Women's health toolkit: Fertility

Fertility

Infertility is defined by the WHO as failure to achieve a pregnancy after ≥ 12 months of regular (every 2-3 days) unprotected intercourse. 80% of couples in which the woman is aged under 40 will conceive in this timeframe and about half of those who don’t will conceive naturally in the next year.

Infertility can be caused by a variety of factors – the most recent figures for the UK are male factor (30%), ovulatory disorder (25%), tubal damage (20%), uterine or peritoneal disorders (20%) and unexplained (25%) – around 40% of couples have both a male and a female contributory factor and there may be more than one female factor.

Useful advice in primary care would include the avoidance of smoking for both men and women who want to conceive, that women should take folic acid, that an alcohol intake of >14 units/week may damage semen quality and that a body mass index over 30 kg/m²is likely to reduce fertility in both sexes, as will a body mass index of < 19kg/m²in a woman.

Table on factors which should prompt consideration of referral to a fertility clinic. Our main input into the management of infertility is to recognise it and refer appropriately, after initial investigations in primary care. NICE advises that investigation and referral should generally start at one year. Women who are aged ≥ 36 should be referred after six months, and those who have other factors which might indicate a cause for subfertility (listed in the box on this page) should also be considered for earlier referral.

Eligibility criteria for fertility treatment will vary by area and may include consideration of age, BMI, smoking status and existing children in the current relationship or with previous partners. A list of investigations is also usually expected at the time of referral – these may include FBC, rubella immunity, tests for hepatitis B/C and HIV, a basic hormone screen, chlamydia test, pelvic ultrasound and semen analysis.

More information can be found in the following resources:

• NICE CKS page on infertility and NICE CKS scenario on antenatalcare – uncomplicated pregnancy, nutritional supplements; the latter has a list of which women who are trying to conceive should be prescribed 5mg of folic acid rather than buying 400µg over the counter.

• NICE guidance on fertility problems – assessment and treatment.

• Website of the Human Fertilisation and Embryology Authority, which may be useful for patients who want to know more information about the clinics available for referral, and their outcomes.

• Patient support groups – fertility network, British Infertility Counselling Association and the relevant page on the Macmillan website, for those whose fertility issues are due to treatment for cancer.

• RCGP eLearning on sexual and reproductive needs of the LGBT community, which has information on how a lesbian couple may be able to access fertility treatment on the NHS.