Reviewed on : 11 Sep 2024

Reviewed by : Dr Rina Agrawal - Consultant Obstetrician and Gynaecologist, Lucy Dyde CWICB

Expires : 11 Sep 2026

Subfertility is a problem of a couple, not an individual, therefore all referrals must have male and female history and couples must attend appointments together.

Male factor infertility accounts for 30-40%, female 40-50% and combined 10-20%. 92% of couples will conceive within two years.

Please refer in the name of the female adding male investigations to the referral letter

Do not refer for fertility treatment before 1yr UNLESS:  age ≥ 35yr OR known to have: PCOS OR fibroids OR endometriosis OR previous ectopic pregnancy OR previous pelvic surgery OR PID, infrequent/absent periods, anovulatory progesterone concentrations, endocrine problems, semen abnormalities.

There are five different infertility clinics at UHCW so to enable us to get your couple to the correct clinic the first time we need you to do some initial investigations.

History

We need the following history from both partners (where relevant)

1. 1. Duration of infertility
2. 2. Menstrual history
3. 3. Lifestyle Issues: Smoking, BMI, alcohol, STDs (pelvic/testicular infections), work, stress, diet and exercise routine
4. 4. Any previous children/pregnancies
5. 5. Previous contraceptive use
6. 6. Up to date cervical smears, PMH, FH, DH
7. 7. Rubella immunisation status
8. 8. Child welfare issues

Investigations

MALE:

Semen analysis: One semen sample is sufficient if normal.

When the seminal fluid analysis report is received we will state whether the patient is required to have the test repeated.

Please find the SFA notes for info document attached – this provides an explanation of the terminology used on our reports and will assist you in treatment.

Please do not book semen analysis via the NHS eReferral Service. The patient can call us directly on the appointment line: 02476 96 88 73. A referral is NOT required for seminal fluid analysis.

See the tab to the right for further information about arrangements for semen analysis.

Semen results can be seen on the Other Events tab of CRRS.

Questions about semen analysis should be addressed to either:

Paula Frost, Senior Cryobank Officer. Email paula.frost@uhcw.nhs.uk

Abi O’Neill, Senior Clinical Andrologist. Email Abi.O’Neill@uhcw.nhs.uk

or call 02476 96 88 73 between 08:30 and 15:30, Monday to Friday.

FEMALE:

• Full blood count
• Haemoglobinopathy screen
• Rubella serology
• Day 2-3 FSH, LH, Oestrogen, Prolactin, TSH, FT4, Thyroid peroxidase antibody
• Day 21 progesterone (or 7 days before next period due)
• High Vaginal Swab and Chlamydia screen (can’t do tubal patency testing without this)

Preconception Advice

• Folic Acid 400 micrograms/day
• Reduce alcohol intake, <4 units per week
• Reduce caffeine consumption, not >1 cup a day
• Stop smoking
• Lose weight if BMI >29 or gain weight if BMI <19 (BMI 19-29 for NHS treatment)

Treatment Criteria

Please refer all couples irrespective of the female’s age as the initial investigations can be done on the NHS.

They would then be offered an initial consultation and investigations only.

Those who are not eligible for NHS funding can make an informed decision if they wish to continue their treatment on a self-funded basis or privately.

If they do not wish to pay and not eligible for NHS funding they will be discharged back to GP care.

Local Criteria for NHS Fertility Interventions

1. Category: Threshold

Threshold procedures and therapies are those in which a clinical threshold has been set which needs to be met before funding will be made available for treatment

For patients who DO NOT meet the eligibility criteria, the ICB will only consider funding the treatment if an Individual Funding Request (IFR) detailing the patient’s clinical presentation issubmitted to the ICB

2. Background

One cycle of infertility treatment (IVF or ICSI), including drug costs, will be made available to couples who meet the definition for infertility and eligibility criteria, together with up to two associated frozen cycles (including drug costs if necessary)

3. Indication

o Infertility is defined as the period of time people have been trying to conceive without success after which formal investigation is justified and possible treatment implemented

o Investigations for infertility are not usually recommended until the couple has been unable to conceive after 1 year of regular unprotected sexual intercourse. However, investigations should be offered earlier than 1 year to couples who have been identified as less likely to conceive (for example if the maternal partner is aged 36 years and older)

Following the first year and clinical investigation:

• Where the cause of infertility is known and all of the eligibility criteria, set out below, are met, the couple should be offered NHS funded infertility treatment without further delay
• In the absence of any known cause of infertility, the couple should be offered NHS infertility treatment where all eligibility criteria are met after a further 1 year of regular unprotected vaginal sexual intercourse
• In circumstances where the above definition cannot be applied, for example, females in a same sex relationship, people who are unable to, or would find it very difficult to, have vaginal intercourse because of a clinically diagnosed physical disability or psychosexual problem or a transgender male, infertility is identified where the couple have not conceived after 6 cycles of self-funded donor/partner insemination OR 2 cycles of self-funded IVF, undertaken at a HFEA registered clinic, in the absence of any known medical cause of infertility, and therefore should be offered NHS infertility treatment where all eligibility criteria are met

4. Eligibility Criteria

Eligibility criteria to access NHS funded infertility treatment once infertility has been defined is as follows:

• Childlessness – treatment will only be available where neither partner has living or adopted children of any age
• Sterilisation – treatment will not be available if infertility is the result of a sterilisation procedure in either partner
• Previous Infertility Treatment – any couple who has had one or more previous  cycle (i.e., including embryo implantation) of stimulated IVF/ICSI funded on the NHS or had three or more privately funded cycles will not be eligible
• Age of Maternal Partner – Where the protocol indicates the use of the named infertility procedures within the policy then they will only be offered to the maternal partner under 40 years at the time of referral. For maternal partner’s aged 39 years, the expectation is that treatment, including any frozen embryo transfers (FETs), is undertaken within 12 months of referral. Where preliminary infertility investigations and/or treatment unexpectedly delay referral to the fertility provider, the ICB considers the point of referral to be at the point of starting investigations as long as these can be reasonably considered to be part of the same episode of care.
• Age of Non-maternal Partner – there is no restriction on the age of the non-maternal partner, although this issue may be raised under medical suitability or welfare of the child considerations
• Body Mass Index – treatment will not be provided or commence where the maternal partner has a Body Mass Index (BMI) <19 kg/m2 or >30kg/m2 and patients should be encouraged to attend the weight management clinic to achieve the recommended BMI. If there are special circumstances relating to BMI then the final paragraph in Section 3 relating to Individual Funding Requests can be followed
• Smoking Status – the expectation is that couples accepted for treatment would be non-smoking. Smokers should initially be referred to the Smoking Cessation Service and should have stopped smoking for at least 4 weeks prior to referral for infertility treatment and continue to refrain from smoking throughout the treatment process

Preferred providers – The ICB’s local provider, the Centre of Reproductive Medicine, University Hospitals of Coventry and Warwickshire NHS Trust, is preferred; however other providers are available under Right to Choose.

Guidance/References

British Fertility Society (2005). Key facts on infertility, IVF and NHS provision. Bristol: BFS Secretariat.

De La Rochebrochard E et al. Paternal age over 40 years: the “amber light” in the reproductive life of men?J Androl. 2003 24(4):459-65.

de La Rochebrochard E, de Mouzon J, Thépot F, Thonneau P. Fathers over 40 and increased failure to conceive: the lessons of in vitro fertilization in France. FertilSteril. 2006; 85 (5):1420-4.

Frattarelli JL, Miller KA, Miller BT, Elkind-Hirsch K, Scott RT Jr FertilSteril. Male age negatively impacts embryo development and reproductive outcome in donor oocyte assisted reproductive technology cycles. 2008;90 (1):97-103.

HFEA Glossary of Terms, https://www.hfea.gov.uk/about-us/a-z-fertility-glossary/Human Fertilisation and Embryology Authority (2007). Code of Practice 7th Edition. R.4, London: The Human Fertilisation and Embryology Authority.

Hull MG, Glazener CM, Kelly NJ et al. Population study of causes, treatment, and outcome of infertility. Br edClin Res Ed, 1985; 291: 1693–1697.

Infertility Network UK (2009) Standardising Access Criteria to NHS Fertility Treatment.

National Collaborating Centre for Women’s and Children’s Health Commissioned by the National Institute for Clinical Excellence (2004) Fertility: assessment and treatment for people with fertility problems. CG 11, London: RCOG Press.

National Institute for Health and Care Excellence CG156 Guideline 2013 & Addendum 156.1 August 2016 Available at http://guidance.nice.org.uk/CG156/NICEGuidance/pdf/English

Nelson SM, Lawlor DA (2011) Predicting Live Birth, Preterm Delivery, and Low Birth Weight in Infants Born from In Vitro Fertilisation: A Prospective Study of 144,018 Treatment Cycles. PLoS Med 8(1): e1000386. doi:10.1371/journal.pmed.1000386

NHS Choices; BMI calculator | Check your BMI – NHS | Please fill in your details (www.nhs.uk)

Oakley L,Doyle P,Maconochie N. Lifetime prevalence of infertility and infertility treatment in the UK: results from a population based survey of reproduction. Hum Reprod 2008; 23: 447–450.

Spandorfer SD, Avrech OM, Colombero LT, Palermo GD, Rosenwaks Z. Effect of parental age on fertilization and pregnancy characteristics in couples treated by intracytoplasmic sperm injection. Hum Reprod. 1998; 13(2):334-8.

Templeton A, Fraser C, Thompson B. The epidemiology of infertility in Aberdeen. Br Med J1990; 301: 148– 152

Wilkes, S. and Chinn, D. and Murdoch, A. and Rubin, G. (2009) ‘Epidemiology and management of infertility: a population based-study in UK primary care’, Family practice 26 (4). pp. 269-274.

Mackenna A.I., Zegers-Hochschild F., Fernandez E.O., Fabres C.V., Huidobro C.A.,

Guadarrama A.R. Intrauterine insemination: Critical analysis of a therapeutic procedure. HumanReproduction. 1992; 7/3: 351-354

Peek J.C., Godfrey B., Matthews C.D. Estimation of fertility and fecundity in women receiving artificial insemination by donor semen and in normal fertile women. British Journal of Obstetrics and Gynaecology.1984; 91/10:1019-1024