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Infertility guideline (provisional) for primary care

Initial Management of Infertility

Definition

Infertility should be defined as failure to conceive after regular unprotected sexual intercourse for 2 years in the absence of known reproductive pathology. 1

The scale of fertility problems

One in seven couples have fertility problems (approximately 3.5 million people). Male factors are responsible in 30%, female factors in 40%, and the rest are associated with combined male and female factors and unexplained infertility. 2

Causes of infertility:

1. Unexplained (27%),

2. Male factor (24%),

3. Anovulation (21%),

4. Tubal factor (14%),

5. Endometriosis (6%),

6. Sexual dysfunction (6%),

7. Cervical mucus hostility (2%)

Infertility is the commonest reason for women aged 20-45 to see their GP, after pregnancy itself. 2

Of 100 couples trying to conceive naturally

• 20 will conceive within one month

• 70 will conceive within six months

• 85 will conceive within a year

• 90 will conceive within 18 months

• 95 will conceive within two years 2

Natural conception rate in the female declines from the age of 30 years and the decline is more marked after 35. This is similar for IVF and donor insemination treatment.

The lifetime chance of childlessness are as follows:

 Success rates of IVF and donor insemination (DI) treatment in relation to age

Therefore it would be prudent to commence investigations and treatment of women with infertility close to 30 years, if applicable, rather than 35 years as the natural conception rate and success rates of any treatment including artificial reproductive techniques would be substantially lower as they approach 35 years and beyond. If we see them in the secondary care around 30 years, and investigate and/or treat them for another year or so, majority of them could still have IVF etc in the tertiary care, if required, before they cross 35 years (as the waiting list is about 4 years). As the success rate of IVF would be greater compared with women around 39 years (the upper age limit), it would potentially save substantial amount of money that could be used for other women on the waiting list. Therefore, the waiting list would become shorter.

[To achieve this objective it is important to try to increase the awareness in the general population (particularly young generation) of the problem of infertility and its positive correlation with advanced female age.]

Referral criteria

I. Women aged <30 years unable to conceive after regular unprotected sexual intercourse for 2 years in the absence of known reproductive pathology

II. Women aged >30 years unable to conceive after regular unprotected sexual intercourse for 12 months in the absence of known reproductive pathology

III. Women unable to conceive after regular unprotected sexual intercourse for 6 months

1. Women aged >34 years

2. In the presence of known reproductive pathology (e.g. amenorrhoea/oligomenorrhoea, endometriosis, H/0 PID/STD, H/0 abdominal/pelvic surgery or abnormal pelvic examination etc)

Or

3. In the presence of male problems e.g. H/0 genital pathology, H/0 urogenital surgery, H/O STD, Varicocele, significant systemic illness or abnormal genital examination

Investigations to be performed in the primary care

Female partner

• Check Weight, Height, Body Mass Index (BMI) and Waist:Hip Ratio (WM.) BMI weight in Kg/ height in M2

• Measurement of Waist:Hip Ratio (WHR)

  1. Using a tape measure, measure the waist 2.5 cm (1 inch) above the umbilicus in centimetres (or inches)

  2. Next, measure the hips in centimetres (or inches) at the top of the iliac (hip) bone on the right front of the body. The level will be slightly lower than the umbilicus.

  3. Now, calculate the Waist:Hip Ratio (WHR) using these two measurement values.

• Perform Chlamydia (endocervical) swab, and high vaginal and endocervical swabs for C/S

• Blood tests

  • FBC

  • Rubella antibody

  • Chlamydia trachomatis antibody

  • Endocrine tests

I. Women with regular menstrual periods (every 21-35 days)

1. Arrange serum mid-luteal progesterone for 2 cycles (ask the woman to document the date when the next menstrual period following the blood test starts, so that the test result could be interpreted properly).

Mid-luteal progesterone is performed 7 days prior to the next menstrual period. Therefore, for a woman having regular 28 days cycle it is done on D21. But for a woman having regular 21 days cycle it is done on D14 and for 35 days cycle it is done on D28.

2. Arrange serum FSH on D2-3.

II. Women with irregular menstrual periods

• Arrange serum mid-luteal progesterone for 2 cycles (ask the woman to document the date when the next menstrual period following the blood test starts, so that the test result could be interpreted properly). In these cases, it is difficult to ascertain the date when to check mid-luteal progesterone. Usually, it needs to be checked on multiple occasions with a gap of 7 days in each cycle. The first sample should be taken on 7 days prior to the shortest cycle duration (e.g. D14 if the shortest cycle duration is 21 days) and repeated every 7 days till the date 7 days prior to the longest cycle duration (e.g. D28 if the longest cycle duration is 35 days). Therefore, in a woman with cycle lengths ranging from 21-35 days, the mid-luteal progesterone should be checked on D14, D21 and D28.

• Arrange serum FSH, LH, prolactin and TFT on D2-3.

III. Women with oligomenorrhoea (cycle length greater than 42 days) and/or amenorrhoea (no menstrual period for 6 months)

• Arrange serum FSH, LH, prolactin, TFT, testosterone, SHBG and free androgen index on D2-3 or anytime (if amenorrhoeic).

IV. Women with hirsutism

• Arrange serum FSH, LH, prolactin, TFT, testosterone, SHBG and free androgen index on D2-3.

Male partner

• Arrange one semen analysis only

Initial management

• Provide the general information leaflet to the couple (enclosed at the end of this document)

• Ensure that the woman is taking Folic acid 0.4 mg orally daily [5 mg orally daily if on antiepileptic drug(s)]

• Ensure that they have sexual intercourse at least 2-3 times/week

• Advise to stop smoking if applicable

• Advise to reduce drinking alcohol if applicable

• Advise to stop using drugs of abuse if applicable

• Advise women with a BMI of >30 to lose weight

• Women who are susceptible to rubella should be offered rubella vaccination and advised not to become pregnant for at least 1 month following vaccination.

Referral

Refer to the Reproductive Medicine Clinic at West Cumberland Hospital, Whitehaven (Mr S Paul) or Cumberland Infirmary, Carlisle (Dr L Hipple) whichever is convenient to the woman.

*Please send copies of the actual results of investigations with your referral letter.

References

1. Fertility: assessment and treatment for people with fertility problems. Clinical Guideline 2004, NICE.

2. Facts and figures (2005) Latest Press Release. www.hfea.gov.uk.

3. Menken J, Larrsen U. In: Mastroianni L, Paulsen A (eds). Aging, Reproduction and the Climacteric. New York:Plenum, 1986:147-166.

4. Jenkins J. Epidemiology of infertility. In: Balen A ed. Infertility Update.. Amsterdam: Excerpta Medica, 2000: 4-7.

• West Cumberland Hospital, North Cumbria Acute Hospitals NHS Trust: last updated Dec 2006
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