Infertility:
RCOG guidelines
Initial management
- 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).
Initial investigations (primary care or secondary care)
- (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).
Semen collection and assessment of progesterone
Initial investigation and management of couple in secondary care
