be trained in how to examine the female and male genital tract and what abnormalities to look for.
The clinical examination of the female reproductive tract should involve the following: (ASRM, 2006a) ASRM, 2008f; ASRM, 2012c)
- Abdominal palpation:
- A palpable mass may suggest uterine fibroids or an ovarian mass
- Scars indicate previous surgery or injury
- Tenderness may suggest acute or chronic pelvic inflammatory disease, an ovarian cyst or endometriosis
- Speculum examination and inspection of the cervix
- An abnormal discharge should be treated
- Any cervix suspicious of cancer or pre-cancer should be investigated. This is unlikely to be the cause of infertility but is an opportunity to prevent or treat cervical cancer.
- Bimanual palpation
- An enlarged uterus suggests uterine fibroids or adenomyosis
- Adnexal masses or tenderness point towards acute or chronic pelvic inflammatory disease, ovarian cysts or endometriomas (‘chocolate cysts’)
If the male partner is present he also should be examined to establish that both testes are present and of normal size. Both abnormally small testes (testicular atrophy) and enlarged testis (hydrocele) can be associated with abnormal sperm production. Abnormalities of the penis may suggest causes of infertility such as hypospadias, injury or infection.