A comprehensive female fertility evaluation should be thorough, systematic, and personalized. Here's what it typically includes:

1. Detailed Medical History

• Menstrual history: age at first menstrual period, cycle regularity, flow characteristics, pain (dysmenorrhea), premenstrual symptoms.
• Pregnancy history: previous pregnancies, miscarriages, live births, ectopic pregnancies.
• Sexual history: frequency, timing, any difficulties (painful intercourse, low libido), use of lubrication products.
• Contraceptive use: past and current.
• Medical history: thyroid disorders, diabetes, autoimmune diseases, sexually transmitted infections (STIs), pelvic infections (PID).
• Surgical history: pelvic, abdominal, or uterine surgeries (like fibroid removal).
• Family history: fertility issues, genetic conditions, early menopause.
• Lifestyle factors: smoking, alcohol, drug use, exercise habits, stress levels, nutrition.

2. Physical Examination

• General exam: height, weight, BMI, signs of hormonal imbalance – excessive hair growth (hirsutism), acne, hair loss.
• Pelvic exam: evaluation of uterus size and position, ovarian masses, signs of infections.
• Breast exam: abnormal "milky" discharge from the breasts (galactorrhea).

3. Laboratory Tests

Hormone levels (timing of tests is based on the menstrual cycle):

• FSH (follicle-stimulating hormone) — pituitary gland and ovarian function
• LH (luteinizing hormone) — pituitary gland and ovarian function
• E2 (estradiol) — ovarian function
• AMH (Anti-Müllerian hormone) — ovarian reserve
• Progesterone — ovarian function; confirm ovulation
• TSH (thyroid stimulating hormone) – thyroid function
• Prolactin — pituitary gland function
• Androgens (testosterone, DHEAS) — if signs of PCOS
• Free T4 — secondary evaluation of thyroid gland if TSH result is abnormal

STI screening: chlamydia, gonorrhea, others if indicated.

4. Imaging and Functional Tests

• Transvaginal ultrasound:
• Evaluate antral follicle count – ovarian reserve
• Uterine structure - fibroids, polyps, anomalies
• Ovarian appearance - polycystic ovaries, cysts

• Hysterosalpingogram (HSG): X-ray with contrast dye to check for fallopian tube patency (openness) and uterine cavity shape.
• Sonohysterogram (SHG) / Saline Infusion Sonogram (SIS): A specialized ultrasound procedure used to evaluate the uterine cavity.

5. Ovulation Assessment

• Home ovulation predictor kits (OPK): detects "LH surge" (hormonal signal that precedes ovulation)
• Serum progesterone: done in the mid-luteal phase; result >3 ng/mL confirms ovulation

6. Ovarian Reserve Testing

AMH, Cycle-day 3 FSH/LH/E2, and Antral Follicle Count ultrasound - together give a clearer picture of egg quantity/quality.

7. Uterine and Tubal Evaluation

• Structural and functional assessment via HSG, saline ultrasound (described above)
• Surgical visualization of reproductive structures (hysteroscopy or laparoscopy) – if indicated

8. Lifestyle and Psychosocial Assessment

• Nutrition counseling if BMI is outside the ideal range.
• Mental health screening: stress, anxiety, depression, especially if fertility struggles are longstanding.
• Referral to counseling if needed

9. Partner Evaluation

While technically not part of the "female" evaluation, a semen analysis of the male partner is always recommended early in the process because male factors account for about 40-50% of infertility cases.