INFERTILITY-an overview for GPs

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.

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)

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%

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%

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

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

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

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

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

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

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.

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)

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.

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

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

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

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???

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.

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

Funding for IVF• NICE states that up to 3 cycles of IVF or ICSI should be

available to all women 23-39.• 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.

ReferencesMore 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 608-611