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The couple have been trying to conceive for approximately 18 months without success. Karen is 32 with regular periods, no history of gynaecological disease or sexually transmitted infection, normal blood tests aside from a borderline ovulation result that is supported by home ovulation prediction testing, and a negative cervical smear. Examination is normal, and she is mildly overweight with BMI 28; she has been advised to lose weight and is taking folic acid 400 micrograms daily. William is 33, reports no significant medical issues, has disputed the degree of alcohol intake compared with earlier history, works away from home part of the month, and declined physical examination. He has reluctantly agreed to a semen analysis, with results pending. 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