Infertility: A Review of Current Practice

Happiness, anxiety, and despair — these are the words I would use to describe the experiences of patients in fertility clinics. Having spent six months in gynaecology, I have encountered many cases of infertility.

For many patients, the despair can be overwhelming. I have seen couples go through multiple rounds of IVF without success. These are some of the most challenging situations, as having children is often a deeply held desire.

In fertility clinics, consultations are often lengthy, discussing the various treatments patients have already tried. Many patients will try everything available, and some pursue treatments so experimental that even fertility consultants may not have heard of them. These interventions are often unproven and were recently highlighted in a BBC article.

My aim is to explore the topic of infertility and provide an update on current practice. I hope this will be helpful for clinicians who consult with patients on these issues, and offer some insight into what happens from the patient’s perspective.

A Case Study

The idea for this newsletter came from a case I assessed a few weeks ago. The patient was 40 years old and concerned that, despite her efforts, she had not been able to have children. Her husband, slightly older than she was, accompanied her. Both had been married before, and the husband already had children from his previous marriage. The woman had experienced two miscarriages in the past but had never been investigated for fertility issues, as she had moved to this country only after marrying her husband.

She was anxious — very anxious. It was clear that her difficulty conceiving was having a profound effect on her mental health. She even told me that she had married again at her age specifically because she wanted children. Her husband’s main concern seemed to be his wife’s wellbeing rather than having children, but it was evident that their year-old marriage was already under strain.

I am not a counsellor, so I did not explore the relationship issues in detail. Instead, I asked her some key questions, including:

• The frequency of sexual intercourse
• Menstrual health
• Signs and symptoms of STIs
• Lifestyle - BMI, smoking, alcohol, diet

Everything checked out so I proceeded to do some bloods AND fire off a referral to the fertility clinic.

What Investigations are Necessary?

Firstly, both the male and female partners require investigation. This is one of the most common challenges faced by fertility services after referral. The vast majority of concerns are raised by women, and it can be easy to overlook the potential contribution of male factors to infertility.

NICE recommends starting investigations after one year of regular, unprotected sexual intercourse. However, because my patients were slightly older, the recommended timeframe is reduced to six months.

Males:

• Sperm analysis - Males should be advised to NOT use lubricants when providing a sample.

Females:

• Progesterone - Help to establish ovulation. Should ideally be done “mid-cycle” - day 21
• FSH/LH - If these are raised, they could indicate hypothalamic-pituitary abnormalities such as PCOS
• Prolactin - High levels can suppress ovulation
• Thyroid Function Tests - abnormalities (hypo- or hyper-) can indicate significant issues with ovulation.
• Chlamydia - This must be done for allpatients. Chlamydia can cause significant tubal abnormalities resulting in problems with fertility
• Rubella - This is a new one to the list. It is done to establish immunity to rubella before conception.

From experience, most of these investigations return normal results. If the sperm sample is abnormal, the lab will usually recommend repeating the test after 2 months.

Regarding referrals, the criteria are straightforward. Early referral should be considered for any patient over 36 years old, and most referrals are made with a view to IVF.

IVF Criteria

IVF is very expensive privately, so it is unsurprising that patients often push for early referrals. It is important to note that there is both national and local guidance, and these can sometimes differ. Nationally, the current guidance for NHS-funded IVF treatment is as follows:

• Women under the age of 40: Offered up to 3 cycles of IVF. If they have had previous IVF (private), this counts toward the 3 cycles.
• Women aged 40–42: Offered 1 full cycle of IVF treatment.

So why the difference? Most would cite a decrease in fertility, but the ages 39–41 represent a narrow window. However, there is robust evidence cited by NICE. For instance, studies show success rates of approximately 25% per cycle in women under 35, dropping to less than 10% per cycle by ages 40–42.

There is also an increased risk of complications with age. Conditions such as chromosomal abnormalities, preeclampsia, and premature birth are more common in women over 40.

IVF itself carries certain risks, including ovarian hyperstimulation syndrome and an increased chance of multiple pregnancies.

Are there any other options other than IVF?

Yes, and this is why I was very careful when committing to a particular mode of treatment with my patient. Most patients consider IVF as a goal, but it is not always the most appropriate option. Here are some other treatment modalities:

• Letrozole: A medication specifically used for anovulatory infertility, e.g., in PCOS. Metformin is another option.
• Gonadotrophin injections: Used in patients with hypogonadotrophic hypogonadism.
• Intrauterine insemination (IUI): This is used if there is an issue with male sperm. NICE recommends up to 6 cycles of IUI on the NHS.
• Surgical options: These depend on risk factors (e.g., chlamydia) and imaging findings that indicate obstruction. Procedures such as endometrial ablation (for endometriosis) or adhesiolysis (for post-surgical adhesions) can be considered.

IVF is typically offered in cases of:

• Failed first-line treatments
• Severe male factor infertility
• Bilateral tubal occlusion
• Situations where natural conception is very unlikely

Are Treatments in the Private Sector Any Different?

The answer is yes. Whilst there is regulation of private clinics, the exact treatments they offer are constantly evolving. More recently, governments have looked into the types of treatment offered outside of IVF and have evaluated them to not carry any evidential standard. Some of these include:

• Endometrial scratch: A procedure where the womb lining is gently disturbed using a thin, sterile plastic tube prior to IVF treatment.
• Hysteroscopy: A procedure using a thin, telescope-like instrument to look inside the womb, sometimes done before IVF to check for and treat abnormalities.
• Endometrial receptivity testing: Special tests performed on the womb lining (endometrium) to determine the best timing for embryo transfer, sometimes offered as an optional add-on.

The patient I referred was eligible for IVF and after this point there is very little the NHS could do. In which case many patients will go the private route and should be made aware of options that may possibly not work. Unfortunately, there is a lot of misinformation on the internet and due to the sensitivity of the subject matter it is important to speak to patients with care.

Until next time

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Originally published on Substack.