Recent NICE guidance gives evidence-based recommendations for GPs managing subfertile patients, says Dr Chris Barclay
The pace of development in fertility science is phenomenal. What we have needed for some time is a clear statement of what treatment should be offered to subfertile couples and how it should be delivered.
To answer this need, NICE, following collaboration with interested groups, has published an evidence-based guideline on the subject; but how useful will it be for primary care?
The guidance for clinicians is divided into 16 sections, five of which are directly relevant to primary care.
The guideline gives figures about natural conception: 84% of couples trying to conceive will do so within 1 year; by 2 years the figure is 92%.
There are very useful subsections on the possible effects of body weight, alcohol and smoking on fertility in women and men, and there are helpful suggestions on the timing and frequency of intercourse.
Recommendations for GPs are to ensure that women are taking folic acid and to check rubella antibody and cervical cytology status.
Defining infertility, assessment and referral
Infertility is defined as "failure to conceive after regular unprotected sexual intercourse for 2 years in the absence of known reproductive pathology” (Figure 1, below).
|Figure 1: Algorithm for assessment and treatment of people with fertility problems|
Couples who are concerned about a delay in conception should be offered an initial assessment. This should include enquiries about lifestyle and sexual history to identify those less likely to conceive.
Those who have not conceived after a year should be offered further investigations, including analysis of semen and ovulation assessment.
An earlier referral for a specialist opinion should be made if the woman is aged 35 years or over or if there is a history of predisposing factors such as amenorrhoea, oligomenorrhoea, pelvic inflammatory disease or undescended testes.
Principles of care
The guideline stresses that infertility services should be couple-centred and that couples should be seen together in circumstances conducive to informed, unpressured decision making.
They should be offered counselling by someone who is not directly involved in the management of their fertility problems to deal with the attendant psychological stress.
It is recommended that management of infertility cases is undertaken by specialist teams.
Investigation and management
Many GPs measure progesterone to confirm ovulation, and the guideline recommends doing this 7 days before the next expected period.
It also recommends that prolactin measurement should be offered only to women who have an ovulatory disorder, galactorrhoea or a pituitary tumour. Similarly, in the absence of symptoms of thyroid disease there is no advantage in assessing thyroid function.
I was glad to see that basal body temperature charts are not recommended as a means to confirm ovulation, and that routine assessment of post-coital cervical mucus for sperm presence and function is not recommended as it is not thought to be helpful.
GPs may find the section on ovulation induction relevant because many (myself included) have for years given clomifene to women with polycystic ovary syndrome, with great success.
The GP’s role was not explicitly mentioned in relation to this, but the guideline states that those administering clomifene should inform the woman of the risk of multiple pregnancy.
It is recommended as a ‘good practice point’ to offer ultrasound monitoring during the first cycle of clomifene to minimise the risk of multiple pregnancy.
One of the guideline’s key priorities for implementation is that couples where the woman is aged 23-39 years who have an identified cause of infertility or infertility of at least 3 years’duration should be offered up to three stimulated cycles of in vitro fertilisation.
The guideline recommends transferring a maximum of two eggs per IVF cycle to minimise the risk of a multiple birth; and it is sensibly suggested that fertilised eggs in storage be used before more ovulation induction cycles are initiated.
Much of the guideline is aimed at secondary and tertiary level care, and while GPs may find these parts of interest, they will not find them particularly relevant.
This may deter GPs from reading the guideline, which would be a shame because the sections that relate to primary care are of real practical help. I came away wishing that NICE had produced a smaller digest aimed specifically at GPs.
However, the NICE guideline is a remarkable achievement and is now the benchmark for NHS provision. If fully implemented it should enable all fertility units to offer a standardised, scientifically validated service.
National Institute for Clinical Excellence. Fertility: assessment and treatment for people with fertility problems. Clinical Guideline No 11 can be downloaded free of charge from the NICE website: www.nice.org.uk
- Available at www.rcog.org.uk