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Infertility

Previous NICE definition of infertility was ” failure to conceive after regular unprotected 
intercourse for 2 years in absence of known reproductive pathology “

This has now been changed in the updated guidelines to ” the period of time people have been trying to conceive without success after which formal investigation is justified and possible treatment implemented “
 ( NICE 2013 )

Definition also can vary across countries. In the USA infertility is defined as inability to become pregnant after 12 months of regular unprotected intercourse

How common –It is estimated that infertility affects 1 in 7 heterosexual couples in the UK The problem has increased slightly and more people are now seeking help Female fertility declines with age – effect of age on male fertility is less clear In a survey from 2006 to 2010 more than 1.5 million US women or 6 % of the married population 15-44 yrs of age reported infertility and 6.7 million women reported impaired ability to get pregnant or carry baby to term In the US among couples 15-44 yrs of age nearly 7 million have used fertility services at some point UK studies have shown that 31-52 % of infertile couple do not seek medical help at all 
( Bovin , Bunting and Nygren 2007 )

Causes – ovulatory in 25 % , unexplained in 25 %, tubal damage in 20 % , male causes 30 % , uterine or peritoneal disorders in 10 %. In about 40 % of cases disorders are found in both man and the woman Uterine or endometrial factors , gamete or embryo defects and pelvic conditions such and endometriosis may also play a role Causes of male infertility include
○ infection ○ injury ○ toxin exposures ○ anatomic variances ○ chromosomal abnormalities ○ systemic diseases ○ sperm antibodies
Note than in about 44 % of cases of infertility in men – no cause can be found In women the causes can be 
○ ovulation diorders
○ uterine abnormalities
○ tubal obstruction
○ peritoneal factors

Ideally see the couple 
together but if they present separately 
address the concerns carry out an 
 initial evaluation

Reassurance- Inform that over 80 % of couples in the general population will conceive within 1 year if 
○ the woman is under 40 yrs of age and 
○ they do not use contraception and have regular sexual intercourse Of those who do not conceive in the first year , about 1/2 will do so in the 2nd year ( cumulative pregnancy rate of over 90 % ) That fertility declines with age Advice to have vaginal intercourse every 2-3 days optimizes the chance of pregnancy

History –A full medical , general and reproductive history may not be possible in primary care setting. The aim is to identify the small subsection of people who may benefit with referral and further interventions.

You can either use a printed form ( see links ) as used in most infertility clinics and attach in patient documents or take a brief focused history

female-menstrual history timing and frequency of intercourse previous use of contraception previous pregnancies and out come pelvic infections / STIs medication use occupational exposures substance abuse alcohol / tobbacco any previous surgery on reproductive organs occupation

Male –previous fertility pelvic or inguinal surgery varicocele systemic disease erectile dysfunction ejaculatory problems STI/ mumps orchitis alcohol tobacco occupation stress

When do i start investigations –Start for couples who have not conceived after 1 year of regular ( every 2-3 days ) unprotected intercourse Offer investigations early for those couples who have been identified as less likely to conceive Same criteria ( as below for early referral ) can be also used for offering investigations

Investigations in males –Arrange for semen analysis Give written instructions – see under links Use WHO guidance on interpretation- most labs attach a report these days ( see links as well ) If repeating test it is recommended to wait for 3 months ( as sperm generation is just over 2 months ) before repeating but if result shows azoospermia or severe oligospermia – repeat earlier Morning testosterone and FSH levels can be requested if hypogonadism is suspected ( for e.g analysis shows oligospermia or azoospermia ) Screen for chlamydia

Females –Mid-luteal phase progesterone 
In all women to confirm ovulation
7 days before the expected period or 
day 21 of a 28 day cycle or day 25 of 32 day cycle Chlamydia screen Rubella immunity Gonadotrophin ( FSH , LH ) if ovulation disorder is suspected
Often requested on day 2-5 of cycle Thyroid function test Prolactin ( if an ovulatory disorder is susepcted e.g PCOS , galactorrhoea or a suspected pituitary tumour )

Special category-People who are concerned about their fertility and who are known to have chronic viral infections such as Hep B , Hep C or HIV should be referred to centres that have appropriate expertise and facilities to provide safe- risk reduction investigation and treatment

Referral Women < 36 yrs refer if all investigations / examinations are normal in both partners and the couple has not conceived after 1 year

Consider early referral if any of these apply
 Age 36 or older ( refer after 6 months ) Amenorrhoea or oligomenorrhoea Previous abdominal or pelvic surgery Previous PID ( women ) / STI ( men and women ) Abnormal pelvic examination ( women ) A known reason for infertility – e.g h/o prior Rx of cancer Previous genital pathology in men or urogenital surgey Varicocele Men- significant systemic illness Abnormal genital examination ( men )

LINKS AND RESOURCES

PATIENT INFORMATION

The starting point can be the HFEA website for all couples who present for the first time in the UK  https://www.hfea.gov.uk/

ACOG has produced guidance for patients in the US https://www.acog.org/Patients/FAQs/Evaluating-Infertility?IsMobileSet=false

For patients in USA Resolve is a good starting point https://resolve.org/infertility-101/what-is-infertility/fast-facts/

HHS. gov on infertility https://www.hhs.gov/opa/reproductive-health/fact-sheets/female-infertility/index.html

British Fertility Society explanatory page on infertility https://www.britishfertilitysociety.org.uk/fei/what-is-infertility/

Factsheets from Fertilitynetwork UK https://fertilitynetworkuk.org/fertility-faqs/fertility-conditions/

CDC infertility FAQs https://www.cdc.gov/reproductivehealth/infertility/index.htm

Please advise ignoring the specifics ( e.g appt time , contact details ) these sheets have the basic information that the patient needs to understand for a semen test https://www.elht.nhs.uk/application/files/5015/4480/5288/CP_AF32_Fertility_patient_information_leaflet-_Rev_14.pdf

From Royal Free London https://www.royalfree.nhs.uk/services/services-a-z/pathology/andrology-semen-analysis/sample-requirements/

Poole NHS https://www.poole.nhs.uk/pdf/Leaflet-Producing.pdf

Understanding your semen analysis– a useful 8 page publication from University Hospital of Birmingham https://www.uhb.nhs.uk/Downloads/pdf/PiUnderstandingSemenAnalysis.pdf

ASRM an overview – patients can download the booklet https://www.reproductivefacts.org/news-and-publications/patient-fact-sheets-and-booklets/documents/fact-sheets-and-info-booklets/infertility-an-overview-booklet/

INFORMATION FOR HEALTHCARE PROFESSIONALS

WHO 2010 normal values https://mft.nhs.uk/saint-marys/services/gynaecology/reproductive-medicine/andrology/reference-ranges/

Fertility problems: assessment and treatment NICE Guideline 2013 https://www.nice.org.uk/guidance/cg156/chapter/Recommendations

Occupational hazards – fertility https://www.hse.gov.uk/research/rrpdf/rr979.pdf

Infertility history form from the American Society of Reproductive Medicine https://www.ahn.org/sites/default/files/file/womens/infertility-history-form.pdf

Male fertility questionnaire from John Hopkins https://www.hopkinsmedicine.org/brady-urology-institute/_documents/new-fertility-patient-questionnaire.pdf

Female fertility questionnaire from Atlantic Assisted Reproductive Therapies http://www.aart.ca/wp-content/uploads/2014/09/AART_female_infertility_questionnaire.pdf

ACOG Infertility workup for the women’s health specialist https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Gynecologic-Practice/Infertility-Workup-for-the-Womens-Health-Specialist?IsMobileSet=false

AFP Evaluation and Treatment of Infertility https://www.aafp.org/afp/2015/0301/p308.html

 

 

References References CKS NHS Infertility Evaluation and Treatment of Infertility Tammy J Lindsay MD et al Am Fam Physician Mar 1;91 (5) : 308-314 Fertility problems : assessment and treatment NICE Clinical guideline CG156 Feb 2013 Primary care management of infertility Dr Nicholas Riches and Mr Rohit Arora InnovAiT , 7 (1) , 5-13 Assessment and treatment for people with fertility problems : NICE guidelines Normal O’Flynn Br J Gen Pract 2014 Jan ; 64 ( 618 ) : 50-51

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