One in seven couples suffer from primary infertility. This figure has not changed greatly in recent years, but the number of couples consulting for the problem has and now equates to 230 referrals per year in a typical district health authority.
Infertility can be defined as failure to achieve a pregnancy after 18 months of regular intercourse. The RCOG defines this as intercourse two to three times a week during that period. In my experience, couples tend to consult well before 18 months.
General practice is the first port of call and many investigations can be arranged to allay fears and reassure the infertile couple. The consultation is also a useful time to advise on other lifestyle factors that may be affecting fertility.
The RCOG has recently (October 1998) published guidelines for infertility management in both primary and secondary care.
They include an excellent algorithm (Figure 1,below) and are evidence based. The evidence is weighted in categories A to C, with A being clinical trial based and C relying more on expert opinion. I found this helpful in weighing up the relevant effects of different factors.
|Figure 1: Algorithm from the RCOG guidelines showing the initial investigation and management of the infertile couple in primary care|
Referral before 18 months is indicated only if the woman is aged over 35 years.
Smoking reduces fertility in both sexes, and alcohol appears to have a similar effect. Excess weight in women also seems to have an important effect on fertility.
Advice on rubella screening and folic acid consumption, by way of preconceptual counselling, can be given at the same time.
Irregular or absent cycles should be a reason for referral. The work-up should include a luteal phase progesterone. Ovulation does not always occur on day 21, especially if a woman's cycle is irregular. There is no value in measuring thyroxine or prolactin levels in a patient with regular periods.
Two sperm counts should be performed at a recognised, accredited WHO laboratory. The guidelines contain suggested protocols for collection of a semen sample and assessment of serum progesterone.
Abnormal findings on pelvic examination or in the history, such as past pelvic inflammatory disease or a varicocele, should prompt early referral.
If all of these investigations are normal, the guidelines reassure us that referral is not really necessary in couples where infertility is less than 18 months.
If these guidelines are followed, your local gynaecologist should have all of the information he/she needs to proceed to laparoscopy or hysterosalpingography. Chlamydial antigen testing is suggested as a secondary care step; however, this is readily available in Eastbourne both from endocervical swab testing and serological methods.
Ultrasound and postcoital tests are not indicated as routine investigations.
These guidelines are concise and easy to follow, but do not cover ongoing treatment. Guidelines as to what GPs should or should not prescribe for infertility would be welcome. The cost and legal implications for general practice often place us in an impossible position in this respect.
I would be happy to prescribe to agreed protocols, but too often the lack of back-up of an infertility clinic makes confident treatment difficult.
- Copies of the full guidelines and guidelines summary may be obtained from the Royal College of Obstetricians and Gynaecologists Bookshop (0161 276 6300).