subfertility
Doctor Information
Karen Williams, age 39
No PMH
No regular medication
No known allergies
Last consultation over a year ago.
Last smear 1 year ago, no dyskaryosis, routine recall.
No PMH
No regular medication
No known allergies
Last consultation over a year ago.
Last smear 1 year ago, no dyskaryosis, routine recall.
Patient Information
Karen Williams age 39
History: You have been trying to have a baby for the past 2 years but nothing has happened. You and your partner have regular sex three times a week, and your periods are perfectly regular with 30 day cycles. You feel like something must be wrong and want to see a specialist. Your colleague at work has managed to get free NHS treatment for infertility, after she couldn't conceive for two years. You are keen to go down the same route.
If asked only:
You have a 15 year old son from your first marriage, who lives with his father in Scotland. You have been with your partner Phil for 3 years and want to have a child together. Phil has no children from other relationships. You work full time as a pharmacist and enjoy your job.
You have never smoked, and only drink alcohol on special occasions. You have not any sexually transmitted infections to your knowledge and and never had any pelvic surgery. You have no other health problems. You do not bleed after sex or between periods and have no abnormal discharge. No family history of any medical problems.
You are happy to be examined if a chaperone is offered.
Ideas: You think that something must be wrong, maybe your tubes are blocked?
Concerns: can you get IVF on the NHS, as Phil has never had children?
Expectations: Referral to a fertility specialist
If asked only: you would be willing to pay for IVF if this was required. Phil would be happy to book another appointment to come and see a gp for his tests.
History: You have been trying to have a baby for the past 2 years but nothing has happened. You and your partner have regular sex three times a week, and your periods are perfectly regular with 30 day cycles. You feel like something must be wrong and want to see a specialist. Your colleague at work has managed to get free NHS treatment for infertility, after she couldn't conceive for two years. You are keen to go down the same route.
If asked only:
You have a 15 year old son from your first marriage, who lives with his father in Scotland. You have been with your partner Phil for 3 years and want to have a child together. Phil has no children from other relationships. You work full time as a pharmacist and enjoy your job.
You have never smoked, and only drink alcohol on special occasions. You have not any sexually transmitted infections to your knowledge and and never had any pelvic surgery. You have no other health problems. You do not bleed after sex or between periods and have no abnormal discharge. No family history of any medical problems.
You are happy to be examined if a chaperone is offered.
Ideas: You think that something must be wrong, maybe your tubes are blocked?
Concerns: can you get IVF on the NHS, as Phil has never had children?
Expectations: Referral to a fertility specialist
If asked only: you would be willing to pay for IVF if this was required. Phil would be happy to book another appointment to come and see a gp for his tests.
Examination Findings
Pulse 67 regular
Blood pressure 128/76
Abdomen soft and non tender, BMI 25
Pelvic Examination: normal sized anteverted uterus, healthy appearance of cervix, no adnexal mass or tenderness. No Pv discharge seen.
Urine dip normal.
Blood pressure 128/76
Abdomen soft and non tender, BMI 25
Pelvic Examination: normal sized anteverted uterus, healthy appearance of cervix, no adnexal mass or tenderness. No Pv discharge seen.
Urine dip normal.
Mark scheme
Data Gathering
|
Positive indicators
Clarifies history of subfertility, taking in account both male and female factors Takes past obstetric history and social history Offers to examine patient |
Negative indicators
Disorganised information gathering Does not ask about male fertility history or past history Makes assumptions about the problem Fails to examine or advise examination |
Clinical Management Skills
|
Positive indicators
Provides reassurance and relevant information about subfertility Offers appropriate guidance and options for management (e.g. investigations to assess hormones, screening for infection, semen analysis: this may include referral to secondary care depending on local protocol) Gives appropriate advice regarding IVF treatment |
Negative indicators
Does not explain sub fertility or signpost to relevant information Fails to provide accurate information about fertility investigations Fails to discuss IVF treatment or provides incorrect information |
Inter Personal Skills
|
Positive indicators
Explores understanding of fertility and the patient’s agenda Identifies effect on quality of life and current concerns Establishes good rapport with the patient |
Negative indicators
Fails to explore health understanding or agenda Does not explore beliefs or concerns Poor rapport, doctor centred consultation |
Management
Explanation: Lots of couples have difficulty conceiving despite having regular sex and not using any contraception. 8 out of every 10 couples who have difficulty will still get pregnant within one year, and for those who don’t conceive in the first year, half will in the second year. There are a few different causes of subfertility, some are easier to treat than others.
Infertility is primary if the couple has never conceived, and secondary if the couple has conceived.
Of 100 healthy couples who try to conceive naturally, 84% will succeed in one year, 92% in 2 years.
In a quarter of cases, a specific cause is not found, but when it is, the most commons ones are ovulation problems (such as having anolvulatory cycles), damage to the fallopian tubes, problems in the pelvic (PID or endometriosis), or male factors.
In primary care, you should offer a concerned couple an initial assessment, by taking a thorough history and looking at modifiable risk factors such as BMI and smoking. This meeting is also useful to identify couples who are likely to need early intervention (for example advanced maternal age).
Assessing the woman:
Age; previous children born to her, and also pregnancies/miscarriages and terminations; length of time spent trying to conceive; length of time since stopping contraception, and type of contraception used previously; frequency of sexual intercourse.
Take a thorough menstrual history - length of cycle, menorrhagia, dysmenorrhoea, oligomenorrhea
Any history of hirsutism (could she have PCOS?)
Any systemic illnesses, e.g diabetes, IBD, thyroid dysorder
Areas of social history include any excessive dieting or exercise, smoking, alcohol, psychological distress
History of sexually transmitted disorders, pelvic pain, dyspareunia, intermenstrual or postcoital bleeding
Smear history
Examination: Check BP and BMI, look for acne or hirsutism. Perform a pelvic exam with consent to check for signs of PID (cervical excitation, adnexal tenderness) and for fibroids.
Assessing the man:
Children born to him (with same or different partner)
Frequency and any difficulties with sexual intercourse (premature ejaculation, difficulty getting or maintaining an erection)
Previous undescended testes or orchidopexy, any history of STI, mumps, or testicular trauma
Systemic illnesses e.g. diabetes, thyroid disease, liver disease
Prescribed or illicit drugs including steroids, any exposure to chemicals or pesticides
Lifestyle factors e.g. smoking, weight, alcohol, excessive exercise
Physical examination should look for hypogonadism (reduced body hair and muscle mass, gynaecomastia), undescended testes, scrotal lumps, varicocele, penile abnormalities.
General Advice:
Try and involve both partners in the consultation, and in particular discuss their beliefs and expectations. Many people find that basic information about normal patterns of contraception is useful, even if just to reassure them. Avoid regular intercourse, 2-3 times per week, and do not recommend temperature or ovulation detecting methods. Women should take pre-conceptual folic acid (400 micrograms daily).
You should only start investigating causes of inability to conceive after 12 months, unless there is a pressing reason to start sooner (e.g. advanced maternal age). Remember stress can reduce libido/frequency of intercourse and contribute to difficulty conceiving.
Smoking reduces fertility in both men and women, and women with BMI >29 are less likely to ovulate, so weight loss is advised.
Initial investigations:
In the woman - mid luteal phase progesterone to confirm ovulation (7 days before expected period)
- often FSH and LH are done in women with irregular cycles, and TFT if there is any suggestion of thyroid disease
- screen for chlamydia
In the man - semen analysis (explained in detail in mens health)
If these investigations are normal, consider secondary care referral
Consider earlier referral if the woman is >36, there is a known cause of sub fertility, or there is planned treatment such as chemotherapy that may result in infertility.ń
Infertility is primary if the couple has never conceived, and secondary if the couple has conceived.
Of 100 healthy couples who try to conceive naturally, 84% will succeed in one year, 92% in 2 years.
In a quarter of cases, a specific cause is not found, but when it is, the most commons ones are ovulation problems (such as having anolvulatory cycles), damage to the fallopian tubes, problems in the pelvic (PID or endometriosis), or male factors.
In primary care, you should offer a concerned couple an initial assessment, by taking a thorough history and looking at modifiable risk factors such as BMI and smoking. This meeting is also useful to identify couples who are likely to need early intervention (for example advanced maternal age).
Assessing the woman:
Age; previous children born to her, and also pregnancies/miscarriages and terminations; length of time spent trying to conceive; length of time since stopping contraception, and type of contraception used previously; frequency of sexual intercourse.
Take a thorough menstrual history - length of cycle, menorrhagia, dysmenorrhoea, oligomenorrhea
Any history of hirsutism (could she have PCOS?)
Any systemic illnesses, e.g diabetes, IBD, thyroid dysorder
Areas of social history include any excessive dieting or exercise, smoking, alcohol, psychological distress
History of sexually transmitted disorders, pelvic pain, dyspareunia, intermenstrual or postcoital bleeding
Smear history
Examination: Check BP and BMI, look for acne or hirsutism. Perform a pelvic exam with consent to check for signs of PID (cervical excitation, adnexal tenderness) and for fibroids.
Assessing the man:
Children born to him (with same or different partner)
Frequency and any difficulties with sexual intercourse (premature ejaculation, difficulty getting or maintaining an erection)
Previous undescended testes or orchidopexy, any history of STI, mumps, or testicular trauma
Systemic illnesses e.g. diabetes, thyroid disease, liver disease
Prescribed or illicit drugs including steroids, any exposure to chemicals or pesticides
Lifestyle factors e.g. smoking, weight, alcohol, excessive exercise
Physical examination should look for hypogonadism (reduced body hair and muscle mass, gynaecomastia), undescended testes, scrotal lumps, varicocele, penile abnormalities.
General Advice:
Try and involve both partners in the consultation, and in particular discuss their beliefs and expectations. Many people find that basic information about normal patterns of contraception is useful, even if just to reassure them. Avoid regular intercourse, 2-3 times per week, and do not recommend temperature or ovulation detecting methods. Women should take pre-conceptual folic acid (400 micrograms daily).
You should only start investigating causes of inability to conceive after 12 months, unless there is a pressing reason to start sooner (e.g. advanced maternal age). Remember stress can reduce libido/frequency of intercourse and contribute to difficulty conceiving.
Smoking reduces fertility in both men and women, and women with BMI >29 are less likely to ovulate, so weight loss is advised.
Initial investigations:
In the woman - mid luteal phase progesterone to confirm ovulation (7 days before expected period)
- often FSH and LH are done in women with irregular cycles, and TFT if there is any suggestion of thyroid disease
- screen for chlamydia
In the man - semen analysis (explained in detail in mens health)
If these investigations are normal, consider secondary care referral
Consider earlier referral if the woman is >36, there is a known cause of sub fertility, or there is planned treatment such as chemotherapy that may result in infertility.ń