INFERTILITY+ A. Infertility, after at least a year of unprotected coitus, now affects about one couple in six, who should be viewed as a unit because either partner or both may have problems. Identify female risk factors relating to in utero DES exposure, menstrual disorder, fetal wastage, IUD usage, pelvic inflammatory disease, cervical cautery or conization, and sexual history (e.g., frequency of coitus and technique). Male risks relate to venereal disease, undescended testes, orchitis, delayed puberty, and exposure to heat. + B. Examine the women for virilization, DES effects (p. 102), cervical stenosis, endometriosis, and inflammatory disease. In the male, examine for undescended or undeveloped testes, varicocele, hypospadias, gynecomastia, and metabolic or debilitating disease.C. The basal body temperature chart (BBT) is an important tool. Its purpose is not to help time coitus, but rather to schedule and interpret tests and treatment. D. Cervical factors, present in 5-10% of cases, are diagnosed by postcoital test. Schedule it at the low point of the BBT or 1-2 days earlier. With irregular cycles, administer clomiphene citrate to aid ovulatory timing. Although post-coital tests are often done 2 hours after coitus, we use a 12-hour or overnight delay to reduce stress. Sperm numbers do not correlate well with fertility, but 20 or more sperm per high-power field suggest a good prognosis. Repeat the test if sperm are absent. Both male and cervical factors must then be excluded. The commonest cause of a poor post-coital test is incorrect scheduling.