Who should I see for advice on fertility?

It is advisable to visit your GP if you have not conceived after one year of trying. Around 1 in 7 couples may have difficulty, but about 84% will conceive naturally within a year if they have regular unprotected sex every 2 to 3 days. If you are over the age of 36, you should see your GP sooner as there is a faster decline in fertility from your mid-30s. Furthermore, if you have a reason to be concerned about your fertility (you may have had a sexually transmitted infection or cancer treatment), you should seek advice.

Your GP will perform an initial assessment to rule out potential causes of fertility problems and advise on further investigations or onward referral. It is useful for both partners to attend. A large part of the first consultation will involve your GP taking a medical and sexual history, and your GP will ask about previous gynaecological problems (including any history of sexually transmitted infections), contraception used in the past, other pregnancies, births and miscarriages or complications. You may be asked how often you have sexual intercourse and if you have any difficulties during sex. Depending on what medications you take and what they are used to treat, your GP may suggest alternatives as these could be affecting fertility. Your GP may also discuss your lifestyle and whether you smoke and how much alcohol you consume. If there are specific lifestyle factors that could be changed to improve your fertility, your GP will discuss these with you.

After the initial discussion, your GP may perform a physical examination and organise more tests. For females, this will include recording your height and weight and a pelvic exam to check for any lumps or soreness, or infection, which may indicate causes of fertility such as fibroids, pelvic inflammatory disease or endometriosis. For men, the exam includes a testicular check to look for lumps or deformities and any scrotal abnormalities.

Tests for infertility

Infertility may be due to hormone imbalance. Therefore, specialist fertility tests for women include blood tests where progesterone levels can be checked to ensure ovulation. This hormone testing is done at a certain point in your menstrual cycle which will be easy to calculate if your periods are regular. If you have irregular periods, then other hormone profiles can be tested, including follicle-stimulating hormone (FSH), the hormone that stimulates the ova (eggs) to mature, and luteinizing hormone (LH), which triggers ovulation. The levels of LH in your bloodstream may indicate your ovarian reserve and an estimate of how many viable eggs may remain in your ovaries. High levels could indicate the menopause (or premature ovarian failure, where a woman’s ovaries stop working before the age of 40) or a diagnosis of Polycystic ovary syndrome (PCOS). Low levels can cause a lack of menstruation. Your GP will also test for prolactin and thyroid hormone levels.

A vaginal swab will also be sent to test for chlamydia; alternatively, this can also be tested on a urine sample. Lastly, you may be referred for an ultrasound scan to check your ovaries, womb and fallopian tubes to ensure there are no conditions such as endometriosis and fibroids which can affect your ability to get pregnant. If there is any suggestion that the fallopian tubes (the tubes that carry the egg from the ovaries to the womb) are blocked, the GP may refer you for more specialist tests.

If there are blockages or other abnormalities detected on scans, a keyhole surgical procedure called a laparoscopy may be performed. This involves a small cut in the lower abdomen and then passing a small camera inside to look inside the womb and fallopian tubes. During this procedure, dye can be injected into the fallopian tubes through the cervix to detect any blockages.

Tests for men include a chlamydia test (on a urine sample) and semen analysis to check for sperm problems such as low sperm count or sperm that do not move properly.

Treatments

There are three main types of treatment for infertility: medications, surgical procedures and assisted conception. In terms of treating hormonal problems leading to infertility, medication may be all that is necessary, especially for lack of regular ovulation. Assisted conception involving intrauterine insemination (IUI) or in vitro fertilisation (IVF) may be necessary and led by a specialist fertility unit. The treatment offered will depend on the cause of infertility but also on what is available in your local area.

Medication: If women have PCOS, most cases can be treated successfully with a medicine called clomifene used at the start of each cycle. This medicine helps ovulation. If this is not successful, then another medicine called metformin may be used which can lower blood sugar levels in women with PCOS (this medication is also used to treat type 2 diabetes). It can help to encourage ovulation and a regular monthly period, and also reduce the risk of miscarriage. If neither medications work, fertility experts may recommend an injectable medication called gonadotrophins. These medications risk multiple pregnancies as they can overstimulate the ovaries.

An alternative to gonadotrophins is a surgical procedure called laparoscopic ovarian drilling (see below). This treatment can be as effective as using gonadotrophins, but it doesn’t increase your risk of multiple pregnancies. Medication used to stimulate ovulation is not recommended in those women who have unexplained infertility as it does not increase their chance of conceiving.

Surgical Procedures: Surgical procedures are mainly used for women with blockages in their fallopian tubes due to scarring from previous infections, for example. Surgery can also be used to remove fibroids (small growths in the womb) or to treat endometriosis (where the lining of the womb grows outside of the womb). If women have PCOS, then keyhole surgery called ovarian drilling can be used to try and stimulate the ovaries (this does not carry the risk of multiple pregnancy like gonadotrophins do).

Assisted conception: If the above treatments fail, then the options include intrauterine insemination (IUI) where sperm is inserted into the womb directly through the cervix, or in vitro fertilisation (IVF) where the woman’s egg is fertilised outside the body, and the fertilised egg (an embryo) is returned to the womb to develop.

Main Points

• It is advisable to visit your GP if you have not conceived after one year of trying (or sooner if you’re over the age of 36).
• Your GP will perform an initial assessment to rule out potential causes of fertility problems and advise on further investigations or onward referral.
• Specialist fertility tests for women include blood tests to check hormone levels. Your progesterone levels will be checked to ensure ovulation. If periods are irregular, the levels of follicle-stimulating hormone and luteinizing hormone may also be tested. Your GP will also test for prolactin and thyroid hormone levels.
• A vaginal swab will be sent to test for chlamydia; alternatively, this can also be tested on a urine sample.
• You may be referred for an ultrasound scan to check your ovaries, womb and fallopian tubes. If there are blockages or other abnormalities detected on scans, a keyhole surgical procedure called a laparoscopy, where a small camera is passed through a small cut in the abdomen to look inside the womb and ovaries, may be performed.
• Tests for men include a chlamydia test (on a urine sample) and semen analysis to check for sperm problems such as low sperm count or sperm that do not move properly.
• There are three main types of treatment for infertility: medications, surgical procedures and assisted conception. The treatment offered will depend on the cause of infertility but also on what is available in your local area
• Most cases of PCOS can be treated successfully with a medicine called clomifene used at the start of each cycle. This medicine helps ovulation. If this is not successful, then another medicine called metformin may be used.
• If neither medications work, fertility experts may recommend an injectable medication called gonadotrophins.
• An alternative to gonadotrophins is a surgical procedure called laparoscopic ovarian drilling, which can be used to try to stimulate the ovaries.
• If these treatments fail, then the options include intrauterine insemination (IUI) where sperm is inserted into the womb directly through the cervix, or in vitro fertilisation (IVF) where the woman’s egg is fertilised outside the body.

References

Fertility Problems; NICE Quality Standards, October 2014

Manders M, McLindon L, Schulze B, et al; Timed intercourse for couples trying to conceive. Cochrane Database Syst Rev. 2015 Mar 173:CD011345. doi: 10.1002/14651858.CD011345.pub2.

Fertility – Assessment and treatment for people with fertility problems; NICE Guidance (February 2013, updated Aug 2016)

Contraception – natural family planning; NICE CKS, June 2012 (UK access only)

Trying to get pregnant; nhs.uk website.  Accessed on October 20^th 2018. https://www.nhs.uk/conditions/pregnancy-and-baby/getting-pregnant/