Excerpt

This guideline offers best practice advice on assisting people of reproductive age who have problems conceiving.

It is estimated that infertility affects about one in seven heterosexual couples in the UK. Since the original NICE guideline on fertility was published in 2004 there has been a small increase in the prevalence of fertility problems and a greater proportion of people now seeking help for such problems.

The main causes of infertility in the UK are (percentage figures indicate approximate prevalence): ovulatory disorders (25%); tubal damage (20%); factors in the male causing infertility (30%); uterine or peritoneal disorders (10%).

In about 25% of cases infertility is unexplained, with no identified male or female cause.

In about 40% of cases disorders are found in both the man and the woman. Uterine or endometrial factors, gamete or embryo defects, and pelvic conditions such as endometriosis may also play a role.

Given the range of causes of fertility problems, the provision of appropriate investigations is critical. These investigations include semen analysis; assessment of ovulation, tubal damage and uterine abnormalities; and screening for infections such as Chlamydia trachomatis and susceptibility to rubella.

Once a diagnosis has been established, treatment falls into three main types: medical treatment to restore fertility (for example the use of drugs for ovulation induction); surgical treatment to restore fertility (for example laparoscopy for ablation of endometriosis); assisted reproduction technology (ART) – any treatment that deals with means of conception other than vaginal coitus; frequently involving the handling of gametes or embryos.

Contents

• 1. Guideline summary
  • 1.1. Original guideline development group (GDG) membership (2004), NCC-WCH staff and acknowledgements
  • 1.2. Updated (2013) guideline: guideline development group (GDG) membership, NCC-WCH staff and acknowledgements
  • 1.3. Foreword
  • 1.4. Care pathway
  • 1.5. Key priorities for implementation
  • 1.6. Recommendations
  • 1.7. Key research recommendations
  • 1.8. Research recommendations
  • 1.9. Schedule for updating the guideline
• 2. Introduction
  • 2.1. Fertility
  • 2.2. Update of Fertility guideline
  • 2.3. For whom is this guideline intended
  • 2.4. Related NICE guidance
• 3. Guideline development methodology
  • 3.1. Introduction
  • 3.2. Methodology for 2004 guideline
  • 3.3. Methodology for 2013 update
• 4. Principles of care
  • 4.1. Introduction
  • 4.2. Providing information
  • 4.3. Psychological effects of fertility problems
  • 4.4. Specialist and generalist care
• 5. Initial advice to people concerned about delays in conception
  • 5.1. Introduction
  • 5.2. Chance of conception
  • 5.3. Frequency and timing of sexual intercourse or artificial insemination
  • 5.4. Alcohol
  • 5.5. Smoking
  • 5.6. Caffeinated beverages
  • 5.7. Body weight
  • 5.8. Tight underwear
  • 5.9. Occupation
  • 5.10. Prescribed, over-the-counter and recreational drug use
  • 5.11. Complementary therapy
  • 5.12. Folic acid supplementation
  • 5.13. Defining infertility
• 6. Investigation of fertility problems and management strategies
  • 6.1. Introduction
  • 6.2. Investigation of suspected male factor infertility
  • 6.3. Investigation of suspected ovulation disorders
  • 6.4. Investigation of suspected tubal and uterine abnormalities
  • 6.5. Additional investigations for viral infection and cancer
  • 6.6. Strategies for management of fertility problems
• 7. Medical and surgical management of male factor fertility problems
  • 7.1. Introduction
  • 7.2. Medical management
  • 7.3. Surgical management
  • 7.4. Management of ejaculatory failure
• 8. Ovulation disorders
  • 8.1. Introduction
  • 8.2. WHO Group I ovulation disorders
  • 8.3. WHO Group II ovulation disorders
  • 8.4. Hyperprolactinaemic amenorrhoea – dopamine agonists
  • 8.5. Monitoring ovulation induction during gonadotrophin therapy
• 9. Tubal and uterine surgery
  • 9.1. Introduction
  • 9.2. Tubal microsurgery and laparoscopic tubal surgery
  • 9.3. Tubal catheterisation or cannulation
  • 9.4. Surgery for hydrosalpinges before in vitro fertilisation treatment
  • 9.5. Uterine surgery
• 10. Medical and surgical management of endometriosis
  • 10.1. Introduction
  • 10.2. Medical management (ovarian suppression) of endometriosis
  • 10.3. Surgical ablation
• 11. Unexplained infertility
  • 11.1. Introduction
  • 11.2. Ovarian stimulation for unexplained infertility
• 12. Intrauterine insemination
  • 12.1. Introduction
  • 12.2. Review question
• 13. Prediction of IVF success
  • 13.1. Introduction
  • 13.2. Prediction of IVF success
• 14. Access criteria for IVF
  • 14.1. Introduction
  • 14.2. Review of existing cost effectiveness models
  • 14.3. Development of health economic model
  • 14.4. Results
  • 14.5. Conclusions
  • 14.6. Discussion of the model
• 15. Procedures used during in vitro fertilisation treatment
  • 15.1. Introduction
  • 15.2. Pre-treatment for IVF
  • 15.3. Down-regulation or other regimens to avoid premature luteinising hormone surges
  • 15.4. Controlled ovarian stimulation in IVF
  • 15.5. Triggering ovulation in IVF
  • 15.6. Oocyte and sperm retrieval in IVF
  • 15.7. Embryo transfer strategies
  • 15.8. Luteal phase support after IVF
  • 15.9. Gamete intrafallopian transfer and zygote intrafallopian transfer
• 16. Intracytoplasmic sperm injection
  • 16.1. Introduction
  • 16.2. Indications for intracytoplasmic sperm injection
  • 16.3. Genetic issues and counselling
  • 16.4. Intracytoplasmic sperm injection versus IVF
  • 16.5. Cost effectiveness of intracytoplasmic sperm injection
• 17. Donor insemination
  • 17.1. Introduction
  • 17.2. Clinical indications for donor insemination
  • 17.3. Information and counselling
  • 17.4. Screening of sperm donors
  • 17.5. Assessment of the woman
  • 17.6. Intrauterine insemination versus intracervical insemination
  • 17.7. Unstimulated versus stimulated donor insemination
• 18. Oocyte donation
  • 18.1. Introduction
  • 18.2. Indications for oocyte donation
  • 18.3. Screening of oocyte donors
  • 18.4. Oocyte donation and ‘egg sharing’
• 19. People with cancer who wish to preserve fertility
  • 19.1. Introduction
  • 19.2. Cryopreservation of semen, oocytes, embryos and ovarian tissue
• 20. Long-term safety of assisted reproduction treatments in women with infertility and their children
  • 20.1. Introduction
  • 20.2. Long-term safety of ovulation induction and ovarian stimulation
  • 20.3. Long-term safety of IVF
• 21. References
• 22. Abbreviations and glossary
• Appendix A. Scope
• Appendix B. Stakeholders
• Appendix C. Declarations of interest
• Appendix D. Review protocols
• Appendix E. Search strategies
• Appendix F. Summary of identified studies
• Appendix G. Excluded studies
• Appendix H. Evidence tables
• Appendix I. GRADE tables
• Appendix J. Key priorities for research
• Appendix K. Deleted material from 2004 version
• Appendix L. Proposed changes to original recommendations
• Appendix M. Cost-effective treatment of IVF analyses
• Appendix N. Sensitivity analysis of cost-effective treatment of IVF analyses
• Appendix O. UK NEQAS embryo morphology scheme

While every effort has been made to ensure the accuracy of the information contained within this publication, the publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check current indications and accuracy by consulting other pharmaceutical literature and following the guidelines laid down by the manufacturers of specific products and the relevant authorities in the country in which they are practising.

This guideline has been fully funded by NICE. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient.

Implementation of this guidance is the responsibility of local commissioners and/or providers