1. INFERTILITY-an overview for GPs

2. 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.

3. 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)

4. 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%

5. 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%

6. 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

7. 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

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

9. 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

10. 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

11. 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

12. 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.

13. 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)

14. 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.

15. 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

16. 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

17. 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

18. 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???

19. 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.

20. 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

21. Funding for IVF
NICE states that up to 3 cycles of IVF or ICSI should be available to all women
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.

22. 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