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One Stop Fertility Service GHNHSFT - Care pathway Overview

The pathway highlights to GPs the tests that should have been done in Primary Care prior to being referred into secondary care Fertility Service. It is currently estimated that a high proportion of referrals received into the service have not had the appropriate primary care work up (a 2017 audit by the service suggested only 7 of the 77 referrals received in a 3 month period had had the correct tests undertaken in primary care.

The information presented doesn't change the current pathway but by highlighting the tests required it will help ensure that patients are only referred into the service at the appropriate time.

Please click the relevant flowchart box to be taken directly to the textual information.

                                                                                   

Presentation

Presentation to Primary Care with subfertilty:

  • polycystic ovarian syndrome
  • endometriosis and pelvic pain along with subfertility
  • fibroids and subfertility
  • recurrent miscarriages
  • premature menopause or ovarian failure
  • fertility preservation counselling for cancer patients pre chemotherapy or radiotherapy
  • Male subfertility
Initial Primary Care Assessment/Management

Initial advice for patients concerned about delays in conceiving:

People who are concerned about their fertility should be informed that over 80% of couples in the general population will conceive within 1 year if:

  • the woman is aged under 40 years

and

  • they do not use contraception and have regular sexual intercourse.

Of those who do not conceive in the first year, about half will do so in the second year (cumulative pregnancy rate over 90%).

Inform people who are concerned about their fertility that female fertility and (to a lesser extent) male fertility decline with age.

Discuss chances of conception with people concerned about their fertility who are having sexual intercourse (see table 1 below).


Frequency and timing of sexual intercourse 

People who are concerned about their fertility should be informed that vaginal sexual intercourse every 2 to 3 days optimises the chance of pregnancy.


Table 1: Cumulative probability of conceiving a clinical pregnancy in different age categories (assuming vaginal intercourse occurs twice per week)

Age category (years)

Pregnant after 1 year (12 cycles) (%)

Pregnant after 2 years (24 cycles) (%)

19–26

92

98

27–29

87

95

30-34

86

94

35-39

82

90

Alcohol

Women who are trying to become pregnant should be informed that drinking no more than 1 or 2 units of alcohol once or twice per week and avoiding episodes of intoxication reduces the risk of harming a developing fetus.

Men should be informed that alcohol consumption within the Department of Health's recommendations of 3 to 4 units per day for men is unlikely to affect their semen quality.

Men should be informed that excessive alcohol intake is detrimental to semen quality.

For further information please see the Alcohol misuse pathway

 

Prescribed, over-the-counter and recreational drug use

A number of prescription, over-the-counter and recreational drugs interfere with male and female fertility, and therefore a specific enquiry about these should be made to people who are concerned about their fertility and appropriate advice should be offered.

 

Body weight

Women who have a Body Mass Index (BMI) of 30 or over should be informed that they are likely to take longer to conceive.

Women who have a BMI of 30 or over and who are not ovulating should be informed that losing weight is likely to increase their chance of conception. Women should be informed that participating in a group programme involving exercise and dietary advice leads to more pregnancies than weight loss advice alone.

Men who have a BMI of 30 or over should be informed that they are likely to have reduced fertility

For further information please see the Obesity pathway

Low body weight

Women who have a BMI of less than 19 and who have irregular menstruation or are not menstruating should be advised that increasing body weight is likely to improve their chance of conception.

 

Folic Acid Supplementation

Women intending to become pregnant should be informed that dietary supplementation with folic acid 400 micrograms per day before conception and up to 12 weeks' gestation reduced the risk of having a baby with neural defects (Available to purchase over-the-counter). 

For women who have previously had an infant with a neural tube defect or who are receiving anti-epileptic medication or who have diabetes, a higher dose of 5 mg per day is recommended. (This strength is prescription only medicine)

 

Smoking

Advise women who smoke that this is likely to affect their fertility and passive smoking may also affect their fertility.

Advise men who smoke that there is an association between smoking and reduced semen quality.

Refer any patients that are smokers to Smoking Cessation and provide information leaflet.

Assessment

A specific enquiry about lifestyle and sexual history should be taken to identify people who are less likely to conceive.

Female Partner

DOB:

MRN:

 

 

Date Taken:

FSH (Day 1-5)

 

 

LH (Day 1-5)

 

 

Prolactin (Day 1-5)

 

 

Testosterone (Day 1-5)

 

 

STSH (Day 1-5)

 

 

L2 C> TRACHOMATIS antibodies (Day 1-5)

 

 

Progesterone (luteal phase)

 

 

 

Male Partner

DOB:

MRN:

Date Taken:

 

 

Viscosity

 

 

Volume (ml)

 

 

pH

 

 

Total count x 109/l

 

 

Motility (%)

 

 

Rapid motility (%)

 

 

Sluggish motility (%)

 

 

Non-progressive motility (%)

 

 

Immotile (%)

 

 

Normal forms

 

 

Printable version available here

When to Refer

Onward referral to Secondary Care is advised for any patients with known/suspected:

  • polycystic ovarian syndrome
  • endometriosis and pelvic pain along with subfertility
  • fibroids and subfertility
  • recurrent miscarriages
  • premature menopause or ovarian failure
  • fertility preservation counselling for cancer patients pre chemotherapy or radiotherapy
  • Male subfertility

All NHS referrals should be made via E-referral to the fertility services GHNSFT.

Paper referrals will not be accepted.

Mrs K Reddy FRCS,FRCOG
Consultant Gynaecologist
Lansdown Lodge
Lansdown road
Cheltenham
GL51 6QL

Please note: No NHS referrals should be made to COTSWOLD FERTILITY UNIT based at the above address

One Stop Fertility Clinic - GHNHSFT

                                                                                     

The fertility clinic (male and female subfertility) at Gloucestershire hospitals NHSFT aims to provide first class services, advice and support for couples seeking fertility treatment in Gloucestershire

This is a 'One-Stop' Fertility Clinic offering appointments to all patients with Subfertility (female and male fertility problems, single women and same sex couples) such as:

  • polycystic ovarian syndrome
  • endometriosis and pelvic pain along with subfertility
  • fibroids and subfertility
  • recurrent miscarriages
  • premature menopause or ovarian failure
  • fertility preservation counselling for cancer patients pre chemotherapy or radiotherapy
  • Male subfertility

The clinic is run by Mrs Kalpana Reddy, who is a consultant gynaecologist and Specialist in Reproductive Medicine and Surgery at the Gloucestershire Hospitals NHS Foundation Trust. She is also the Director for Cotswold Fertility Unit.

  1. all referrals vetted by Mrs K Reddy.
  2. fertility secretary sends out a fertility heath questionnaire with checking all the results to be done at the right time.
  3. outpatient clinic appointment sent out once the questionnaire arrives with all confirmed blood test results. Initial clinic consultation will take place with Mrs K Reddy or her team and will include treatment planning, scan and counselling (all in one visit)
  4. on completion of all relevant treatment pathways, if Assisted Conception becomes vital, the patients are advised accordingly (NHS or private). All patients will be reviewed by Mrs K Reddy before accepting treatment with the satellite unit (criteria for acceptance will be individualised and advised accordingly)
  5. patients (NHS & Private) are placed on to the waiting list and the fertility secretary will organise all the necessary investigations for the IVF cycle to progress treatment

All patients (NHS & Self funded) are placed on the waiting list. The fertility secretary organises all the necessary investigations for the IVF cycle. Once investigations are complete, an IVF consultation appointment with Mrs K Reddy or one of her team members will be sent to the couple.

All patients who are concerned about their fertility or have diagnosed subfertility/infertility (single women and couples) are comprehensively reviewed and will be advised of all the options open to them during the consultation. This intial consultation is useful in avoiding unneccesaary tests and investigations.

Patients will have:

  • medical history review
  • full medical consultation
  • transvaginal and transabdominal ultrasound
  • plan of management

All of this will take place during one appointment. Patient centred written and verbal information will be provided, as appropriate, following the investigations and findings. This will included any surigcal treatment options.

Mrs Reddy and her team will perform surgery to rectify infertility problems. Surgery can include infertility, laparoscopic and hysteroscopic surgery for endometriosis, tubal surgery, adhesiolysis, fibroids, PCOS and ovarian cysts.

If you have had fertility investigations in the past or other related/relevant medical history, it would be helpful if the patient was advised to take details to the consultations. However, prior to any surgical intervention, a detailed medical history will be taken.

A treatment plan can be developed in most cases of infertility as understanding around this clinical area increases. Appropriate treatment options will be fully explained and discussed with the patient by Mrs Reddy, or a member of her team, to ensure next steps in treatment are clear.

Assisted Conception Treatment

If assisted conception treatment is appropriate/recommended,and the patient chooses to progress treatment within the county, Mrs Reddy will advise the patient accordingly and offer the following at the Satellite IVF Unit (Cotswold Fertility Unit) located at Lansdown Lodge, Lansdown road, Cheltenham.

  • satellite in-vitro fertilisation (IVF)
  • Intracytoplasmic Sperm Injection (ICSI)
  • IVF with donor egg (cycle monitoring)
  • ICSI after surgical sperm recovery (cycle monitoring)
  • ovulation induction with gonadotrophins treatment services

Please visit www.cotswoldfertilityunit.co.uk.

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