Factors important to fertility Eggs Sperm Tubes Sex
Primary Care Assessment Fertility Risk factors Ovulation Sperm [Tubes] Sexual function NICE 2004 General General health and wellbeing Sexual health Weight, smoking, alcohol Folic acid Smear [FBC, TSH], rubella
Who/when to refer Immediately Significant risk factors Identified cause Early Significantly anxious Female age >35 years Otherwise At 1-2 years trying Issues Female age Relationship Welfare of the child Medical/psychiatric problems Desire to proceed
Old Technologies Acceptance of childlessness Adoption Fostering Extended families
Unexplained subfertility 2 years failure to conceive with regular intercourse and normal investigations
Ideal Referral Details of both partners Relationship Duration of trying Salient risk factors Significant medical/psychiatric history Previous pregnancies/children WoC issues Confirmation of ovulation FBC, rubella (TSH) Semen analysis (x2 if relevant) [Tubal patency if access] With results in the letter.
Referral Pathways PCT directed 2y/3y services Patient choice Choose and book Treatment availability There are no eligibility requirements for fertility assessment.
Secondary Care Provision Investigation More detailed investigation Tubal patency testing Unlicensed treatments Licensed treatments Overlap with tertiary centres
Aims of Process WITHOUT UNDUE DELAY Diagnose a cause where possible Reassure if appropriate Give an estimate of chance of conceiving without treatment Offer appropriate treatment options Provide timely access to appropriate treatment
EUTCD HFEA Bring under licence from April 2007 (now June 2007) Sperm prep IUI-H GIFT EU directive Stringent tissue handling conditions
Tertiary Referral “2y care” facilities Unlicensed treatments Licensed treatments Non- ART ART GP support for tertiary treatment Welfare of the child Pregnancy support
GP support for 2y/3y treatment Prompt appropriate referral Welfare of the child Ongoing medical/psychiatric management Weight management Counselling Pregnancy support Shared prescribing
PCT Support Facilitate access to pathway of care Provide appropriate funding to comply with the NICE Guidelines and the associated DoH targets allowing treatment to be provided in a timely fashion Determine local criteria for application of limited funding To apply funding criteria equitably Remain open to new developments
NFCL - What do we do? Clinics Trans-vaginal ultrasound scanning Andrology Embryology Treatment Counselling Education Multidisciplinary links Research
Clinics Fertility Accept 1y, 2y and 3y referrals Investigation, results review, treatment options discussed Gynae-endo Investigation endocrine related fertility problems Management ovulatory dysfunction Young peoples clinic Advice on fertility for future Oncology/endocrinology/ urology etc. IVF clinics Investigated patients arranging treatment Follow-up following unsuccessful treatment PP clinic
Trans-vaginal Ultrasound Diagnostic Natural cycle follicle tracking for DI/IUI Ovulation induction Ovarian stimulation for IVF Early pregnancy Up to 30 scans/morning 5 days/week and Sat am limited facility