Fertility

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Please note pre-referral criteria have been agreed across Devon and are applicable to this referral.

Referrals will be returned if the proforma has not been completed with the following results which must have been taken within the last 12 months:

FSH/LH (Day 1-5 of cycle)
Chlamydia serology
Progesterone (7 days before period) only needed if periods regular (26-36 days)
Semen analysis x 1, but if 1st abnormal 2nd specimen and result after a minimum of 6 weeks
Female MMR vaccination history (see investigations/proforma for details)
Female BMI

For same sex couples please complete the appropriate part of the proforma.

If patient has previously had IVF treatment please include how many cycles and if privately and/or NHS funded in the referral letter.

It's important to identify those couples who may benefit from early referral- see assessment below:

Couples where no cause for subfertility has been identified from the history and basic investigations have a good chance of spontaneous pregnancy. Advise them to continue trying with regular intercourse for another year to avoid the risk of multiple pregnancy from fertility treatment.

Couples experiencing delay in getting pregnant are likely to be anxious and stressed and may need extra support.

The following groups of patients are not entitled to initial consultation, investigation or treatment according to the NEW Devon and South Devon and Torbay Assisted Conception Commissioning Policy:

Individuals concerned about current or future fertility who have not been trying to conceive for the requisite time (unless they meet the criteria for the cryopreservation – see cryopreservation policy)
Previous sterilisation in either partner even if it has been reversed
Couples who have already had NHS funded assisted reproduction techniques including intrauterine insemination (IUI), in vitro fertilisation (IVF), intracytoplasmic sperm injection (ICSI) and donor insemination (DI)

All other patients are entitled to initial consultation if they meet criteria for referral outlined below but will only be offered NHS treatment if eligible according to the NHS Devon Commissioning Policy: Assisted Conception

Same sex couples are eligible for consultation with a fertility specialist for advice and to discuss the options available to them, prior to commencing artificial insemination. Please be aware that the commissioning policy requires that the couple are demonstrably sub-fertile before investigation or possible treatment can be offered. For female same-sex couples, failure to conceive after six (6) privately funded cycles of artificial insemination within the past 12 months, in the absence of any known cause of infertility, should be the indication for NHS funded fertility investigations.

For male same-sex couples, failure to conceive after six (6) privately funded cycles of artificial insemination within the past 12 months or 12 months with vaginal intercourse, in the absence of any known cause of infertility, should be the indication for NHS funded fertility investigations.

Please note there are separate eligibility criteria for assisted reproduction techniques (including IUI, IVF, ICSI and donor insemination) (page 5 of policy). However, in patients who are undergoing investigations for infertility, who do not meet the criteria for NHS funded assisted reproduction techniques (ART), if subsequent investigation demonstrates the need for ART, then this will need to be self-funded. It may be useful to make patients aware of this prior to referral.

Prior to referral patients must have been trying to conceive for at least 12 months, except where a woman is 36 years or over when earlier referral can be offered (local specialist advice is that 6 months is a reasonable period of time)

However in the following instances early referral is recommended if there is a known cause for infertility:

Anovulation : irregular or absent periods or luteal progesterone less than 30nmol/L
Tubal disease, raised chlamydia titres
Where there is a history of predisposing factors e.g. Pelvic Inflammatory Disease or Undescended testes, prior treatment for cancer
Sperm dysfunction
Pelvic pathology identified on ultrasound

Kernow CCG Assisted Conception policy can be seen here.

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History and Examination

Couple presents with fertility concerns

Take history to exclude "red flags"

Irregular periods - cycles frequently outside 26-36 days (as per NICE) (These women are anovulatory so there is no point doing progesterone and they need earlier referral)
If periods irregular consider these additional tests but it is not mandatory for the GP to include these as part of the referral
- Thyroid Function Tests ( TFTs)
- Prolactin
- Free Androgen Index
- Sex Hormone Binding Globulin
- Testosterone
Risk factors for tubal disease e.g. previous chlamydia, PID, ectopic pregnancy, abdomino- pelvic surgery
Male factor – undescended testes, mumps, testicular surgery (torsion/orchidectomy)
Woman of 36 years or above in age

Ask if woman has had 2 MMR vaccinations. Recommend vaccination if not/not sure. Advise secure contraception for 1 month after vaccination.

(Rubella testing is no longer recommended)

Opportunistic review of medical co-morbidities, drugs and uptake of cervical screening services.

Early referral is recommended if there is a known cause for infertility e.g.

Anovulation : irregular or absent periods or luteal progesterone less than 30nmol/L
Tubal disease, raised chlamydia titres (greater than or equal to 1/512)
Where there is a history of predisposing factors e.g. pelvic inflammatory disease or undescended testes, prior treatment for cancer
Sperm dysfunction
Pelvic pathology identified on ultrasound

If no red flags and have been trying to conceive for a minimum of 12 months then perform base line investigations to exclude red flag diagnoses which can't be detected on history:

FSH/LH day 1-5 of cycle – to identify women with FSH above 12 but still having regular periods as they have reduced ovarian reserve
Progesterone 7 days before predicted menses (regular cycle only 26-36 days) if less than 30 nmol/l may not be ovulating consider referral. If 15- 30 nmol/l may be mis-timed so consider repeat test. Not needed if periods are irregular
Chlamydia serology – if titre greater than 1/64 increased chance of tubal blockage /adhesions

Semen analysis x 1 - if first result abnormal repeat after 6 weeks

NB: It is vital that that the semen is collected and transported to the laboratory in the correct way. Otherwise the result will be affected. The recommended technique is available here

Initial investigations prior to referral for fertility treatment form

Semen Analysis Request form - please complete before referring

Patient information sheet - Semen Analysis at Centre for Reproduction and Gynaecology Wales and West (CRGW)

If history and investigations reveal no problems then advise couple about:

folic acid
lifestyle factors (smoking, alcohol, obesity)
encourage regular intercourse every 2-3 days and try for another year

Couples where no cause for subfertility has been suggested from history and basic investigations have a good chance of spontaneous pregnancy. They should be advised to continue trying with regular intercourse for another year to avoid the risk of multiple pregnancy from fertility treatment.

If any "red flags" have been identified on history or investigation, please refer to secondary care.

Referral Criteria

Please note pre-referral criteria have been agreed across Devon and are applicable to this referral.

Referrals will be returned if the proforma has not been completed with the following results which must have been taken within the last 12 months:

FSH/LH (Day 1-5 of cycle)
Chlamydia serology
Progesterone (7 days before period) Only needed if periods regular (26-36 days)
Semen analysis x 1 but if first abnormal then a second specimen will be required with result after a minimum of 6 weeks
Female MMR vaccination history (see investigations/proforma for details)
Female BMI

For same sex couples please complete the appropriate part of the proforma.

If patient has previously had IVF treatment please include how many cycles and if privately and/or NHS funded in the referral letter.

BMI for male is helpful but not mandatory, and smoking status for both partners is also helpful. (There is a link between abnormal BMI, positive smoking status and infertility).

Please note eligibility criteria on page 5/6 of the policy regarding NHS Funded Assisted Reproduction Techniques; it may be beneficial to discuss these criteria prior to referral to help manage patient expectations.