The perception of subfertility varies with the individual and encompasses many aspects including the need for investigation and the speed of investigation. An older patient may warrant full investigation after six months of unprotected coition even though the diagnosis of infertility cannot be made until there have been 12 months of unprotected coition. A couple presenting for routine consultation may say that they wish to attempt conception yet may have a history, symptoms, or signs that strongly suggest difficulties in procreation. They should undergo appropriate investigations early.

The investigation of the infertile couple requires an organized approach that encompasses andrology, endocrinology and pelvic assessment so that appropriate pathways of therapy can be planned.

Counselling

The establishment of an optimal doctor–patient relationship is paramount in the management of the infertile couple. Time spent initially in understanding the patients' perceptions of their infertility in terms of their real chance of having a child of their own and in understanding past events or current lifestyle practices that they believe will inhibit their chances of pregnancy, is crucial. Assessment of the patients' understanding of their own anatomy and physiology is important, with guidance being given about appropriate references for the patients to read.

High levels of stress are recognized in patients undergoing investigation and treatment for infertility (Downey et al., 1989; Wright, Duchesne and Sabourin, 1991), although men score less disturbance than their female partners on scales of anxiety, depression, hostility, cognitive disturbance, stress and self-esteem (Wright et al., 1991).