HNY Policy and Pathway Repository - York

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

None provided

Clinical Exclusions

• Subfertility treatment is not commissioned for females with BMI >35 due to risk of pregnancy complications
• Secondary care fertility treatment is restricted to women with BMI <30 complying with the Optimising Health Outcomes criteria.
• Smoking increases miscarriage risk and active smoking is an exclusion criteria.

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

Assisted Conception:

• IVF is funded for couples meeting the CCG’s criteria 
• There is a proforma to complete to confirm these criteria and attach supporting documents.

Information to include in referral letter

• Length of subfertility
• Parity, past pregnancies outcomes
• Cycle (e.g. K 5/28)
• Past contraception – not uncommon for up to 9m amenorrhoea to follow Depo-provera® cessation, up to 6 months for COC
• Significant past medical history and drug medical history
• BMI (must be <35 for referral)
• Results of the above investigations

Investigations prior to referral

• Chlamydia screening required.
• High Vaginal Swab only if symptomatic with PV Discharge.
• Men should have Chlamydia and Gonococcal screening (consider self swab kit from YorSexual Health)
• Pelvic USS (please request antral follicle count) ONLY AVAILABLE AT YORK HOSPITAL
• Smear test (ensure up to date)
• D1-5 FSH/LH and Estrogen level
• D21 Progesterone (or 7d prior to predicted next period)
• Rubella serology only if no GP record of 2 MMR vaccinations.
• If cycle irregular: TFTs and Prolactin
• Semen analysis – if abnormal repeat in 3m. (please ensure result available even if partner registered with another GP).

Desirable Information

Pre-conceptual advice given:

• Regular intercourse (every 2-3 days) throughout the cycle
• Alcohol advice - 30: encourage group therapy for weight loss (shown to increase pregnancy rates)
• Referral for smoking cessation prior to subfertility treatment
• Folic acid 400mcg daily or 5mg (if high risk e.g. Epileptics), ideally a multi-vitamin for pregnancy containing iron and Vitamin D. eg. Pregnacare® or Sanatogen Pronatal® OTC.
• Rubella immunization if needed (contraception required for 4weeks post MMR)

Referral forms

• Standardised proforma for referral to the fertility clinic
• Histology and Cytology Referral Form

Patient information leaflets/ PDAs

• Patient UK leaflet

References

• NICE CKS: https://cks.nice.org.uk/infertility#!scenario:1