Fertility

Short Text

Assessment and treatment for people with fertility problems

Introduction

This pathway covers assessment and treatment for people with fertility problems.
It is estimated that infertility affects 1 in 7 heterosexual couples in the UK. Since the original NICE guideline on fertility 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 'unexplained infertility' (no identified male or female cause), ovulatory disorders, tubal damage, factors in the man, and uterine or peritoneal disorders. 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 3 main types: medical or surgical treatment to restore fertility and assisted reproduction techniques.

Source guidance

The NICE guidance that was used to create the pathway.
Fertility: assessment and treatment for people with fertility problems. NICE clinical guideline 156 (2013)

Quality standards

Quality statements

Effective interventions library

Successful effective interventions library details

Implementation

Service improvement and audit

These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.
Fertility: clinical audit tools
Fertility: baseline assessment tool
Fertility: costing report
Fertility: costing template

Pathway information

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on fertility

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If someone does not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent, the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards. In Wales, healthcare professionals should follow advice on consent from the Welsh Government.

Supporting information

Glossary

Treatments designed to lead to conception by means other than sexual intercourse.
Body mass index
A formal approach that encourages conception through unprotected vaginal intercourse. It involves supportively offering an individual or couple information and advice about the regularity and timing of intercourse and any lifestyle changes which might improve their chances of conceiving. It does not involve active clinical or therapeutic interventions.
A full cycle of IVF treatment, with or without ICSI comprises 1 episode of ovarian stimulation and the transfer of any resultant fresh and frozen embryo(s).
Intracytoplasmic sperm injection
In vitro fertilisation
Defined for the purposes of this pathway as meaning when 2 or more semen analyses have 1 or more variables below the 5th centile (as defined by the WHO, 2010). The effect on the chance of pregnancy occurring naturally through vaginal intercourse within 2 years would then be similar to people with unexplained infertility or mild endometriosis.
An IVF procedure in which one or more oocytes are collected from the ovaries during a spontaneous menstrual cycle without the use of drugs.
World Health Organization Group I ovulation disorders are classified as hypothalamic pituitary failure (hypothalamic amenorrhoea or hypogonadotrophic hypogonadism).
World Health Organization Group II ovulation disorders are classified as hypothalamic-pituitary-ovarian dysfunction (predominately polycystic ovary syndrome).

People who are concerned about their fertility

People who are concerned about their fertility

Providing information

Providing information

Providing information

Couples who experience problems in conceiving should be seen together because both partners are affected by decisions surrounding investigation and treatment.
People should have the opportunity to make informed decisions regarding their care and treatment via access to evidence-based information. These choices should be recognised as an integral part of the decision-making process. Verbal information should be supplemented with written information or audio-visual media.
Information regarding care and treatment options should be provided in a form that is accessible to people who have additional needs, such as people with physical, cognitive or sensory disabilities, and people who do not speak or read English.
NICE has produced information for the public explaining the guidance on fertility problems.

Source guidance

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CG156

Psychological effects of fertility problems

Psychological effects of fertility problems

Psychological effects of fertility problems

When couples have fertility problems, both partners should be informed that stress in the male and/or female partner can affect the couple's relationship and is likely to reduce libido and frequency of intercourse which can contribute to the fertility problems.
People who experience fertility problems should be informed that they may find it helpful to contact a fertility support group.
People who experience fertility problems should be offered counselling because fertility problems themselves, and the investigation and treatment of fertility problems, can cause psychological stress.
Counselling should be offered before, during and after investigation and treatment, irrespective of the outcome of these procedures.
Counselling should be provided by someone who is not directly involved in the management of the individual's and/or couple's fertility problems.

Source guidance

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CG156

Generalist and specialist care

Generalist and specialist care

Generalist and specialist care

People who experience fertility problems should be treated by a specialist team because this is likely to improve the effectiveness and efficiency of treatment and is known to improve people's satisfaction with treatment.

Source guidance

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CG156

Initial advice to people concerned about delays in conception

View the 'Initial advice to people concerned about delays in conception' path

Defining infertility and criteria for assessment and referral

Defining infertility and criteria for assessment and referral

Defining infertility and criteria for assessment and referral

Offer 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.
Healthcare 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.
A 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 (see investigation of fertility problems and management strategies).
A 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 (see investigation of fertility problems and management strategies).
Offer an earlier referral for specialist consultation to discuss the options for attempting conception, further assessment and appropriate treatment where:
  • the woman is 36 years or over
  • there is a known clinical cause of infertility or a history of predisposing factors for infertility.
Where treatment is planned that may result in infertility (such as treatment for cancer), early fertility specialist referral should be offered.
People 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. Also see options for conceiving for couples where the man is HIV positive and cervical screening and testing for infection before fertility treatment.

Source guidance

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CG156

Investigation of fertility problems and management strategies

View the 'Investigation of fertility problems and management strategies' path

Assisted reproduction

View the 'Assisted reproduction for people with fertility problems' path

Cryopreservation to preserve fertility in people diagnosed with cancer

View the 'Cryopreservation to preserve fertility in people diagnosed with cancer' path

Options for conceiving for couples where the man is HIV positive

Options for conceiving for couples where the man is HIV positive

Options for conceiving for couples where the man is HIV positive

For couples where the man is HIV positive, any decision about fertility management should be the result of discussions between the couple, a fertility specialist and a HIV specialist.
Advise couples where the man is HIV positive that the risk of HIV transmission to the female partner is negligible through unprotected sexual intercourse when all of the following criteria are met:
  • the man is compliant with highly active antiretroviral therapy (HAART)
  • the man has had a plasma viral load of less than 50 copies/ml for more than 6 months
  • there are no other infections present
  • unprotected intercourse is limited to the time of ovulation.
Advise couples that if all the criteria above are met, sperm washing may not further reduce the risk of infection and may reduce the likelihood of pregnancy.
For couples where the man is HIV positive and either he is not compliant with HAART or his plasma viral load is 50 copies/ml or greater, offer sperm washing.
Inform couples that sperm washing reduces, but does not eliminate, the risk of HIV transmission.
If couples who meet all the criteria above still perceive an unacceptable risk of HIV transmission after discussion with their HIV specialist, consider sperm washing.
Inform couples that there is insufficient evidence to recommend that HIV negative women use pre-exposure prophylaxis, when all the criteria above are met.

Source guidance

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CG156

Paths in this pathway

Pathway created: February 2013 Last updated: February 2013

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