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Subfertility – Information for GPs

Background

NHS Scarborough and Ryedale CCG (SRCCG) commissions’ healthcare on behalf of its local population across primary, secondary and tertiary care sectors. Commissioning policy including clinical referral pathways and thresholds have been developed and defined using appropriate NICE guidance and other peer reviewed evidence and are summarised here in order to guide and inform referrers.

This commissioning policy is needed in order to clarify the criteria for subfertility.

Commissioning position

Definition

Failure to conceive after a year of regular unprotected intercourse in the absence of any known reproductive pathology

Management

  • All couples should be offered clinical investigations in primary care after 1 year of trying to conceive
  • Secondary care referral after 2 years of subfertility for further investigations
  • Consideration for earlier referral should be given to: - women over 36 - identified cause for subfertility or history of subfertility

Clinical Exclusions

  • Fertility treatment is restricted to women with BMI under 35 (to reduce pregnancy related complications)
  • Smoking increases miscarriage risk and should be addressed prior to referral

Investigations prior to referral

  • Chlamydia screening
  • High Vaginal Swab
  • Pelvic USS
  • Smear test (ensure up to date)
  • D1-5 FSH/LH level
  • D21 Progesterone (or 7d prior to predicted next period)
  • Rubella serology – offer immunisation where appropriate
  • If cycle irregular – TFTs and Prolactin
  • Semen analysis – if abnormal repeat in 3m (please ensure result available even if partner registered with another GP)

Information to include in referral letter

  • Length of subfertility
  • Parity, past pregnancies outcome
  • Cycle (e.g. K 5/28)
  • Past contraception – not uncommon for up to 9m amenorrhoea to follow Depo cessation – up to 6m for COCP
  • Significant PMHx and DHx
  • BMI (must be <35 for referral)
  • Results of the above investigations

Desirable information

Pre-conceptual advice given

  • Regular intercourse (every 2-3 days) throughout the cycle
  • Alcohol advice <2 units/week for females, <4 units for males
  • Referral for smoking cessation prior to subfertility treatment
  • Folic acid 400mcg daily or 5mg (if high risk e.g. epileptics)
  • BMI >30 – encourage group therapy for weight loss (shown to increase pregnancy rates)
  • Rubella immunisation if needed (contraception required for 4w post MMR)

References

NICE Clinical guidelines – https://www.nice.org.uk/guidance/cg156

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