Infertility

Introduction

From 1 April 2023 all referrals for NHS fertility services in BNSSG will be subject to the revised Infertility Assessment & Treatment Policy.  

Main changes in the new policy:

• Under this policy, there is a reduction in upper age for females to 39 years*.
• Single women are eligible for assessment provided they meet the relevant criteria within the policy. This will include having regular unprotected sex for a period of two years or undergoing 6 independently unstimulated cycles of HFEA approved donor insemination.
• Men who have been shown to have low or zero sperm counts can also be assessed.
• Provision for patients who cannot have penetrative sex because of a psychosexual or andrological condition
• Under the revised policy the number of independently funded cycles of unstimulated Intrauterine Insemination (IUI) required before a same sex couple can be referred for NHS funded assessment and treatment has been reduced to 6.
• The individual requiring assessment and/or their partner (if applicable), whether they are a heterosexual or same sex couple, must have no living offspring/children to qualify for funding. This includes genetic and legally adopted children and offspring who are adults but does not include foster children.

*Age range transition period

The age transition period has now ended and so prospective mothers should only be referred where they are younger than 39 years old.

Living Offspring / Children

For heterosexual and same sex couples, if either partner has any living offspring, the couple is not able to access NHS fertility services - this includes assessment.

For single women, if they have any living offspring, they are not able to access NHS fertility services - this includes assessment.

Living offspring includes genetic and legally adopted children and offspring who are adults but does not include foster children or step children. If the individual or couple adopts a child or becomes pregnant naturally during assessment or treatment, they are no longer eligible for fertility assessment or treatment.

There is background information in the Infertility section of the Clinical Knowledge Summary website:

• It is estimated that 1 in 7 couples in the UK has difficulty conceiving.
• Infertility is more common with increasing female age. The effect of age on male fertility is less clear.
• About 84% of couples will conceive within 1 year if they have regular unprotected intercourse increasing to 92 % within 2 years and 93% within 3 years.
• See CKS for possible Causes of Infertility.

Assessment in Primary Care

Many couples presenting with a delay in conception of 1 year duration may only need simple investigations and reassurance.

Assessment should include (clearly evidenced in the primary patient records):

Prospective Mother:

• History and examination to include history of previous conceptions or miscarriages and gynaecological/menstrual history.
• Ensure BMI is between 19 and 29.9 kg/m2 for a period of six months and that this has been evidenced clearly in the primary care records. Being over or underweight can affect fertility and prospective mothers with a BMI of 30 and above should be offered a referral to weight management services to reduce their weight prior to assessment and treatment by fertility services (see NICE Recommendations).
• Advise on folic acid, smoking and alcohol intake (only non-smokers (including vaping) can be referred. 
• Advise regular intercourse 2 or 3 times a week.
• Check blood tests including (or use ICE profile) - FSH,LH, estradiol (taken on day 1-4 of menstrual cycle), testosterone, FBC,TSH, HbA1c or glucose, rubella status, chlamydia serology, prolactin (in women with irregular periods), infection screen (HIV, hepatitis B and C. Syphilis serology is included in ICE profile but is optional).

Male partner (if appropriate):

• History and examination to include history of previous conceptions and genetalia abnormality or surgery.
• Advice on smoking and alcohol.
• Advise regular intercourse 2 or 3 times a week.
• Undertake a semen analysis in the male partner - one test is adequate if normal. A second test is required if the first is abnormal which should be at least 3 months later. Please note: Semen analysis is available as a separate and routine pathology test, not just as part of the fertility pathway. 
• Check infection screen (HIV, hepatitis B and C. Syphilis serology is included in ICE profile but is optional).

If normal reassure and advise couple continue to try for up to 2 years unless there is an indication for early referral (see section below).

Please note that if the prospective mother will be 39 within the two year time frame (they can be referred after one year as long as they can still be referred before their 39th birthday).

Clinical Knowledge Summaries also has details on Initial Assessment of Fertility.

Other Scenarios

Indications for Early Referral

In most cases an individual or couple must try to conceive for 2 years before being eligible for NHS referral. However, there are scenarios that may allow an earlier referral outside of this timeframe as detailed in the policy. This includes:

1. A known condition which is likely to affect fertility in the female partner such as:

• Severe oligomenorrhoea
• Bilaterally blocked fallopian tubes
• Stage 4 (severe) endometriosis -  diagnosed by a gynaecologist.
• Premature ovarian insufficiency, defined as follicle-stimulating hormone (FSH) greater than 25, measured 2 months apart - coupled with oligomenorrhea or amenorrhoea.
• FSH > 25 on 2 occasions 3 months apart.
• Anti-Müllerian hormone (AMH) marker of less than 1 (this is cannot currently be requested from primary care on the NHS but some patients may have had this done privately).

2. A known condition which is likely to affect fertility in the male partner such as:

• Azoospermia
• Low sperm count <1 million per ml taken on two occasions 3 months apart.

3. Age of female partner

• If the female being assessed will be older than their 39th birthday within the two year time frame, they can be referred after one year as long as they can still be referred before their 39th birthday.

4. If the individual has undergone 6 cycles of independently funded unstimulated IUI using sperm from an HFEA approved source.

5. If there is a sexual health condition where the patient is unable to have penetrative sex. Individuals must have completed all relevant therapy provided by Psychosexual or Andrology services.

Clomiphene

Clomiphene (Clomifene) is licensed for use in treatment of anovulatory infertility. It is listed as a blue drug on the BNSSG formulary. Most GPs will not prescribe due to the risk of Ovarian Hyperstimulation Syndrome and the lack of availability of ultrasound monitoring in primary care. Referrals for patients specifically requesting clomiphene will still need to fulfil the referral criteria and follow the same pathway as other fertility referrals.

Miscarriage and Fertility Referral

Women who have had recurrent miscarriages are not suitable for referral to fertility clinic. A referral to the Recurrent Miscarriage clinic may be more appropriate if criteria are met.

If a woman has conceived and then had a miscarriage following a period of infertility, a referral for fertility investigation can only be made once they fulfil the criteria within the policy. e.g. If they then fail to conceive for a further 2 years, or if there is another indication for a referral before this time.

Referral

Heterosexual and same sex couples being referred for Fertility Assessment / Treatment are referred as a couple and not individually as both partners are involved in this process. Although only one partner needs to be registered at the referring GP Practice, it will be the responsibility of that GP practice to ensure that all the relevant information / tests are available for both parties prior to submitting the referral. This will mean co-ordinating with the other partner’s GP practice. The referral would usually be done by the GP practice of the prospective mother. 

Referrals for infertility assessment are subject to the criteria based access (CBA) part of the Infertility Assessment & Treatment Policy and, as such the Infertility Assessment Referral form (available on EMIS) must be completed by the referring GP, demonstrating that the criteria have been met.  This form also includes the preliminary investigations required by the trusts and hard copy tests results must be attached to the referral. It is recommended that investigation results should be no longer a year old at time of referral.

A copy of the male partner’s semen analysis should also be attached to the referral if appropriate.  Please note that a second semen analysis will be required if the result of the first is abnormal, suboptimal, show a low sperm count or even azoospermia. See the Semen Analysis page for further details and referral process.

If all relevant information is not provided, the referral may be returned by the Referral Service and/or the provider.

Referrals should be directed via e-Referral and patients will be offered a choice of one of the following providers:

St Michaels Hospital - Reproductive medicine clinic

Royal United Hospital (RUH) Reproductive Medicine clinics are held at two locations; CARE Fertility Bath at Peasedown St John, Bath and CARE Fertility Bristol at Aztec West, Bristol. Outpatient bookings can be made through the eReferral system. GP enquiries can be made directly to CARE Fertility Bath on 01761 438590.

Southmead Hospital - Southmead General Fertility Clinic on eReferral. Contact Details for Southmead General Infertility Service: 0117 414 7171 for GP queries. 0117 414 6757 for outpatients booking.

Patients can be seen in these clinics for assessment and investigation and then referred on to a suitable provider for assisted conception is this is necessary (see section below)

Licensed Fertility (assisted conception)

Please note - This section applies to referrals from specialists and not to GP referrals:

All referrals for Assisted Conception treatments, coming from General Infertility consultants/gynaecologists are managed by the Individual Funding Request Team who notify couples of eligibility and their options to enable them to choose their provider.

Couples or single women meeting the NHS eligibility criteria for Assisted Conception Treatments have access to a choice of six HFEA Licensed providers of IVF and other fertility treatments. These providers have all been contracted on an approved provider framework having demonstrated they can meet the quality and service standards we have set on behalf of our population, including success and complication rates that are in line with or better than national average.

Eligible couples will be offered choice of the following five providers when their funding is confirmed, with details of each clinic and where to get more information to inform their decision.

• Bristol Centre for Reproductive Medicine (BCRM), Bristol
• Care Fertility Bath or Cardiff (with Bristol satellite - please note as Bristol is a satellite patients will have to have Egg Collections, embryo transfers etc at the Bath clinic)
• CREATE, Bristol
• London Women’s Clinic, Cardiff ( Satellite in Bristol)
• The Centre for Reproductive & Genetic Health, London (CRGH)

Cryopreservation

The freezing and storage of sperm, oocytes and embryos is subject to the ICB's Fertility Preservation Treatment policy.

Funding approval will be provided to patients who receive NHS treatment where there is an adverse, long-term impact on fertility for which there is no clear alternative, and where the individual meets the rest of the criteria. Patients who are to receive oncology treatments which are likely to compromise their fertility are also eligible for fertility preservation, as well as patients prescribed cyclophosphamide, and those prescribed testosterone on the gender dysphoria pathway.

The referral form is available via the link above and also via EMIS.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.