2DEFINITIONInfertility 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.
3INCIDENCECouples 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)
4CAUSES OF INFERTILITY Sperm dysfunction-24% Ovulation disorder-21% Fallopian tube damage-14% -chlamydia causes 80% of thisEndometriosis-6%Coital Failure or infrequency-6%Cervical mucus defects-3%Azoospermia-2%Unexplained -28%Miscellaneous-11%
5CHANGES IN PREVELENCEInfertility and subfertility is likely to increaseIncreased incidence of sexually transmitted diseasesWomen are delaying childbearingIn 1977 the proportion of births to women over 30 was 23%In 2007 the proportion was 48%
6HOW DO WE DIAGNOSE IT? History from the woman AgeAny previous pregnancyPrevious contraceptionMenstrual cycle detailsTiming of intercourse and frequencyDuration of infertilityHistory of abnormal cervical smears, pelvic surgery, STIsPast medical history-e.g. Cancer treatment, hypothyroidismDrug history-prescribed and recreationalLifestyle factors-work, alcohol, smoking, exercise
7History from the manPast medical history- severe illnesses, mumps after pubertyPast history of STIsPrevious surgery e.g. OrchidopexyAny previous childrenDrug history-prescribed and recreational
8Examination Woman Weight Pelvic examination Note any features of PCOS MenScrotum-testis, varicocoels, penisObserve secondary sexual characteristics
9INVESTIGATIONS for the GP WOMANFBC,RubellaAssessment of ovulation-mid luteal progesteroneFSH/LH (ovarian reserve, PCOS) best day 1-3STI screenTarget use of prolactin, TFTsMANSeminal analysis-a single poor result should be repeated checking technique and after advice-loose underwear, smoking , alcohol, drugs,-usually 3 months laterIf azoospermia check FSH/LH , chromozomes
10What can the GP do? Couple centred management Holistic care Advice both partners on smoking, drinking and drugsAdvice re ideal weight-BMI <30 for womanCheck rubella status and correct if none immune, check cervical cytologyStart folic acid.Advise regular intercourseOffer support and encouragement where investigations are negativeRefer in a timely fashion
11WHEN TO REFER? Early referral if Woman aged over 35 Ammenorrhoea/oligomenorrhoeaPrevious abdo/pelvic surgeryPrevious PID/STDAbnormal pelvic exam.Previous genital pathology or urogenital surgery in manPrevious STDsVaricoeleAbnormal genital examsignificant systemic illness
12Plan ongoing support in primary care after referral 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 referralWritten information should be available where appropriate including list of relevant organisations for support.
13What 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)
14What 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.
15TREATMENTS 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
16PSYCHOLOGICAL EFFECTS OF FERTILITY PROBLEMS Stress within the relationshipOffer details of fertility support groupsPeople who experience fertility problems should be offered counselling because the investigations and treatment of fertility problems, can cause psychological stressCounselling may be required before, during and after investigation and treatment
17Factors affecting outcome of IVF Surgery to remove hydrosalpingesFemale age 20% women aged 23-35,15% aged 36-38,10% aged 39,6% over 40.Number of embyos transferred and multiple pregnancyNumber of cycles-chances are consistent for 1st three cycles of treatmentPreviously pregnant
18Human 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???
19GROUP 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.
20SELF HELP, SUPPORT GROUPS Patient.co.ukinfertility –a basic understanding- a summary of treatmentsHFEA offers information about funding and success ratesInfertility network uk
21Funding for IVFNICE states that up to 3 cycles of IVF or ICSI should be available to all womenThose who have an identifiable cause for their infertilityThose who have had > 3 years of fertility problemsImplementation 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.
22References More information NICE –fertility 2004Infertility RCOG guidelinesBMJ learning-infertility in primary careinnovAIT Vol 3 No 2 ,pages 76-82, 2010.HFEA websiteBMJ “Management of Infertility” Balen and Rutherford” 22nd Sept 2007,Vol. 335 pages