Local protocols based on these guidelines should be agreed for the general
practice management and referral of infertile couples (A).
Both partners should be involved in the management of their infertility
(C).
The rubella status of the female partner should be checked. If
seronegative, rubella vaccination should be offered and the woman advised
not to become pregnant within one month of immunisation. All women should be
informed of the result of their antibody test (C).
GPs should advise women presenting with infertility to take 0.4 mg folic
acid as a supplement whilst they are trying to conceive and during the first
12 weeks of a pregnancy in order to prevent neural tube defects. The dose
should be increased to 4 mg daily in women who have previously had an infant
with a neural tube defect or who have epilepsy and are taking medication
(A).
Each stage in the investigation and treatment of infertility should be
fully explained to the couple. Written information in a range of languages
should be available where appropriate. This information should include a
list of addresses of relevant organisations. Consideration should also be
given to providing this information in other media (C).
A detailed drug history, including drugs of abuse, should be taken from
both partners (C).
Environmental factors can affect fertility and therefore an occupational
history should be taken as part of the investigation of the infertile couple
(B).
General advice for practitioners to give to patients
Women complaining of infertility should be advised to give up smoking (B).
Men who smoke should be advised to stop, in order to remove one variable
that may affect their fertility (C).
Women should be advised not to drink more than one or two units of alcohol
once or twice a week when trying to become pregnant (C).
In men there is evidence that excessive drinking can adversely affect
reproductive function and general health. Therefore men who drink
excessively should be advised to limit their drinking (C).
The body mass index of the female partner should be calculated as part of
the primary care management of infertility. A supervised weight loss
programme is advised for any woman with a BMI > SO, whether ovulatory or
not (A).
Although weight loss in overweight men will improve general health, there
is little evidence to suggest that this will improve fertility (C).
Men with poor quality sperm should be advised to wear loose fitting
underwear and trousers, and avoid occupational or social situations that
might cause testicular hyperthermia (B).
There is no evidence that the use of temperature charts and LH detection
methods to time intercourse improves outcome and their use should be
discouraged. Couples seeking advice in this respect should be advised to
have regular intercourse throughout the cycle (C).
(a) The male partner should normally have two semen analyses performed
during the initial investigation (B).
(b) Laboratories that perform semen analysis should undertake this according
to recognised WHO methodology. Laboratories should also practice internal
quality control and belong to an external quality control scheme (C).
(c) GPs should send semen samples to the same laboratory used by the
specialist infertility clinic to which the couple would be referred (C).
While regular menstruation is strongly suggestive of ovulation, this
should be confirmed by the measurement of serum progesterone in the mid-luteal
phase (B).
There is no value in measuring thyroid function or prolactin in women with
a regular menstrual cycle, in the absence of galactorrhoea or symptoms of
thyroid disease (B).
Further investigations (likely to be carried out in
secondary care)
(a) The secondary and tertiary management of infertility should take place
in a dedicated, specialist infertility clinic staffed by an appropriately
trained multiprofessional team with facilities for investigating and
managing problems in both partners (C).
(b) GPs should endeavour to refer patients to such a clinic and patients
should request that they be referred to such a clinic. GPs should continue
to offer ongoing support to the couple after referral (C).
The female partner should normally have a test of tubal patency during the
initial investigation of infertility. A hysterosalpingogram may be used as a
screening test for tubal patency in low risk couples. When an evaluation of
the pelvis is required, however, a diagnostic laparoscopy with dye transit
is the procedure of choice (B).
(a) Before uterine instrumentation, consideration should be given either
to screening women for Chlamydia trachomatis, using an appropriately
sensitive technique, or using appropriate antibiotic prophylaxis (C).
(b) Where chlamydia is detected, there should be a local mechanism available
for notification and treatment of sexual partners in conjunction with a
genito-urinary clinic (C).
An endometrial biopsy to evaluate the luteal phase should not be performed
as part of the routine investigation of the infertile couple (B).
The postcoital test is not recommended in the routine investigation of the
infertile couple (B).
Sperm function tests are specialised tests and should not be used in the
routine investigation of the infertile couple (C).
Routine testing for antisperm antibodies in semen is not recommended (C).
Hysteroscopy should not be considered as a routine investigation in the
infertile couple while there is no evidence linking the treatment of uterine
abnormalities with enhanced fertility (C).
An ultrasound examination of the endometrium is unnecessary in the initial
investigation of infertility. However, ultrasound evaluation of the ovaries
may be useful (C).
