INFERTILITY-an overview for GPs

DEFINITION Infertility is defined as the inability to conceive despite regular unprotected intercourse over a specific period of time, usually 1-2 years. The period of time varies dependant on the circumstances for each couple e.g. Age of woman, previous abdominal surgery, cancer treatment.

INCIDENCE Couples who are concerned about their fertility should be informed that about 84% of couples in the general population will conceive within one year if they do not use contraception and have regular sexual intercourse. Of those who do not conceive in the first year, about half will do so in the second year (cumulative 92% rate)

CAUSES OF INFERTILITY Sperm dysfunction-24% Ovulation disorder-21% Fallopian tube damage-14% -chlamydia causes 80% of this Endometriosis-6% Coital Failure or infrequency-6% Cervical mucus defects-3% Azoospermia-2% Unexplained -28% Miscellaneous-11%

CHANGES IN PREVELENCE Infertility and subfertility is likely to increase Increased incidence of sexually transmitted diseases Women are delaying childbearing In 1977 the proportion of births to women over 30 was 23% In 2007 the proportion was 48%

HOW DO WE DIAGNOSE IT? History from the woman Age Any previous pregnancy Previous contraception Menstrual cycle details Timing of intercourse and frequency Duration of infertility History of abnormal cervical smears, pelvic surgery, STIs Past medical history-e.g. Cancer treatment, hypothyroidism Drug history-prescribed and recreational Lifestyle factors-work, alcohol, smoking, exercise

History from the man Past medical history- severe illnesses, mumps after puberty Past history of STIs Previous surgery e.g. Orchidopexy Any previous children Drug history-prescribed and recreational

Examination Woman Weight Pelvic examination Note any features of PCOS Men Scrotum-testis, varicocoels, penis Observe secondary sexual characteristics

INVESTIGATIONS for the GP WOMAN FBC, Rubella Assessment of ovulation-mid luteal progesterone FSH/LH (ovarian reserve, PCOS) best day 1-3 STI screen Target use of prolactin, TFTs MAN Seminal analysis-a single poor result should be repeated checking technique and after advice-loose underwear, smoking , alcohol, drugs,-usually 3 months later If azoospermia check FSH/LH , chromozomes

What can the GP do? Couple centred management Holistic care Advice both partners on smoking, drinking and drugs Advice re ideal weight-BMI <30 for woman Check rubella status and correct if none immune, check cervical cytology Start folic acid. Advise regular intercourse Offer support and encouragement where investigations are negative Refer in a timely fashion

WHEN TO REFER? Early referral if Woman aged over 35 Ammenorrhoea/oligomenorrhoea Previous abdo/pelvic surgery Previous PID/STD Abnormal pelvic exam. Previous genital pathology or urogenital surgery in man Previous STDs Varicoele Abnormal genital exam significant systemic illness

Plan ongoing support in primary care after referral When to refer? If all initial tests are normal in both partners discuss the results with couple and defer referral until duration of infertility >18 months. Plan ongoing support in primary care after referral Written information should be available where appropriate including list of relevant organisations for support.

What will happen next? Referral to a dedicated, specialist infertility clinic with appropriately trained multiprofessional team with facilities for investigation and managing problems in both partners. Tubal patency testing- hysterosalingogram or lap. And dye. (Chlamydia screening before)

What treatment may be offered? The couple should have the opportunity to make informed decisions regarding their care and treatment via access to evidence based information. They may well return to the GP to discuss their options.

TREATMENTS AVAILABLE Ovulatory problems-clomiphene Tubal problems-IVF Sperm abnormality – ICSI(intracytoplasmic sperm injection) Intra-uterine insemination for mild male factor problems, unexplaine infertility or mild endometriosis

PSYCHOLOGICAL EFFECTS OF FERTILITY PROBLEMS Stress within the relationship Offer details of fertility support groups People who experience fertility problems should be offered counselling because the investigations and treatment of fertility problems, can cause psychological stress Counselling may be required before, during and after investigation and treatment

Factors affecting outcome of IVF Surgery to remove hydrosalpinges Female age 20% women aged 23-35, 15% aged 36-38, 10% aged 39, 6% over 40. Number of embyos transferred and multiple pregnancy Number of cycles-chances are consistent for 1st three cycles of treatment Previously pregnant

Human Fertilisation and Embryology Authority HFEA is dedicated to licensing and monitoring UK fertility clinics and all UK research involving human embryos and providing important and authoritive information to the public. It requires that any fertility clinic in the UK must take account of the welfare of the potential child before offering IVF etc. What will replace it???

GROUP WORK Split into 3 groups Each group will have a leader Each group will discuss a different case considering the role of the GP and any ethical, fitness to practice issues that it may involve. Appoint a spokesperson to feedback to the full group.

SELF HELP, SUPPORT GROUPS Patient.co.uk infertility –a basic understanding - a summary of treatments HFEA offers information about funding and success rates Infertility network uk

Funding for IVF NICE states that up to 3 cycles of IVF or ICSI should be available to all women 23-39. Those who have an identifiable cause for their infertility Those who have had > 3 years of fertility problems Implementation of this varies across the UK/England. Some PCTs fund none, 1, 2, or 3. Other criteria that PCTs use are:-BMI, whether either partner has children and number of previous fertility treatment cycles undertaken. Look at PACE for Bradford.

References More information NICE –fertility 2004 Infertility RCOG guidelines BMJ learning-infertility in primary care innovAIT Vol 3 No 2 ,pages 76-82, 2010. HFEA website BMJ “Management of Infertility” Balen and Rutherford” 22nd Sept 2007,Vol. 335 pages 608-611