Information for General Practitioners

Management of Sub-fertility
Information Sheet

Introduction

Sub-fertility is a common and distressing problem. One in six couples will experience some difficulty in conceiving. CARE Fertility sees over a thousand referrals each year, but a General Practitioner may see only one or two new infertile couples per year. These guidelines have been developed to facilitate the initial assessment and investigation of the sub-fertile couple by their GP or, alternatively to simplify the process of referral to CARE.

Sub-fertility is defined as not being able to conceive following two or more years of unprotected intercourse. However sub-fertility investigations should commence earlier, if the couple feel they have a problem or are anxious. Furthermore immediate referral should be arranged if any of the following are present on history or examination:

Female:

Cycle irregularities

History of pelvic infections/sexually transmitted disease (STD)

Abdominal surgery including ectopic pregnancy

Age is over 35 years

Male:

History of testicular maldescent/undescent

Previous genital pathology

Any urogenital surgery

Eligibility Criteria

Most Primary Care Trusts (PCT's) have contracts with local providers for the purchase of sub-fertility investigations and treatment. This means that treatments like IVF/ICSI, donor insemination, or egg donation, as well as all forms of surgery and non-IVF treatments are available on the NHS to eligible couples. PCT's have different criteria depending on the area they fall into, so you should check directly with your own area PCT for the criteria they work to, if you are unsure.

If a patient is not eligible for NHS funding, then they will require a private referral.

Referral Procedures

Please click here to download a referral form, complete it and post to the Unit of your choice (see locations menu). The couple will be contacted within 2 weeks with sufficient information to enable them to initiate all their preliminary tests. When all the tests are completed, the couple will be given an appointment to see one of our experienced Clinicians. At this consultation the results of the investigations will be discussed, and in the majority of cases a diagnosis will be made and a plan of treatment offered. Information and support from our fully trained nurses and counsellors is available at each CARE Unit.

Notes to assist GP's in the initial management of sub-fertile patients

Female history

In the female, a menstrual history is important to detect any irregularity of the cycle, as this may indicate a problem with ovulation. Amenorrhoea, either primary or secondary, indicates prompt referral, as does oligomenorrhoea (cycle length 35 days to 6 months). Any inter-menstrual or post-coital bleeding should be noted.

The obstetric history, if any, should detail ante-natal or post-natal problems. The medical history should cover any on-going systemic illnesses, any previous gynaecological problems – including pelvic infection or abdominal surgery. Previous lower abdominal surgery, ectopic pregnancy or pelvic infection, warrant immediate referral.

Smoking and obesity both reduce fertility in the female.

It is CARE Fertility's policy to ensure that all women are rubella immune and chlamydia screened before commencing treatment. Unless this has been checked previously and a positive immune result obtained, rubella status should be ascertained, along with the patient chlamydia status if not previously recorded.

Male history

In the male, you should include any pregnancies he may have fathered, and any previous illnesses, particularly in the last 6 months as these may affect their sperm count. It is helpful to document any history of orchitis, epididymitis testicular torsion, maldescent or varicocele, and details of any treatment including at what age surgery was performed are necessary. A history of any of the above, or a significant systemic illness necessitates early referral.

Social factors are of relevance as both smoking and alcohol can depress sperm function.

Sexual

The sexual history of both partners covers problems with dyspareunia, erection or ejaculation. It is also important to ascertain if the couple are aware of and use the fertile period. An estimate of coital frequency should be obtained (2/3 times per week ideal).

Examination

Female

Examination of the female aims to detect signs of underlying endocrine disease so it is important to look for hirsutism, glactorrhoea or other manifestations of endocrine disease. Height and weight are important, as being significantly over or underweight can lead to anovulation. Pelvic and abdominal examination are necessary to detect structural abnormality of adnexal pathology.

Male

In the male partner any urogenital abnormality should be detected. Testicular site, consistency and volume should be noted, and also any varicocele, epididymal thickening or scrotal swelling.

Preliminary Investigations

The couple will be sent information explaining the basic investigations to be organised.

From the results of these basic investigations it should be possible to assign each couple to one of five simple diagnostic categories:

Male factor:

abnormal semen analysis only

Ovulatory factor:

either irregular cycles, low progesterone, or elevated LH or FSH

Tubal factor:

Equivocal or abnormal HSG

Multiple factor:

more than one of the above

Unexplained infertility:

no abnormality detected

It is important to stress to couples that these tests are only screening tests, they can give false results and as in the example of unexplained infertility, they may fail to reveal any abnormalities at this stage.

Endocrine Investigation in the female

1. Follicle stimulating hormone (FSH) and luteinising hormone (LH) between day 2 and 5 of the menstrual cycle – these tests reflect ovarian competency. Elevated FSH (>10 U/L) indicates a degree of ovarian failure/resistance which may be the forerunner of frank ovarian failure (premature menopause). Women with elevated FSH are more difficult to treat and respond poorly to hormone stimulation. Many will eventually require egg donation. Elevated LH (>10 U/L) is suggestive of polycystic ovarian syndrome, and may well be associated oligomenorrhoea as well as obesity or hirsutism. These patients need active treatment, following which many will conceive – although miscarriage rates are high.
2. Progesterone concentration on Day 21 of the menstrual cycle – this test is designed to confirm ovulation. A good result is progesterone>30 nmol/L although ovulation is indicated if progesterone>18 nmol/L. However unless the next menstrual period occurs within 10 days the result is invalid. This test is difficult to interpret in women with irregular cycles.

Tubal patency in the female

This is assessed by means of a hysterosalgingogram (HSG). Xray contrasts material introduced into the uterus is observed spilling from the fallopian tubes. A normal result is where there is free spill from both tubes. An equivocal result, or one in which the uterine cavity appears abnormal, requires further evaluation. Other methods to check tubal patency include saline sonography, hycosy and Laparoscopic hydrotubation.

Semen analysis in the male

In the male, semen analysis in the only necessary initial investigation. In order to standardise results between GP and the clinic, this test should be performed at CARE. Other sources of semen analysis do not provide as wide a range of quantitative quality controlled measurements. Normal ranges for each parameter are shown on the results form, but essentially the following denote a potentially normal semen analysis:

Volume

—> 2 – 4 ml

Sperm density

—> 20 x 106 per mil

Motility

—> or equal 40% (sum of grades I – II)

Morphology

—> or equal 5% by Krueger strict criteria

Anti-sperm antibodies

—> or equal 40%

In this situation, or if there are significant departures from the normal limits given above, early referral should be implemented.

Further investigations and treatment

Generally these can only take place after formal referral to CARE. They may include laparoscopy to survey the pelvis if there is pain, abnormal findings on examination, or where minimally invasive surgery may be possible. A screening cycle may be done to assess cycle normality. Some test may be carried out externally to CARE.

Even though some sub-fertility problems are more amenable to treatment than others, the range of treatments chosen have been designed to ensure an approximately 50% take-home-baby rate for each of the 5 basic diagnostic categories. This although IVF for example is shown as a form of treatment in a number of categories, it is utilised for many different reasons to overcome differing pathology. As a consequence pregnancy rates following IVF may be excellent (35% per attempt) in some patient groups, but relatively poor (10% per attempt) in others. Similarly our experience has shown that tubal microsurgery is generally inappropriate in couples with multiple problems, as although the tubal lesion may be cured the patient does not conceive due to co-existing ovulatory or male infertility factors.

In some groups of patients it is almost impossible to achieve acceptable pregnancy rates. One such group is the older woman, where not only are pregnancy rates low, but spontaneous miscarriage rates can be as high as 50%. This poor outcome is due to the normal phenomenom of reproductive ageing in which the number of competent eggs remaining in the ovary starts declining rapidly form about the age of 37. By the time women reach the age of 40, many are already showing signs of becoming menopausal (raised FSH) even though most will continue menstruating for several years. A number of the eligibility criteria introduced by purchasers of Assisted Reproduction Services are based on objective biological data such as these. GP's or patients who find it difficult to accept that not all problems can be cured and further that in many cases we can predict these individuals in advance, may appreciate the full counselling service that is now offered by CARE. Consequently it is perfectly acceptable to refer patients simply for counselling.

Treatments provided at CARE – please refer to the treatment section on this website.

If this information raised any queries, please email our Group Medical Director Dr Simon Thornton, who will be only too pleased to discuss things further: