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Infertility


Definition
:

Failure to conceive after regular unprotected sexual intercourse for 1 year in the absence of known reproductive pathology.


Refer to the Infertility Clinic:

Refer both partners where they have infertility as defined above

Offer an earlier referral for specialist, even if the couple would not be eligible for NHS funded assisted conception (eg previous children, age 40-45), where:

  • the woman is aged 36 years or over
  • there is a known clinical cause of infertility or a history of predisposing factors* for infertility (see below), or investigations are abnormal

 

A woman who is using artificial insemination to conceive should be referred to secondary care for further clinical assessment and investigation, if she has not conceived after 6 cycles of treatment within the past 12 months, in the absence of any known cause of infertility.

Women over the age of 44 seeking conception should be referred privately and advised that the only effective treatment is likely to be from using donor eggs

BMI >35 is not an exclusion for referral to the fertility clinic, although women with a BMI >=35 will usually be asked to lose weight to bring their BMI below 35 prior to receiving fertility treatment.

Patients should be advised if they require assisted conception (e.g. SO/IUI/IVF/ICSI/DI, Egg donation and cryopreservation) then NHS funding is restricted and only available if they meet the criteria set out in NHS Kernow’s policy.

(SO=Super Ovulation; IUI= intrauterine insemination; ICSI= Intracytoplasmic Sperm Injection; DI=Donor Insemination; IVF= In Vitro Fertilisation)


Investigations prior to referral

  • Semen analysis, if abnormal repeat after 3 months. However if gross spermatozoa deficiency (azoospermia or severe oligozoospermia) has been detected the repeat test should be undertaken as soon as possible
  • Mid luteal serum progesterone (taken 7 days prior to expected onset of menstruation, eg day 19 of a 26 day cycle); repeat in subsequent cycle if <28nmol/l.
  • Rubella serology (if not immune, vaccinate and advise contraception for one month)
  • Chlamydia serology (if raised treat both male and female eg azithromycin 1g STAT)

 

 Predisposing Factors *

  • Amenorrhoea/oligomenorrhoea
  • PMH: Pelvic inflammatory disease
  • Undescended testes
  • Previous treatment for cancer
  • Either partner HIV/Hepatitis positive.

 

Pre-referral advice

  • Aim for BMI <29 in both partners
  • Take folic acid
  • Smoking cessation
  • Sexual intercourse every 2-3 days not timed to any part of the cycle
  • Restrict alcohol to <2U /wk females and <4 U /wk males

 

Notes:

Female same-sex couples will always have to pay for the semen and if no obvious fertility problem they may wish to go to Fertility Exeter or to SWCRM Derriford for private treatment. They can be referred to RCHT if they have predisposing factors or failed conception after self-funded insemination.

Link to NHS Assisted Conception Funding Policy: http://www.kernowccg.nhs.uk/media/97221/assistedconceptionpolicy.pdf

NHS funding criteria for assisted conception: http://rms.kernowccg.nhs.uk/content/files/NHS%20funding%20Criteria%20for%20assisted%20Conception.doc

 

NHS funding Criteria for assisted Conception:

  • Woman aged up to 40 years
  • Both partners BMI 19-29.9
  • Both partners ceased smoking for at least 6 months
  • No living children from the current relationship or from previous relationships, irrespective of abode.
  • Couple in a stable relationship for 2 years
  • Both partners registered with GP in NHS Kernow CCG area
  • No previous NHS or Private IVF
  • Assisted conception treatment is restricted to couples where neither partner has had previous NHS funded specialist fertility treatment. No couple may receive an NHS funded IVF cycle if they have previously received a total of 3 self-funded cycles.
  • Specialist believes that the chance of live birth per cycle of IVF is greater or equal to 10%
  • Infertility is not a result of previous sterilisation

 

 

Date reviewed                        30/01/2020

Next review due                     30/01/2021

Author                                    Dr Sheona Burns

 

Version No.    1.4