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A Guide For Family Doctors

Duration

Put an individual's problems into perspective. For example:

In six months, only 60% of fertile people conceive;

by 12 months, 80% of fertile people will have conceived;

by two years, 95% of people (female aged less than 38) will have conceived;

once a woman is over 35 years, her chances of becoming pregnant reduce significantly.

Intercourse

Regularity and timing

the normal fertility rate is achieved with intercourse two or three times a week;

many people do not appreciate the most fertile time is from day 12 to day 14 of a 28 day cycle;

alternate day intercourse across the fertile time is usually adequate

Common Problems and Investigations

Maternal age is the most significant factor in fertility - there has been a clear trend for delaying starting a family, increasing the infertility rate.

30% of infertility is due to female factor e.g. tubal or ovulatory problems;

30% of infertility is due to male factor — sperm problems;

30% of infertility is due to a combined male/female factor;

up to 10% of infertility remains unexplained.

Ovulatory problems may be indicated by irregular cycles. Confirm ovulation with a mid luteal serum progesterone approximately 7 days prior to expected onset of menses.

Tubal problems may be indicated by lower abdominal operations, IUD usage, PID or lower abdominal pain or may indeed be symptomless (chlamydia).

Semen problems may be indicated by childhood hernia operations, orchidopexy or adult mumps, constant exposure to toxic substances, but most have no predisposing factor or are genetically determined. Arrange semen analysis, culture sensitivity and washing.

Lifestyle factors

Smoking and a large alcohol intake, being chronically under or overweight reduces fertility and increases the miscarriage rate. City Fertility Centre offers "Mind Body and Soul" — a structured program for weight loss and lifestyle changes.

When to Refer

early referral if female is over 35 years or in cases of extreme anxiety;

if no success after 12 months of unprotected intercourse;

low progesterone level and/or irregular cycle;

reduced semen quality;

history suggestive of tubal damage;

recurrent miscarriage e.g. more than two consecutive pregnancy losses;

genetic conditions e.g. Turners syndrome, cystic fibrosis, Klinefelters;

menopause < 40 years.

Counselling

City Fertility Centre has a counselling service accessible to outside referrals (at no cost to the client) for specialised infertility counselling. Information can also be provided on support groups available in your area.

feelings of denial, guilt, blame, self pity, jealousy and sadness are common and may be intense;

increased relationship stress is very common

Oncology Patients

Refer as soon possible before treatment begins;

chemotherapy and/or radiation treatment may result in permanent infertility;

offering a chance of future fertility may give a more optimistic prognosis to the patient;

cryopreservation of sperm, eggs or embryos may be possible.

Fertility Management after Vasectomy or Tubal Ligation

Sterilisation reversal may be possible to achieve, however, surgical aspiration and microinjection of sperm offer an alternative to vasectomy reversal and standard IVF treatment offers an alternative to female sterilisation reversal.

Early Menopause

Clients who have undergone early menopause and desire a pregnancy may be referred to Repromed, which offers full investigation and management of this condition, including the option of donor eggs or embryos.