14:20 6th February 2019 | Infertility
The role of primary care in the management of infertility
General practitioners (GPs) are in most cases the first clinicians consulted by patients who are concerned about possible infertility. Because of the anxiety that often accompanies early attempts to conceive, it is important for primary care providers to have accurate knowledge about what represents normal fecundity, when a couple’s fertility should be investigated, and the availability of various treatment options. Establishing a good referral network of specialists is essential when dealing with difficult fertility cases and helping couples achieve successful pregnancies.
Approximately 10-15 per cent of couple’s experience infertility during their reproductive years. While some women see a gynaecologist for review, most women living in rural areas or with limited access to care seek gynaecological care from primary care providers. However, there may be an increase in the utilisation of primary care providers within inner cities secondary to health care reforms and the fact that women’s preventive health care must be covered.
As more couples are seeking reproductive assistance, primary care providers are often asked to participate in the early stages of this treatment. Many conditions once considered untreatable can now be routinely corrected, typically in conjunction with a referral specialist. Throughout the process, the family physician is in a unique position to provide patient education and ongoing psychosocial support to these couples.
The most important role of a GP is that of advocacy; ensuring that couples in need of fertility treatment receive the correct advice, investigations, management and referrals. Appropriate referrals can be achieved following the initial assessment, investigation and diagnosis. A couple with identified tubal infertility or male factor infertility will require a referral to a specialist fertility centre for in-vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) treatment. Some ovulation disorders can be managed in general practice. Referrals are dictated by local arrangements made with a local secondary care gynaecology service or specialist fertility centre.
GPs continue to be the first point of contact for couples struggling to conceive. The initial investigation of the infertile couple can be performed in general practice where it is essential to ensure appropriate management and onward referral. The investigation includes an assessment of ovulation with hormonal studies, a malefactor with semen analysis, and tubal status with HSG. Management strategies for primary care include obesity management and the treatment of co-morbid conditions—to name a few. Following the initial assessment, couples with male factor infertility or tubal infertility should be referred to a specialist unit that can deliver IVF/ICSI treatments.
All couples should be advised to abstain from tobacco use, limit alcohol consumption and aim for a body mass index less than 30 kg per m2 to help improve their chances of natural conception or assisted reproductive technology (ART) conception. Obesity impairs fertility and the response to fertility treatments, including in vitro fertilisation; therefore, it is advisable to counsel patients who are obese to lose weight before conception or infertility treatments. Preconception counselling is essential and integral to the management of infertility, as such, GPs should undertake this part of management at the early stages.
In conclusion, primary care physicians have an important role to play in the management of infertility. Appropriate diagnosis, counselling and referral to specialist centres by GPs will further increase the number of couples who have timely interventions in fertility related issues.
1. Swarna Jyothi “a study to evaluate the effectiveness of structured teaching programme on knowledge regarding advance infertility management among staff nurses in selected hospital at Bangalore, 2013
2. Gail F. Whitman-Elia, MD, and Elizabeth G. Baxley, MD A Primary Care Approach to the Infertile Couple, JABFP January–February 2001 Vol. 14 No. 1
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