Current thinking on management of infertility
With media interest bringing more infertility problems to GPs and NICE guidance due imminently, Mr Julian Jenkins and Ms Liz Corrigan begin our series to help guide you through the maze of problems and investigations
The National Institute for Clinical Excellence is considering provision of infertility services in the UK with a target to make recommendations early this year.
Although there may be no increase in the prevalence of infertility, there appears to be a trend towards more patients seeing their GP with infertility problems, probably fuelled by the rapid developments in the management of infertility which have attracted media interest.
Of couples trying for a first pregnancy around 16 per cent have not achieved a pregnancy after one year, falling to 9 per cent after two years. Of couples trying for a further pregnancy around 16 per cent of couples after one year have not achieved a pregnancy, falling to 5 per cent after two years.
Overall around one in four couples may experience infertility at some time, leading one in six couples to seek hospital referral.
These figures are based on old studies, partly relying on postal questionnaires, so the true current scale of infertility, particularly the demand for specialist referral, may be even greater.
Multiple factors in fertility problems
Often there is not an absolute factor preventing a couple from becoming pregnant; in many cases there are multiple factors and usually it is a matter of chance even in 'normal' couples, reflecting a variation in fertility rather than absolute infertility.
More than half of young couples discontinuing contraception will achieve pregnancy within a few months of trying, which may be all the more frustrating for those that are not so fortunate and may not be pregnant after a year or much longer.
The chance of achieving a pregnancy each month reduces rapidly from about 30 per cent for the first month after stopping contraception to less than 10 per cent per month from the sixth month.
Nevertheless, the cumulative chance of achieving pregnancy increases over time, thus it is sometimes a difficult balance to decide at what time intervention is appropriate. Certainly assessment after one year of infertility seems reasonable and specific factors may point to earlier assessment.
Fertility declines steadily with increasing age in the female, notably from 35 and exponentially from 40. While much less marked, fertility also diminishes with increasing age in males.
Although there is a lack of strictly-defined definitions for the causes of infertility generally accepted categories include male factor problems, ovulatory problems, tubal problems and endometriosis.
The relative contribution of these different categories is reasonably consistent among studies of different populations with at least one in four couples having no clear cause for their infertility.
Before a couple decide they wish to pursue any fertility treatment they need a guide to their chance of achieving pregnancy without treatment.
Chances of pregnancy are increased by prior pregnancy, duration of infertility less than 36 months and female age less than 30, but decreased by male defect, endometriosis and tubal defect.
This information has been applied to a 'fertility calculator' presented on a website for anyone to use at: www.repromed.co.uk/infertility/interactive
Although some suggest the postcoital test is of no value, for couples that have been trying for less than three years, a poor postcoital test identifies couples with a reduced chance of conception.
The postcode lottery
In 2000 the European Society for Human Reproduction and Embryology revealed that the UK provided the fewest IVF cycles per
one million inhabitants at just 585 cycles compared with the Netherlands and France, which provided more than 960 cycles of
IVF per million and other countries approaching 2,000.
Within the UK, provision further varies dependent on postcode, in 1998 ranging from three to 215 IVF cycles per million people, from the South-West to Scotland respectively.
A 2001 survey in Bristol supported a consistent approach to NHS infertility services throughout the UK treating infertility the same as any other morbidity. It was not generally felt that treatment should be denied solely due to a lower chance of success, but age of the mother was an important consideration with different views on the upper age limit.
When about 800 people were asked the question: 'Do you feel the NHS should fund IVF treatment for infertility in the same manner that the NHS supports treatments for other medical disorders?' approximately 70 per cent said 'yes'.
Overall the questionnaire was supportive of NHS-funded infertility services and an end to the postcode lottery of provision, which the initial released draft NICE guidelines certainly support.
Infertility care improving
UK legislation leads the world in laying down quality standards in infertility.
The two main bodies are the Human Fertilisation and Embryology Authority (HFEA) which focuses on the regulation of practice in assisted conception, and the National Care Standards Commission (NCSC) which deals with the regulation of practice in the clinical situation.
The HFEA was set to up maintain, protect and promote standards and to ensure the welfare of the child is considered.
With therapeutic procedures the potential life of the embryo is taken into account and with research the potential damage to society as a whole.
It licences and audits treatment and storage of eggs, sperms, embryos and research.
The NCSC ensures the providers of independent health care have appropriate safeguards and quality assurance arrangements for their patients.
Both bodies ensure practice is as safe as possible and that documentation reflects this. They address fundamental ethical and social issues, inspecting facilities and providing guidance on how to keep within the law.
Their inspectors look for evidence of patient-centred care, patient information, accountability, safety, quality assurance and consistency. Policies, protocols and guidelines are drawn up to fulfil these requirements.
Although the focus of these bodies is different their underlying fundamental principles are the same, aiming to provide patients the best service.
Infertility is a common problem, but the majority of infertile couples will achieve their desire to have a child.
Whereas past studies have suggested about one in 20 couples never achieves this goal, recent advances in treatment will reduce this figure further.
Issues of health care economics, ethics, patient choice and awareness of options will play a major role on how many couples remain involuntarily childless.
Figure 1 - Investigating and managing infertile couples - please see Pulse Issue January 5th 2004 for this diagram.
Julian Jenkins is clinical director at the Centre for Reproductive Medicine, University of Bristol
he is a member of the executive committee of the British Fertility Society and of the guidelines and audit committee of the RCOG
Liz Corrigan is nursing director at the Centre for Reproductive Medicine, University of Bristol she is an inspector for the Human Fertilisation and Embryology Authority and chair of the paramedical group of the European Society of Human Reproduction and Embryology
NICE guidelines on infertility
·Jenkins JM et al. Infertility matters in health care. Oxford: Radcliffe Medical Press, 2002