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Practical lowdown on...Infertility

·Reassure the couple that 75 per cent of couples achieve conception within six months, and 84 per cent by 12 months. If the woman is aged 38 the success rate is 77 per cent over three years.

·Start investigations as soon as the couple voices anxiety. Explain that in 30 per cent of cases the problem lies with the male alone, in 30 per cent with the female alone, and that in the rest it is mixed or unexplained.

·Consider referral after one year, or sooner if there is good reason, eg oligo- or

amenorrhoea, abnormal sperm count or maternal age over 35. Refer the couple

direct to a tertiary centre holding the

contract for the treatment of subfertility, not to a general gynaecology clinic.

Investigations

Assessment of the woman

·History should include details of

menstrual cycle, previous pregnancies, pelvic infections or operations. Regular

periods are a reliable guide to the fact that the woman is ovulating. Check they are

having intercourse at the woman's most

fertile time (as well as throughout the cycle). Do not bother with temperature charts.

·Check that the woman is rubella immune and taking folic acid.

·Examine for evidence of pelvic pathology.

·Progesterone level. Take blood seven days before menstruation is due. A level of >16nmol/l suggests ovulation, and a level of >30nmol/l confirms it. Borderline levels may be due to a deficient luteal phase, or to mistimed sampling. Levels <16 nmol/l="">

confirm that the cycle was anovulatory.

·Measure FSH and LH in a woman with

irregular cycles in whom it is impossible to predict when to check the blood

progesterone.

Note: There is no value in measuring TFTs or prolactin in women with regular menses in the absence of galactorrhoea or symptoms of thyroid disease.

Assessment of the man

·Medical history should include

operations on or infections of the testes and operations on the prostate.

·Drug history ­ sulfasalazine,

tetracyclines, allopurinol, anabolic steroids, cannabis and cocaine have all been shown to interfere with male reproductive

function.

·Examine him, including genitals and

secondary sexual characteristics.

·Arrange for semen analysis. Semen should be produced by masturbation three days after the last ejaculation, and

examined within an hour.

·If the count is low, repeat after three months and refer to a specialist

fertility clinic if still low. However, if the count is severely low, refer after a single count.

·Warn the patient that even a 'normal' sperm count does not mean that there is not some sperm dysfunction which can

only be detected on more sophisticated tests.

Advice

·Both should stop smoking.

·The woman should drink no more than one or two units of alcohol once or twice weekly while trying to conceive.

·Men who drink heavily should cut their drinking to no more than three to four units in any day.

·Women and men with a BMI >30 should lose weight whether or not ovulation is a problem.

·Men should avoid soaking in hot baths, wearing tight underwear and remaining seated for many hours at a time.

·Couples should be advised to have regular intercourse throughout the cycle, every two to three days; there is no evidence that use of temperature charts and LH detection tests to time intercourse improves

pregnancy rates.

Use of clomifene in general cannot be

justified in general practice in view of

the increased risk of multiple pregnancy and ovarian cancer. An exception to this

is if a woman who previously conceived

using it presents again with anovulatory

cycles.

The role of the GP after referral

·Administer the drugs for assisted

conception according to a protocol agreed with the specialist clinic.

·Support the couple throughout the drawn-out process of investigation and treatment.

Guidelines

NICE. Fertility: assessment and treatment for people with fertility problems. National Institute for Clinical Excellence, February 2004.

Online: www.rcog.org.uk (choose 'Guidelines' then 'National Evidence-based Clinical Guidelines').

Review: Taylor A, Braude P. ABC of subfertility. London: BMJ Books; 2004.

This is an extract from Practical General Practice 5e, ISBN 07506 8867X, Elsevier Ltd, April 2006, Price £47.99. To order your copy please go to www.elsevierhealth.com or phone Elsevier customer services on 01865 474000.

Practical General Practice 5e is compiled by Alex Khot, a GP in East Sussex, and Andrew Polmear, a retired GP and former senior research fellow at the University of Sussex

Further information

Infertility Network UK is a self-help organisation which supplies literature and runs support networks. Tel 08701 188088. Online: www.infertilitynetworkuk.com

The Human Fertilisation and Embryology Authority, 21 Bloomsbury Street, London WC1B 3HF. Tel. 020 7291 8200. Online: www.hfea.gov.uk ­ has books and videos about assisted conception.

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