Fertility - Obsolete

Introduction

**COVID-19 update (16.6.20) - We have been advised that fertility services are accepting referrals as long as the usual referral criteria are met.**

All referrals for NHS fertility services in BNSSG are subject to the Fertility Assessment and Treatment Policy, which includes criteria for heterosexual and same sex couples.

The following flow diagram may also be helpful in guiding GPs and patients on the steps and funding requirements for patients with fertility problems: Summary Guidelines for referring couples for Fertility Assessment/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 [National Collaborating Centre for Women's and Children's Health, 2013]

• 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:

Female partner:

• History and examination to include history of previous conceptions or miscarriages and gynaecological/menstrual history.

• Ensure BMI normal (being over or underweight can affect fertility and referral, if needed, may be restricted). Advise on weight as appropriate.

• Advise on folic acid, smoking and alcohol (only non-smokers can be referred)

• Advise regular intercourse 2 or 3 times a week.  

• Confirm ovulation - serum progesterone (mid luteal i.e 7 days prior to expected menstruation). *This test can be unreliable and is no longer a pre-requisite to referral.

• 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)

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 and syphilis serology).

If normal reassure and advise couple continue to try for up to 2 years - unless where the prospective mother will be older than 18 weeks before her 40th birthday.

If there is a significant abnormality (e.g. amenorrhoea, severe oligomenorrhoea (less than one period in last 12 months) , azoospermia, tubal blockage) or ≥2 years infertility then refer if criteria are met.

The CCG document Guidance for General Practitioners document has further information.

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

Clomiphene

NICE guidelines on clomiphene suggest that clomiphene should only be prescribed in patients with PCOS when ultrasound monitoring is available. As this is not currently available in primary  care then most GPs are now not happy to prescribe. 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 gynae - recurrent miscarriage clinic may be more appropriate.

If a woman has concieved 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 or 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. 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 prior to submitting the referral, which will mean co-ordinating with the other partner’s GP practice as required. The referral would usually be done by the GP practice of the prospective mother.

Referrals for fertility assessment are subject to the criteria based access (CBA) part of the Fertility Assessment and Treatment Policy and, as such the Fertility Assessment Referral form must be completed by the referring GP, demonstrating that the criteria have been met.

In addition, we would recommend completing the Preliminary Investigations form to ensure that all the stipulated investigations have been completed and documented.

A copy of the male partner’s semen analysis should also be attached to the referral if appropriate. Please note that the funding team have advised that a suboptimal semen analysis does not override the 2 year time frame for referral. Azospermia or subfertility due to oncology treatment would usually meet criteria. If in doubt then please discuss with funding team - bnssg.ifr@nhs.net

If all relevant information is not provided then referrals may be returned by the Referral Service or by providers.

Referrals should be directed via eReferral 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 Treatments

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 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 six providers when their funding is confirmed, with details of each clinic and where to get more information to inform their decision.

• CARE Fertility Bath, Peasedown St John, Bath

• CARE Fertility Bristol, Aztec West, Bristol

• Create Health Ltd, Bristol

• Bristol Centre for Reproductive Medicine (BCRM)

• London Women’s Clinic (Wales) Limited

• Royal Devon & Exeter NHS Foundation Trust

• The Centre for Reproductive & Genetic Health, London

 NHS Licensed fertility services transition FAQ update March 2018

Cryopreservation

Patients requiring cryopreservation to preserve fertility will continue to have access to NHS Funded treatment via the providers listed above.

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.