Infertility in General Practice Kate Hooks ST2 GP

Curriculum Statements The General Practice consultation Women's Health Men's Health Sexual Health

Definition Failure to conceive after 12 months of regular unprotected intercourse. 80% of couples will be pregnant after 12 months. 50% of those remaining will conceive in the second year. 50% of those left will conceive within the next 4 years.

The consultation All couples should receive history taking and examination in primary care. Need to identify those couples who require early intervention/referral Those who have modifiable risk factors.

The Woman Age Fertility history Same/new partner Length of time trying to conceive Frequency of intercourse and any difficulties Length of time since stopping contraception and the type

Any suggestion of ovulatory problems- Details of menstrual cycle Galactorrhoea or hirsutism Systemic disease BMI Stress Relevant Gynaelogical history Pain/IMB/PCB Smear history

Drug history Occupation Lifestyle Abdominal and pelvic examination

Male Previous children Length of time- frequency/ difficulties/ED History- Mumps/STDs/Trauma previous urogenital abnormality systemic disease surgery Drugs Occupation Lifestyle

Examine genitalia Secondary sexual characteristics Gynaecomastia

General Advice Find out couples- wishes, plans, beliefs and motives are Provide stats on normal patterns of conception Generally do not investigate until trying >1 yr Be explicit and talk about stress

Provide preconceptual advice Smoking BMI Alcohol Not recommended- BBTC Ovulation kits Post coital testing ASAB

Investigations <1 year only if identified as less likely to conceive Female Mid luteal phase progesterone- know cycle!! Serum gonadotrophins- if cycles are irregular. TFTs- if indicated PL- if indicated Chlamydia screen

Male Screen for Chlamydia Semen analysis- advice 1 st test abnormal- repeat in 3 months 2 nd test abnormal- refer

Referral Woman <35 years old- hx,exam and inv normal- ref if not conceived within 18 months. Woman >35 years or findings abnormal ref earlier Either partner known reason for infertility refer earlier. Counsel- before/during and after

Secondary and tertiary care Women- further hormonal tests Tests of tubal patency Hysterosalpingogram Hysterosalpingo-ultrasonography Problems- diag laparoscopy Men- more detailed examination semen Imaging urinary tract Testicular biopsy

Management Clomiphine Metformin BMI>25 unresponsive to clomiphene Dopamine

IUI- NICE- mild male factor, unexplained, mild endometriosis- up to 6 cycles IVF- NICE- woman aged at time of treatment and infertility for at least 3 years- offered up to 3 stimulated cycle Doh- at least 1 full cycle funded by NHS ICSI- 44% all IVF Donor Insemination Embryo donation GIFT

Finally.... Be aware of the PCT funding in the area you are working