Infertility referral pathway

• Initial investigations for any couple experiencing infertility are inexpensive, non-invasive and likely to yield useful information prior to onward referral
• Couples who experience problems conceiving should ideally be seen together although this may not be possible if registered with different practices
• Full history and examination of both partners if appropriate

Unless indicated as in early referral, do not refer, but do:

• Reassure - 84% of couples will conceive in 1st year of having unprotected sexual intercourse and 92% will conceive by the 2nd year (NICE)
• Advise sexual intercourse every 2-3 days rather than timing intercourse with the menstrual cycle
• Consider underlying psychosexual problems
• Consider need for preconception counselling if pre-existing medical condition
• Offer lifestyle advice
  • Smoking cessation – neither partner to be smoking, both should be nicotine free, and neither vaping
  • Alcohol guidance – advise that there is no known safe level of alcohol for pre-conception or during pregnancy (Government advice)
  • BMI for female partner should be above 18.5 and below 30, though ideally should be less than 25
  • If BMI outwith this range, but less than 35, couple can still be referred to secondary care but may not be able to access assisted conception
  • If BMI more than 35, advice should be given about weight loss before referral
  • Recreational drug cessation for both partners
  • Caffeine only to be taken in moderation by both partners
• Folic acid 5mg per day should be prescribed in women who have had previous pregnancy affected by NTD, BMI more than 30, or who have diabetes or epilepsy. Otherwise recommend 0.4mg daily
• Arrange routine investigations

Female

• Rubella status—ensure has had vaccination
• Chlamydia screen
• Mid-luteal progesterone adjusted for cycle length (day 21 in a 28 day cycle)
• Ensure cervical smear up to date
• In addition, if cycle longer than 42 days or periods are absent:
  • TSH
  • Prolactin
  • Androgen screen
  • FSH/LH
  • Note: these are not required if regular cycle

Male

• Semen analysis - arrange with local fertility clinic on 01387 241205 and leave the patients details - name, CHI and requesting Doctor.  A pack will be sent to the patient, who then books an appointment with the Lab directly and the results will be forwarded back to the GP practice in due course.  
• If sample normal, no need to repeat
• If abnormal, repeat usually requested

Female

• Age >35
• Amenorrhoea
• Oligomenorrhoea
• Previous ectopic pregnancy
• Previous proven PID/STI
• Previous pelvic surgery
• Any significant relevant abnormality on history, examination or investigations
• Previous investigations

Male

• Abnormal results on semen analysis x2 (WHO levels to be used)

Note - Referral can be deferred until the couple have been trying for at least 12 months if:

• history
• examination and routine investigation of both partners is normal
• no indications for early referral exist
• the period of infertility is less than 12 months

The need for referral to tertiary care for assisted conception will be determined following assessment at the secondary care level fertility clinic. When tertiary care assisted conception is required, the following criteria must be met:

• Age - female partner aged less than 39 years at time of referral
• Sterilisation - neither partner should have been previously sterilised
• BMI for female partner should be above 18.5 and below 30
• Smoking - both partners should be non-smokers and nicotine free
• Both partners should abstain from illegal substances and be methadone free for at least one year
• Previous children – couples where one partner has no living biological child can access treatment if all other access criteria are met in full
• Couple co-habiting in stable relationship for at least 2 years
• Number of cycles - eligible couples referred to tertiary centre may have up to 3 cycles