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National Collaborating Centre for Women’s and Children’s Health (UK). Fertility: Assessment and Treatment for People with Fertility Problems. London: Royal College of Obstetricians & Gynaecologists; 2013 Feb. (NICE Clinical Guidelines, No. 156.)

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Fertility: Assessment and Treatment for People with Fertility Problems.

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5Initial advice to people concerned about delays in conception

5.1. Introduction

People wishing to conceive are faced with many sources of advice of varying quality and often conflicting in content. Therefore, it is important that the information they receive at an initial consultation is based on the best available evidence. This chapter outlines the minimum information that people should be aware of before starting fertility investigation and treatment.

5.2. Chance of conception

The natural process of human reproduction begins when spermatozoa are ejaculated into the vagina during sexual intercourse. The spermatozoa travel through the cervix and uterine cavity to the fallopian tubes where they meet the ovum (egg) and fertilisation takes place. The embryo then travels back down the fallopian tube and enters the uterine cavity where implantation takes place.

This process is reliant upon the chance of satisfactory ovulation and transport of viable sperm and ova in the reproductive tract. It is influenced by endocrine control, timing and frequency of sexual intercourse, and the general health status of the man and the woman. The length of a menstrual cycle varies between 26 days and 36 days. Ovulation usually takes place 12 to 16 days before the start of the next period. For a woman with a 28-day menstrual cycle (the first day of menstruation being day 1), ovulation takes place around day 14. After ovulation, the egg usually lives for up to 24 hours. After ejaculation, sperm can survive for up to 7 days in the genital tract and sometimes even longer (see Section 5.3).17

In the general population (which covers all ages and includes people with fertility problems), it is estimated that 84% of women would conceive within 1 year of regular unprotected sexual intercourse. This rises cumulatively to 92% after 2 years and 93% after 3 years (te Velde et al., 2000) 18,19

Fertility may be measured as conception rate per menstrual cycle. This is known as fecundability. Female fertility declines with age. Figure 5.1 shows the effect of maternal age on the average rate of pregnancy, calculated on the basis of studies in 10 different populations that did not use contraceptives. (Heffner, 2004, based on two reviews by Menken et al, 1986, and Anderson et al, 2000).21 However, in general, data on fecundability rates of specific age groups in fertile populations are limited. One study, using a modelling approach in a population with normal fertility who chose to delay child-bearing, reported that after 2 years of trying, women who were age 35 years had a 87% chance of conceiving and 67% of those who were age 38 years became pregnant.25 That study also reported that the decline with age in rates of conception is seen mostly after age 30 years and is more marked after age 35 years.25, A prospective cohort from the European Fecundability Study reported even more favourable conception rates in women aged 35 to 39 years after 2 years follow-up (see Table 5.1 and Figure 5.2) (Dunson et al., 2004).

Figure 5.1. The effect of maternal age on the average rate of pregnancy, calculated on the basis of studies in10 different populations that did not use contraceptives (adapted from Heffner, 2004, based on two reviews by Menken et al, 1986, and Anderson et al, 2000).

Figure 5.1

The effect of maternal age on the average rate of pregnancy, calculated on the basis of studies in10 different populations that did not use contraceptives (adapted from Heffner, 2004, based on two reviews by Menken et al, 1986, and Anderson et al, 2000). (more...)

Table 5.1. Cumulative probability of conceiving a clinical pregnancy by number of menstrual cycles in women in four different age categories attempting to conceive (assuming vaginal intercourse occurs twice per week) (adapted from Dunson et al., 2004).

Table 5.1

Cumulative probability of conceiving a clinical pregnancy by number of menstrual cycles in women in four different age categories attempting to conceive (assuming vaginal intercourse occurs twice per week) (adapted from Dunson et al., 2004).

Figure 5.2. Cumulative probability of conceiving a clinical pregnancy by number of menstrual cycles in women in four different age categories attempting to conceive (assuming intercourse occurs twice per week) (reproduced with permission, Dunson et al., 2004).

Figure 5.2

Cumulative probability of conceiving a clinical pregnancy by number of menstrual cycles in women in four different age categories attempting to conceive (assuming intercourse occurs twice per week) (reproduced with permission, Dunson et al., 2004).

There are very few sources of data to provide similar guidance for people who are using some form of artificial insemination to conceive. The evidence that does exist demonstrates that the chances of success with artificial insemination, with semen from either their partner or donor, are influenced by whether the insemination is intra-uterine or intra-cervical (with the former having higher rates of successful conception) and whether the sperm is fresh or thawed (with fresh sperm being associated with higher rates of successful conception; see Table 5.2) (Schwartz et al., 1982; van Noord-Zaadstra et al., 1991; HFEA data [http://www.hfea.gov.uk/1270.html#1299]). The data from these three sources reflect results using insemination with donor semen and not partner semen. In addition, in clinical practice use of fresh donor sperm is not an option since the appropriate screening and safety checks mandate the use of thawed frozen sperm for artificial insemination. If a partner’s sperm is to be used then the screening is not necessary and fresh sperm would be preferable.

Table 5.2. Probability of conceiving a clinical pregnancy by the number of cycles of insemination in different age categories and according to the method and sperm status where assistaed reproduction technology (ART) is being used.

Table 5.2

Probability of conceiving a clinical pregnancy by the number of cycles of insemination in different age categories and according to the method and sperm status where assistaed reproduction technology (ART) is being used.

In the original guideline it was stated that the effect of age on male fertility was unclear (Wood, 1989, van Noord-Zaadstra et al., 1991). However, there now is evidence of declining male fertility with increasing age which is independent of coital frequency (Dunson et al., 2004). That study showed that men aged 40 years having intercourse twice per week will have approximately 10% lower cumulative success rates compared with men aged 35 years over a period up to 24 months (see Figure 5.3) (Dunson et al., 2004).

Figure 5.3. Cumulative probability of conceiving a clinical pregnancy for a woman aged 35 years with either a partner the same age or 5 years older and with intercourse frequency of once or twice per week (reproduced with permission, Dunson et al., 2004).

Figure 5.3

Cumulative probability of conceiving a clinical pregnancy for a woman aged 35 years with either a partner the same age or 5 years older and with intercourse frequency of once or twice per week (reproduced with permission, Dunson et al., 2004).

Another important factor that can influence conception rates in the general population is coital frequency. Estimates suggest that fecundability rises sharply with frequency of intercourse (te Velde, 1992) (see Section 5.3). With regular intercourse, commonly meaning intercourse two or three times per week, at least 94% and 77% of fertile women aged 35 years and 38 years respectively conceive after three years of trying (te Velde, 1992). These findings have been confirmed in the European Fecundability Study reported above (Dunson et al., 2004). In that study the conception rates within 12 months for couples having intercourse twice per week were 92% for women aged 19 to 26 years, 86% for women aged 27 to 34 years, and 82% for women aged 35 to 39 years (see Table 5.1 and Figure 5.1). For couples having intercourse once per week the figures fell to 85%, 76% and 71%, respectively. Conception rates for those couples having intercourse three times per week were about the same as those having intercourse twice per week (Dunson et al., 2004).

Psychological stress can affect libido and coital frequency and hence fertility (see Section 5.3). Understandably, some couples are concerned about their failure to conceive within a timeframe they consider is reasonable. However, this is often not long enough to have allowed natural conception to occur. In such circumstances, immediate investigation and treatment is not appropriate. Couples who have not conceived but have been trying for less than the recommended time to qualify for fertility assessment and treatment (see Section 5.13) should be advised that they may successfully conceive during a period of ‘expectant management’. This involves supportively offering them information and advice about the regularity and timing of intercourse and any lifestyle changes which might improve their chances of conceiving. This approach does not involve any active clinical or therapeutic interventions. However, part of this care will involve the initiation of assessment and possible treatment after an agreed period of ‘expectant management’. This chapter covers many of these issues.

Recommendations

NumberRecommendation
10People 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%). [2004, amended 2013]
11Inform people who are using artificial insemination to conceive and who are concerned about their fertility that:
  • over 50% of women aged under 40 years will conceive within 6 cycles of intrauterine insemination (IUI)
  • of those who do not conceive within 6 cycles of intrauterine insemination, about half will do so with a further 6 cycles (cumulative pregnancy rate over 75%). [new 2013]
12Inform people who are using artificial insemination to conceive and who are concerned about their fertility that using fresh sperm is associated with higher conception rates than frozen-thawed sperm. However, intrauterine insemination, even using frozen-thawed sperm, is associated with higher conception rates than intracervical insemination. [new 2013]
13Inform people who are concerned about their fertility that female fertility and (to a lesser extent) male fertility decline with age. [new 2013]
14Discuss chances of conception with people concerned about their fertility who are:
  • having sexual intercourse (see table 5.1) or
  • using artificial insemination (see table 5.2). [new 2013]

5.3. Frequency and timing of sexual intercourse or artificial insemination

Daily intercourse results in the highest probability of conception but is not the only factor influencing conception,26 considering the viability of the egg and its short survival time. [Evidence level 3] Ejaculation eight times per week does not reduce the fertility of men though it tends to reduce sperm parameters,2730 The best sperm motility has been found in semen emission every three to four days on average.27 [Evidence level 2b] Coitus every two to three days is likely to maximise the overall chance of natural conception, as spermatozoa survive in the female reproductive tract for up to 7 days after insemination.17,30 [Evidence level 3]

It has been observed that most pregnancies can be attributed to sexual intercourse during a 6-day period starting 5 days before ovulation and including the day of ovulation,31,32 with the highest estimated conception rates associated with intercourse 2 days before ovulation.33 [Evidence level 3]

Six cohort studies that evaluated the use of basal body temperature or urinary luteinising hormone (LH) kits as indicators of ovulation to time intercourse did not report improvement in the chance of natural conception.3439 Timed intercourse has been suggested to be an emotionally stressful intervention in the initial evaluation of infertility.40 However, for the minority of couples who find it difficult to have sexual intercourse every 2 to 3 days, the prediction of ovulation using LH kits can be useful.

In people who are trying to conceive using some form of artificial insemination, insemination should be timed to coincide with ovulation, for example by testing urinary LH levels using a standard kit and scheduling insemination on the day after a surge is detected (Cantineau et al., 2010).

Recommendation 15 (below) has been amended to reflect a revised guideline development group (GDG) interpretation of evidence and current clinical practice.

Recommendations

NumberRecommendation
15People who are concerned about their fertility should be informed that vaginal sexual intercourse every 2 to 3 days optimises the chance of pregnancy. [2004, amended 2013]
16People who are using artificial insemination to conceive should have their insemination timed around ovulation. [new 2013]

5.4. Alcohol

This section deals with the effect of alcohol intake on fertility in general. The impact of alcohol consumption on in vitro fertilisation (IVF) success rates, in contrast, is discussed in Chapter 13.

There is inconsistent evidence about the impact of alcohol intake on female fertility.4146 [Evidence level 2b] Excessive alcohol consumption is harmful to the fetus.47 The Department of Health (DH) has recommended that women who are pregnant or trying to become pregnant should drink no more than one or two units of alcohol once or twice per week and should avoid episodes of intoxication.48

One cohort study showed that female wine drinkers (up to seven units per week) had slightly shorter waiting times to pregnancy than non-wine drinkers and drinkers of other alcoholic beverages, after adjusting for age, parity, smoking and body mass index (BMI).49 [Evidence level 2b]

Excessive alcohol consumption can be detrimental to semen quality but the effect is reversible and there is no evidence of a causal association between moderate alcohol consumption and poor semen quality.5053 [Evidence level 2b] The current recommended guidelines on safe drinking limits for men allow three to four units per day.54

Recommendations

NumberRecommendation
17Women 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. [2004]
18Men 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. [2004, amended 2013]
19Men should be informed that excessive alcohol intake is detrimental to semen quality. [2004]

5.5. Smoking

There is a significant association between smoking and reduced fertility among female smokers.55,56 [evidence level 2b] There is an association in men between smoking and semen parameters.51,5762 [Evidence level 2b] However, the relationship between male smoking habits and fertility is uncertain. Male and female exposure in utero is associated with reduced fertility later in life.63 [Evidence level 2b]

It has been reported that passive smoking in women is associated with delayed conception.64 [Evidence level 2b]

For women with fertility problems, basic information about the impact of smoking on fertility or a scripted three- to five-minute intervention with booklets specific to the woman’s ‘degree of motivation and commitment’, together with exhaled carbon monoxide monitoring, were highly effective in stopping smoking but not in improving pregnancy rates.65 [Evidence level 1b] We found no studies that investigated the effect of the use of nicotine replacement therapy on infertility.

There are significant associations between maternal cigarette smoking in pregnancy and increased risks of small-for-gestational-age infants,66 stillbirth67 and infant mortality.68 [evidence level 2b] For further information please refer to the Antenatal Care Guideline.1147

Recommendations

NumberRecommendation
20Women who smoke should be informed that this is likely to reduce their fertility. [2004]
21Women who smoke should be offered referral to a smoking cessation programme to support their efforts in stopping smoking. [2004]
22Women should be informed that passive smoking is likely to affect their chance of conceiving. [2004]
23Men who smoke should be informed that there is an association between smoking and reduced semen quality (although the impact of this on male fertility is uncertain), and that stopping smoking will improve their general health. [2004]

5.6. Caffeinated beverages

This section deals with the effect of caffeine intake on fertility in general. The impact of caffeine consumption on IVF success rates is discussed in Chapter 13.

Caffeine is present in coffee, tea, colas and chocolate. The association between caffeine and female infertility is inconsistent.45,6980 [evidence level 2b] We did not find any studies reporting the effect of caffeine on pregnancy rates, nor studies which investigated the effect of decaffeinated beverages on fertility.

We found one study addressing the question of caffeine intake and male fertility. This study showed no evidence of an association between caffeine intake and poor semen parameters. However, the combination of coffee drinking with smoking diminished sperm motility and increased the proportion of dead sperm.51 [evidence level 2b]

Recommendations

NumberRecommendation
24People who are concerned about their fertility should be informed that there is no consistent evidence of an association between consumption of caffeinated beverages (tea, coffee and colas) and fertility problems*. [2004]
*

See Recommendation 127 for a recommendation about caffeine intake and IVF treatment.

5.7. Body weight

Obesity

BMI is a measure of body fat calculated from an individual’s weight and height (kg/m2). The internationally accepted range for BMI is from less than 18.5 kg/m2 (underweight) to 30 kg/m2 or over (obese).81 Women with BMI over 30 kg/m2 take longer to conceive, compared with women with lower BMI, even after adjusting for other factors such as menstrual irregularity.8284 [evidence level 2b] For infertile anovulatory women with BMI of over 29 kg/m2, there is evidence that a supervised weight loss programme or a group programme including exercise, dietary advice and support helps to reduce weight,85,86 resume ovulation85 and improve pregnancy rates.86 [Evidence level 1b]

A BMI of 30 or over was reported to be an independent risk factor for spontaneous abortion in women who were oocyte recipients.87 [Evidence level 3]

An increased risk of miscarriage has been reported in moderately obese women (BMI 25–27.9 kg/m2) with polycystic ovary syndrome (PCOS; see Section 8.3) undergoing ovulation induction.88 [Evidence level 2b]

An observational study reported an inverse relationship between BMI and the total number of normal-motile sperm cells. There was a significant reduced number of normal-motile sperm cells in men who were overweight (BMI 25–30) and obese (BMI greater than 30) when compared with men of normal weight (BMI 20–24).89 [evidence level 3] A higher incidence of sperm DNA fragmentation has also been observed in men with a BMI of over 25.90 [Evidence level 3]

Obesity may have a deleterious effect on erectile function in men with existing vascular risk factors such as heart disease and diabetes.91 [Evidence level 2b]

More general guidance about about nutrition and exercise can be found in:

Recommendations

NumberRecommendation
25Women who have a body mass index (BMI) of 30 or over should be informed that they are likely to take longer to conceive. [2004, amended 2013]
26Women 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. [2004, amended 2013]
27Women should be informed that participating in a group programme involving exercise and dietary advice leads to more pregnancies than weight loss advice alone. [2004]
28Men who have a BMI of 30 or over should be informed that they are likely to have reduced fertility. [2004, amended 2013]

Low body weight

Low body weight is recognised as an important cause of hypo-oestrogenic amenorrhoea. It is important that the subgroup of women who have anorexia nervosa are detected and managed appropriately. Many women with hypo-oestrogenic amenorrhoea associated with low body weight do not wish to conceive and the management priority for these women will lie outside the scope of this guideline.

In women, weight loss of over 15% of ideal body weight is associated with menstrual dysfunction and secondary amenorrhoea when over 30% of body fat is lost.92 Restoration of body weight may help to resume ovulation and restore fertility.93,94 [Evidence level 2b]

An increased risk of preterm delivery has been associated with women who are underweight, and ovulation induction in such women has been associated with a higher incidence of babies who were small for gestational age.95 [Evidence level 2b]

More general guidance about about nutrition can be found in NICE Public Health Guidance 11, Maternal and Child Nutrition (2008).

Recommendations

NumberRecommendation
29Women 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. [2004]

5.8. Tight underwear

Increased scrotal temperature is closely associated with reduced semen quality in healthy populations.9698 [Evidence level 3] Important determinants of testicular temperature such as a sedentary work position and occupational heat exposure have been associated with abnormal semen quality (see Section 5.8).98,99 [Evidence level 3] There is some evidence that, in a fertile population, wearing tight-fitting underwear can impair semen quality.100 [Evidence level Ib] However, the effect of impaired semen quality on pregnancy rates has not been established. A cohort study of 97 men with subfertility showed that there was no difference in scrotal temperatures and semen parameters between a group wearing boxer shorts and a group wearing briefs.101 [Evidence level 2b]

Recommendations

NumberRecommendation
30Men should be informed that there is an association between elevated scrotal temperature and reduced semen quality, but that it is uncertain whether wearing loose-fitting underwear improves fertility. [2004]

5.9. Occupation

More than 104 000 chemical and physical agents have been identified in the workplace but the effects on reproduction of at least 95% of them have not been assessed, partly because of the fast rate of introduction of these agents into industry.102 Tables 5.3 and 5.4 summarise the main occupational agents implicated in the reduction of human fertility.103109 [Evidence level 2b–3] The lists of agents presented in the tables is not exhaustive.

Table 5.3. Occupational agents and their effects on male fertility.

Table 5.3

Occupational agents and their effects on male fertility.

Table 5.4. Occupational agents and their effects on female fertility.

Table 5.4

Occupational agents and their effects on female fertility.

Evidence suggestive of a harmful effect on the human reproductive system has been recognised for specific agents, such as heat, X-rays, metals and pesticides, whereas for many other agents the association is only suspected and needs further evaluation.

Recommendations

NumberRecommendation
31Some occupations involve exposure to hazards that can reduce male or female fertility and therefore a specific enquiry about occupation should be made to people who are concerned about their fertility and appropriate advice should be offered. [2004]

5.10. Prescribed, over-the-counter and recreational drug use

A number of prescribed, over-the-counter and recreational drugs may interfere with male or female fertility. However, the potential benefits and risks of certain medications need to be weighed and medical advice sought in order to determine the appropriate course for individual patients.

Prescribed drug use

There is evidence that nonsteroidal anti-inflammatory drugs inhibit ovulation.158,159 [Evidence level 1b] Immunosuppressive and anti-inflammatory drugs for rheumatic diseases may affect conception.160[evidence level 3] In a case–control study, women who had ever used thyroid replacement hormones, antidepressants, tranquilisers or asthma medication were reported to have elevated risks of anovulatory infertility.161 [Evidence level 2b] Chemotherapy treatment with cytotoxic drugs can induce ovarian failure at different rates for various types of malignancies and treatment regimens.162,163 [Evidence level 2b]

Medication such as cimetidine and sulphasalazine and long term-daily use of some antibiotics and androgen injections can affect semen quality and cause oligozoospermia.164166 The effect is generally reversible after three months following withdrawal of medication. Use of beta-blockers and psychotropic drugs may lead to impotence.167 Chemotherapy treatment can induce azoospermia, which is permanent in most cases.168 [Evidence level 3]

The effect of anti-psoriatic treatment for arthritis with methotrexate on male infertility is unclear.169 [Evidence level 3]

Recreational drug use

The use of recreational drugs or drugs of abuse such as marijuana and cocaine can adversely affect ovulatory and tubal function.170 The use of drugs such as anabolic steroids and cocaine can adversely affect semen quality.171173 [evidence level 2b–3] Overall, use of these recreational drugs diminishes the fertility potential of the couple. We did not find any studies that assessed the effect of recreational drug use on pregnancy rates.

Recommendations

NumberRecommendation
32A 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. [2004]

5.11. Complementary therapy

We found four RCTs that evaluated the effects of various substances on semen quality,174,175 ovulation and pregnancy rates.176,177 Three of the RCTs174,176,177 were of poor design with unclear methods of randomisation and clinical heterogeneity. The fourth RCT175 compared oral selenium supplementation with selenium plus vitamins or placebo in a group of subfertile men. This RCT reported an improvement in sperm motility and pregnancy rates in the selenium group compared with the placebo group (11% with selenium versus 0% with placebo).175 [Evidence level 1b]

An increase in pregnancy rates was observed in a preliminary trial assessing the effect of intercessory prayer on patients undergoing IVF treatment. However, there is no biological mechanism to explain such an effect.178

Recommendations

NumberRecommendation
33People who are concerned about their fertility should be informed that the effectiveness of complementary therapies for fertility problems has not been properly evaluated and that further research is needed before such interventions can be recommended. [2004]

5.12. Folic acid supplementation

A systematic review119 of four RCTs (n = 6425 women) showed that periconceptional folate supplementation reduced the incidence of neural rube defects (anencephaly and spina bifida) in children (relative risk [RR] 0.28, 95% confidence interval [CI] 0.13 to 0.58). In all four RCTs, folic acid was taken before conception and up to 6–12 weeks of gestation. The dose assessed ranged from 0.36 to 4 mg. Multivitamins alone were not associated with prevention of neural tube defects and did not produce additional preventative effects when given in combination with folate.179 An Expert Advisory Group to the Department of Health recommended a dose of 0.4 mg/day of folic acid for women who have not had a previous infant with a neural tube defect and a dose of 5.0 mg/day for women who have previously had an infant with a neural tube defect and those who are receiving anti-epileptic drugs. The NICE clinical guideline 63 Diabetes in Pregnancy (2010) also recommends the use of a higher dose of 5 mg/day in diabetic women planning a pregnancy. Supplementation should continue until 12 weeks into pregnancy.180 The British National Formulary recommends that women taking anti-epileptic drugs wishing to become pregnant should be referred to an appropriate specialist to discuss the risk of teratogenecity.181 The size of the effect for a given dose of folic acid was recently quantified and modelling has suggested that a reduced risk is associated with higher doses (that is 5 mg instead of 0.4 mg). The practical implication of an increased dose of folic acid has yet to be investigated.182,183

Recommendations

NumberRecommendation
34Women intending to become pregnant should be informed that dietary supplementation with folic acid before conception and up to 12 weeks’ gestation reduces the risk of having a baby with neural tube defects. The recommended dose is 0.4 mg per day. For women who have previously had an infant with a neural tube defect or who are receiving anti-epileptic medication or who have diabetes (see Diabetes in pregnancy, NICE clinical guideline 63), a higher dose of 5 mg per day is recommended. [2004, amended 2013]

5.13. Defining infertility

The United Nations defines reproductive health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity in all matters relating to the reproductive system and to its functions and processes’.190 [Evidence level 4] Infertility should, therefore, be considered to be a disease process worthy of investigation and treatment.

Infertility has been defined variably as failure to conceive after frequent unprotected sexual intercourse for one or two years.1,3,191213 Diagnosis of infertility based on a failure to conceive within 1 year has been argued to exaggerate the risk of infertility, since up to 50% of women who do not conceive in the first year are likely to do so in the second year.118,119

The prevalence of infertility in European countries is around 14%, affecting about one in seven couples.1,3,193,196,197,201205,208,210,212,214,215 Data from historical populations estimate the average prevalence of infertility to be 5.5%, 9.4% and 19.7%, respectively, at ages 25–29 years, 30–34 years and 35–39 years.216

The first consultation should include an assessment of the perceived fertility problem. For many couples, information about normal patterns of conception will provide reassurance that they are likely to have a good chance of conception. However, there should also be a specific enquiry about the medical, surgical, sexual, contraceptive and pregnancy history and a general physical examination to detect abnormalities, including measurement of height and weight to calculate BMI to identify couples who are likely to experience delays in conception.217 Couples should be offered information about lifestyle such as smoking, alcohol intake, occupational factors and diet which may impact on their fertility.

The GDG considered it appropriate to use a pragmatic and practical approach to the definition of infertility, namely, defining the period of time people should be trying to conceive after which it would be reasonable to initiate formal assessment (see Chapter 6) and possible treatment.

For people having unprotected regular vaginal intercourse

Conception rates for women or couples having unprotected vaginal intercourse two or three times per week are shown in Figure 5.1. In summary, over 80% of couples where the women is age 39 years or less will conceive within 12 months. The figure is over 85% where the woman is less than 35 years.

Given these data, the GDG was of the opinion that where the woman is of reproductive age and having regular unprotected vaginal intercourse two to three times per week, failure to conceive within 12 months should be taken as an indication for further assessment and possible treatment. The GDG acknowledged that, in practice, there would be occasions where natural conception occurred before couples were waiting for their specialist appointment or during the period of investigation.

If the woman is age 36 or over then such assessment should be considered after 6 months of unprotected regular intercourse since her chances of successful conception are lower and the window of opportunity for intervention is less. This age threshold was chosen as it was consistent with the age categories for IVF treatment agreed in The British Fertility Society and The Association of Clinical Embryologists standards (Cutting et al., 2008).

If, as a result of the investigation, a cause for the infertility is found, the GDG felt that the individual should be referred for appropriate treatment without further delay.

For men and women in same-sex relationships not having vaginal intercourse

The Scope of this guideline makes it clear that it is intended for people who have a possible pathological problem (physical or psychological) to explain their infertility.

For women in same-sex relationships, there should be some period of unsuccessful artificial insemination (AI) before they would be considered to be at risk of having an underlying problem and be eligible to be referred for assessment and possible treatment in the NHS. While the Scope did not allow the GDG members to make recommendations about this period of AI before referral for further assessment and possible treatment, they were of the majority view that ideally such AI should be undertaken in a clinical setting with an initial clinical assessment and appropriate investigations. However, they acknowledged that such pre-requisites and safeguards did not always apply.

Men in same-sex relationships wanting a baby can either adopt or use some form of surrogacy using the sperm of one partner, the latter being the usual way that male couples will be able to have a baby in which one of them will be a genetic parent. The Scope specified that surrogacy was not to be covered in this guideline. However, when a pregnancy does not occur through surrogacy after an appropriate period of time (equivalent to the 12 months with vaginal intercourse or 6 cycles of AI for other people) there is an increased risk of some underlying problem. In those circumstances, the man whose sperm is being used and the surrogate partner would be eligible to be referred for further clinical assessment and possible treatment.

In people using AI to conceive, as with people having vaginal intercourse, the success rates in women with normal fertility declines with age. Success rates also vary with the assisted reproduction method used. There are no data for the success of AI outside a clinical setting (sometimes called a ‘do-it-yourself’ approach where fresh donor semen is deposited in the upper vagina or even into the cervical os) and so the GDG was unable to comment on the efficacy of this approach. However, in a clinical setting, success rates are higher with fresh compared with frozen–thawed sperm and with intrauterine insemination (IUI) compared with intracervical insemination (ICI).

These data show that in the absence of any known cause of infertility, the cumulative chances of a pregnancy occurring after ICI or IUI in women who are 35 years or less are:

Given these data, the GDG discussed the options for the number of failed cycles of AI that should be undertaken before further assessment and possible treatment be initiated. The aim was to decide the number of failed AI cycles that would be equivalent to failure to conceive after 12 months of unprotected vaginal intercourse. The GDG’s discussions covered a number of ethical and practical issues relating to ‘equivalence’ including:

  • the financial cost of AI and disadvantage of those attempting to conceive by that route
  • the time to conception and disadvantage of those attempting to conceive by vaginal intercourse.

Women having vaginal intercourse do not have to pay to get pregnant, whereas those in same-sex relationships are at a disadvantage as they have to pay for a number of cycles of AI before they can be considered for assessment and possible treatment in the NHS. Therefore, the cost to the woman and her partner would be lower if 6 cycles of AI were recommended compared with 12 cycles of AI.

The GDG recommends that people having regular vaginal intercourse should be assessed and possibly treated if they have not conceived after 12 months (see Recommendation 29). The GDG decided that in a same-sex couple ‘numerical equivalence’ would be 12 cycles of AI, with the AI being undertaken once a month over 12 months, though the GDG acknowledged that using the criterion of 12 cycles of AI did not quite give equivalence in terms of cumulative success rate compared with vaginal intercourse. The GDG discussed using a lower number of cycles of AI in order to offset the financial impact and inconvenience of AI. However, the GDG stated that using a lower criteria could give same-sex couples a perceived advantage in terms of the time they had until further investigations were required.

Other factors that the GDG took into consideration in reaching a conclusion were:

  • The acknowledged limited ‘supply’ of sperm donors in the UK.
  • Recommending 6 cycles of AI would provide consistency with the recommended number of cycles of AI used in a therapeutic setting (see chapter 17).
  • The cumulative success rates with AI are lower in cycles 7 to 12 compared with cycles 1 to 6.
  • AI transfers are often not undertaken consecutively but spread over a longer period of time due to problems with scheduling of procedures. Therefore, undertaking 12 cycles of AI could take considerably longer than 12 months.

In the light of the AI data, the majority view of the GDG was that, for same-sex couples, failure to conceive after 6 cycles of AI within the 12 past months should be the indication for further assessment.

Again, if the woman is 36 years or over, then such assessment should be considered after fewer cycles of AI, since her chances of successful conception with AI are lower.

Other groups requiring special consideration

Three separate groups were considered under this heading:

  • People where there is a known cause of infertility or a history of predisposing factors (such as amenorrhoea, oligomenorrhoea, pelvic inflammatory disease or undescended testes).
  • People who are unable to, or would find it very difficult to, have vaginal intercourse (such as people with a clinically diagnosed disability or psychosexual problem) and would have to try to conceive using IUI with the male partner’s fresh sperm. In these cases, the GDG was of the opinion that most of the points covered in the discussion in relation to women in same-sex couples trying to conceive with AI (above) applied in this setting. Specifically, the GDG felt that the same criteria (that is, 6 unsuccessful cycles of IUI with partner sperm) applied to people in this group for referral for formal investigation and possible treatment.
  • People with conditions that require specific consideration in relation to methods of conception. This includes people who are about to be treated for cancer and wish to preserve their fertility (see Chapter 19), couples where the male is HIV positive or Hepatitis C positive, and people where the woman wishing to conceive is Hepatitis B positive (see Chapter 6).

In these circumstances the GDG was of the opinion that all people in these groups should be referred for early assessment and appropriate treatment.

Because of the implications of these issues, it could be argued that it would be appropriate to offer an initial consultation to same-sex couples to discuss the options for attempting conception, further assessment and appropriate treatment.

Recommendations

NumberRecommendation
35People who are concerned about delays in conception should be offered an initial assessment. A specific enquiry about lifestyle and sexual history should be taken to identify people who are less likely to conceive. [2004]
36Offer an initial consultation to discuss the options for attempting conception to people who are unable to, or would find it very difficult to, have vaginal intercourse. [new 2013]
37The environment in which investigation of fertility problems takes place should enable people to discuss sensitive issues such as sexual abuse. [2004]
38Healthcare professionals should define infertility in practice as the period of time people have been trying to conceive without success after which formal investigation is justified and possible treatment implemented. [new 2013]
39A woman of reproductive age who has not conceived after 1 year of unprotected vaginal sexual intercourse, in the absence of any known cause of infertility, should be offered further clinical assessment and investigation along with her partner. [new 2013]
40A woman of reproductive age who is using artificial insemination to conceive (with either partner or donor sperm) should be offered further clinical assessment and investigation if she has not conceived after 6 cycles of treatment, in the absence of any known cause of infertility. Where this is using partner sperm, the referral for clinical assessment and investigation should include her partner. [new 2013]
41Offer an earlier referral for specialist consultation to discuss the options for attempting conception, further assessment and appropriate treatment where:
  • the woman is aged 36 years or over
  • there is a known clinical cause of infertility or a history of predisposing factors for infertility. [new 2013]
42Where treatment is planned that may result in infertility (such as treatment for cancer), early fertility specialist referral should be offered. [2004, amended 2013].
43People who are concerned about their fertility and who are known to have chronic viral infections such as hepatitis B, hepatitis C or HIV should be referred to centres that have appropriate expertise and facilities to provide safe risk-reduction investigation and treatment. [2004]
Copyright © 2013, National Collaborating Centre for Women’s and Children’s Health.

No part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK [www.cla.co.uk]. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use.

Bookshelf ID: NBK327786

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