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Infertility in General Practice Kate Hooks ST2 GP
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Curriculum Statements The General Practice consultation Women's Health Men's Health Sexual Health
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Definition Failure to conceive after 12 months of regular unprotected intercourse. 80% of couples will be pregnant after 12 months. 50% of those remaining will conceive in the second year. 50% of those left will conceive within the next 4 years.
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The consultation All couples should receive history taking and examination in primary care. Need to identify those couples who require early intervention/referral Those who have modifiable risk factors.
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The Woman Age Fertility history Same/new partner Length of time trying to conceive Frequency of intercourse and any difficulties Length of time since stopping contraception and the type
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Any suggestion of ovulatory problems- Details of menstrual cycle Galactorrhoea or hirsutism Systemic disease BMI Stress Relevant Gynaelogical history Pain/IMB/PCB Smear history
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Drug history Occupation Lifestyle Abdominal and pelvic examination
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Male Previous children Length of time- frequency/ difficulties/ED History- Mumps/STDs/Trauma previous urogenital abnormality systemic disease surgery Drugs Occupation Lifestyle
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Examine genitalia Secondary sexual characteristics Gynaecomastia
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General Advice Find out couples- wishes, plans, beliefs and motives are Provide stats on normal patterns of conception Generally do not investigate until trying >1 yr Be explicit and talk about stress
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Provide preconceptual advice Smoking BMI Alcohol Not recommended- BBTC Ovulation kits Post coital testing ASAB www.hfea.gov.uk www.bica.net
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Investigations <1 year only if identified as less likely to conceive Female Mid luteal phase progesterone- know cycle!! Serum gonadotrophins- if cycles are irregular. TFTs- if indicated PL- if indicated Chlamydia screen
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Male Screen for Chlamydia Semen analysis- advice 1 st test abnormal- repeat in 3 months 2 nd test abnormal- refer
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Referral Woman <35 years old- hx,exam and inv normal- ref if not conceived within 18 months. Woman >35 years or findings abnormal ref earlier Either partner known reason for infertility refer earlier. Counsel- before/during and after
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Secondary and tertiary care Women- further hormonal tests Tests of tubal patency Hysterosalpingogram Hysterosalpingo-ultrasonography Problems- diag laparoscopy Men- more detailed examination semen Imaging urinary tract Testicular biopsy
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Management Clomiphine Metformin BMI>25 unresponsive to clomiphene Dopamine
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IUI- NICE- mild male factor, unexplained, mild endometriosis- up to 6 cycles IVF- NICE- woman aged 23-39 at time of treatment and infertility for at least 3 years- offered up to 3 stimulated cycle Doh- at least 1 full cycle funded by NHS ICSI- 44% all IVF Donor Insemination Embryo donation GIFT
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Finally.... Be aware of the PCT funding in the area you are working
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