Women's Health · Full case

Infertility

NICE CG156

12 monthsInvestigate after (regular unprotected sex)

6 monthsInvestigate after if woman ≥35 yrs

1 in 7Couples affected by infertility (UK)

84%Conceive within 1 year (regular sex)

92%Conceive within 2 years

400 ng/mLAMH threshold for IVF eligibility discussion

<35 yrsNHS IVF age limit (most CCG/ICBs)

3 cyclesNHS-funded IVF (NICE recommendation)

📋 Clinical Stem — Infertility Consultation

A couple presents with failure to conceive — to seek investigation, explanation, and a management plan.

"A 31-year-old woman attends with her 33-year-old partner. They have been trying to conceive for 14 months with regular unprotected intercourse. Her periods are regular, every 28–30 days. She has no significant medical history. Her partner had a vasectomy reversal 3 years ago. She is taking folic acid 400 mcg. She works as a nurse. She is visibly anxious and has been researching IVF online."

Infertility consultations require simultaneous attention to both partners, sensitive emotional support, and a structured investigation pathway. The GP does not diagnose the cause of infertility — but initiates the pathway, identifies modifiable factors, and determines the referral route and urgency.

Scenario A — Unexplained infertility Regular cycles, normal semen analysis, patent tubes on HSG; 2-year history; discuss expectant management vs IUI vs IVF.

Scenario B — PCOS and anovulation Irregular cycles, raised LH:FSH ratio, polycystic ovaries on USS; first-line ovulation induction discussion.

Scenario C — Male factor Semen analysis shows severe oligospermia; discuss ICSI; partner psychological impact; urological referral.

Scenario D — Tubal factor Previous PID or chlamydia; HSG shows blocked tube; discuss IVF as primary treatment; ectopic risk.

Scenario E — Same-sex couple / single woman Donor sperm required; discuss regulated fertility clinic pathway; HFEA guidance; storage options.

Key variables to adapt Age (both partners), duration, previous pregnancies, menstrual regularity, STI/PID history, occupation, BMI, smoking, alcohol, medications, IVF funding eligibility.

Steps:

Step 1

History Taking — Open Question First · Both Partners · ICE · Psychosocial Context

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Infertility history must include both partners — male factor accounts for 30% of cases, combined male and female factors a further 20%. An open question first allows the couple to express the emotional burden of infertility, which is often profound and rarely acknowledged in rushed GP consultations. NICE CG156 recommends that investigations are initiated after 12 months of regular unprotected intercourse (or 6 months if woman is ≥35 years).

🎓 Consultation opener — acknowledge the emotional weight first

"I know this is something that can be really stressful and all-consuming — before I ask about the details, can you tell me how you've both been finding this experience, and what you're most hoping we can do today?"

Beginning with empathy before data-gathering scores Relating to Others marks and ensures the couple feel heard before the clinical interrogation begins.

1A — Core infertility history: targeted questions with clinical rationale

Question	Why it matters clinically	Changes what?
🟢 OPEN QUESTION first"Tell me what's been happening and how it's been affecting you both."	Allows couple to lead with emotional experience and perceived cause. Reveals whether they have already investigated (private clinic, home OPKs, online tests) and what expectations they bring.Emotional distress is an independent predictor of treatment dropout in infertility — acknowledging it first improves adherence.	PsychosocialRx plan
Duration and definition"How long have you been trying, and are you having regular sex — around 2–3 times per week?"	NICE defines infertility investigation threshold: 12 months (<35) or 6 months (≥35). Frequency matters — "trying" may mean once monthly, which significantly reduces per-cycle conception probability.Optimum conception rate is intercourse every 2–3 days throughout the cycle — not just around perceived ovulation.	Refer threshold
Female menstrual history"Are your periods regular? How long is your cycle? Any spotting between periods or pain?"	Regular cycles (24–35 days) suggest ovulation. Irregular cycles suggest anovulation (PCOS, hypothalamic, thyroid). Short luteal phase (<10 days) may indicate inadequate progesterone. Intermenstrual bleeding may suggest fibroids or endometrial polyp.Anovulation is the cause of infertility in 25% of couples.	DDxInvestigations
Previous pregnancies (both partners)"Have either of you had any previous pregnancies, including miscarriages, terminations, or children from previous relationships?"	Previous successful conception changes the differential — secondary infertility (failure to conceive after previous successful pregnancy) suggests acquired factors (pelvic adhesions, new-onset anovulation, male factor change). Previous termination increases tubal factor risk if complicated by infection.Previous male fertility (children from another relationship) does not exclude current male factor.	DDx
STI and pelvic history (female)"Have you ever been treated for a pelvic infection, chlamydia, or a sexually transmitted infection?"	Chlamydia trachomatis is the most common preventable cause of tubal factor infertility in the UK. One episode of PID reduces fertility by 15%; recurrent PID increases risk to 75%. Ectopic pregnancy risk also elevated.Most women with chlamydia-related tubal damage were unaware of the infection — ask specifically.	DDxReferral route
Male history: vasectomy, previous fertility, testicular history"Have you ever had a vasectomy? Any previous children? Any history of undescended testis, mumps orchitis, or groin surgery?"	Vasectomy reversal success rates decline with time (90% <3 years; 75% 3–8 years; <30% >15 years). Undescended testes, orchitis, and varicocele all impair spermatogenesis. Previous chemotherapy/radiotherapy may cause azoospermia.Obstructive azoospermia (vasectomy) vs non-obstructive (testicular failure) have completely different treatment pathways.	DDxReferral
Medications (both partners)"Are you on any regular medications? Any chemotherapy or hormone treatments past or present?"	Sulfasalazine causes reversible azoospermia (switch to mesalazine). Anabolic steroids suppress spermatogenesis and hypothalamic-pituitary-gonadal axis. Methotrexate = teratogen (3-month washout before conception). Antiepileptics: sodium valproate teratogenic; switch pre-conception.SSRI use in men may impair sperm motility and morphology — discuss risk vs benefit.	Rx modification
BMI, smoking, alcohol (both partners)"Can I ask about your weight, smoking and alcohol? I know it seems like I'm covering a lot but these all directly affect fertility."	BMI <19 or >29: significant impairment of ovulation and implantation. Smoking reduces ovarian reserve (AMH lower), reduces sperm quality, increases miscarriage risk, impairs IVF outcomes. Alcohol >14 units/week (female) significantly reduces fertility. Male alcohol >14 units/week reduces testosterone and sperm quality.NICE CG156: advise women with BMI >30 to lose weight before IVF; outcomes significantly better.	Lifestyle RxIVF eligibility
Occupation and stress"What work do you both do? Any exposure to heat (scrotum), chemicals, radiation?"	Scrotal hyperthermia (bakers, welders, cyclists, tight clothing, hot baths) reduces spermatogenesis. Pesticide and solvent exposure is linked to reduced sperm quality. Significant occupational stress impairs hypothalamic-pituitary-ovarian axis.Cyclists with prolonged saddle time have higher rates of scrotal hyperthermia; advise cycling shorts change and rest periods.	Lifestyle advice

1B — Red flags: must not miss · must act

🚨

Red Flags in infertility history

Red flag	Why dangerous	Action
Symptoms of ectopic pregnancy in a woman actively trying to conceive (one-sided pelvic pain, shoulder tip pain, collapse)	Women with infertility, tubal pathology, or IVF have higher ectopic risk. A positive pregnancy test with pain is ectopic until proven otherwise.	999 / A&E
Galactorrhoea (spontaneous nipple discharge) — suggests hyperprolactinaemia	Elevated prolactin inhibits GnRH; causes anovulation. Prolactinoma must be excluded (pituitary MRI). Treatable cause of infertility that responds to dopamine agonists.	Prolactin; MRI pituitary
Severe dysmenorrhoea or deep dyspareunia — suggests endometriosis	Endometriosis affects 10% of women and is present in 25–50% of women with infertility. Laparoscopic treatment may improve fertility outcomes.	Gynaecology referral
Signs of testicular cancer (painless testicular mass in man presenting with infertility)	Testicular malignancy is most common in men aged 20–40; reduced fertility may be the presenting complaint. Urgent USS required.	Urgent testicular USS; 2WW urology
Sodium valproate in pregnancy or pre-conception	Valproate causes neural tube defects in 1–2% and has a 10% risk of serious fetal malformation. MHRA 2023: valproate must not be prescribed to women of childbearing potential without specialist sign-off and pregnancy prevention programme.	Urgent neurology/psychiatry review; switch AED
Recurrent miscarriage (≥3 early losses)	Different pathway to infertility — requires antiphospholipid, thrombophilia, karyotype, and uterine cavity investigation. Recurrent miscarriage clinic referral.	Recurrent miscarriage clinic

🛡️

Safeguarding Considerations

🛡️ Reproductive coercion

Pressure to conceive against one partner's will is a form of reproductive abuse and domestic violence
Sabotage of contraception to cause pregnancy is reportable; assess each partner separately
If possible, see each partner alone for part of the consultation — not standard practice but appropriate if abuse is suspected

👴 Child safeguarding (existing children)

Couples with existing children under safeguarding plans — fertility treatment decisions should be communicated to the relevant safeguarding team
IVF clinics have their own welfare of child assessment process (HFEA code of practice)
Do not withhold infertility investigation but document concerns appropriately

🧠 Mental health crisis

Infertility is associated with levels of psychological distress equivalent to cancer diagnosis and chronic disease
Screen for depression and anxiety in both partners using validated tools (PHQ-9, GAD-7)
Suicidal ideation has been reported in women following failed IVF — always assess mood and safety
Refer to NHS fertility counselling as part of any IVF pathway (NICE mandated)

🕊 Vulnerability in donor conception

Women seeking donor insemination may be in abusive relationships where conception is forced or coerced
Single women and same-sex couples using donor sperm should be assessed for wellbeing and support network as part of HFEA welfare of child process
Ensure independent consent and access to counselling before any donor treatment

If reproductive coercion or domestic abuse is identified: follow standard GP safeguarding protocols. Document clearly. Offer individual consultations. Refer to IDVA service. Do not delay infertility investigation if the patient is safe to proceed.

1C — ICE: Ideas · Concerns · Expectations

💭 Ideas

"What do you think might be causing the difficulty? Have you had any investigations done already, privately or otherwise?"

Many couples have already consulted Dr Google, purchased ovulation predictor kits, or had private tests. Their beliefs about the cause directly affect their emotional state and openness to investigation. Acknowledging prior self-investigation avoids repetition and builds trust.

😟 Concerns

"What's been your biggest worry going through this — is it about whether treatment will work, about what investigations involve, or something else?"

Common concerns: IVF cost and NHS eligibility, fear of injections, partner blaming, fear of genetic abnormality, age-related anxiety. Unexplored concerns prevent engagement with the investigation and treatment pathway.

🔇 Expectations

"What are you hoping we can arrange today? Are you looking to start investigations, get a referral, or is it more about understanding what might be happening?"

Some couples want immediate IVF referral; others want to first understand why they are not conceiving. Some come after private treatment failure and want NHS access. Without asking, the consultation may completely miss the patient's actual agenda.

1D — Psychosocial context: the couple behind the clinic

🛡️ Grief and identity

Infertility causes grief disproportionate to its outward presentation. The loss of anticipated parenthood triggers a bereavement process. Women often report that infertility defines their identity and social world in ways that are invisible to others.

"It sounds like this has become the main focus of your life right now — that's completely understandable and very common. How are you both managing emotionally?"

👴 Relationship strain

Medicalisation of sex, blame attribution, and unequal emotional processing between partners causes significant relationship strain. Male partners often cope through problem-solving; female partners through emotional processing. This mismatch is a source of conflict.

"How are you both coping as a couple? Sometimes the stress of this puts a real strain on relationships, and there's support available specifically for that."

📚 Social and cultural pressure

Cultural and family pressure to produce children is immense in many communities. Women from some backgrounds face shame, stigma, and in-law pressure that is rarely volunteered. This context shapes help-seeking behaviour and treatment preferences.

"Is there any pressure from family or your wider community that's been adding to the stress of this?"

💥 Financial and occupational stress

IVF costs £3,000–£5,000 per cycle privately. The financial burden causes enormous stress and affects treatment decisions. NHS eligibility is subject to local ICB variation. The patient needs accurate information about NHS pathway and likely timelines.

"I want to make sure you know what's available on the NHS locally — the rules vary by area and I want to give you an accurate picture of what to expect."

🧠 Mental health impact

Infertility-related psychological distress levels are equivalent to those of cancer and heart disease in validated studies. Depression and anxiety are present in 30–50% of women undergoing IVF. NICE CG156 mandates counselling as part of licensed fertility treatment.

"Have you found this affecting your mood, your sleep, or your ability to concentrate at work? It's very common, and there's specific support we can access."

🌼 Folic acid and pre-conception health

Folic acid 400 mcg OD should be started 3 months before conception and continued to 12 weeks. Women with epilepsy, diabetes, or BMI >30 need 5mg folic acid. Both partners should have rubella and varicella immunity checks. Cervical screening should be up to date.

"Before we talk about investigations, let's make sure the basics are in place — are you taking folic acid and have you had your rubella immunity checked?"

🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills

Key phrases that score

"Before I ask all the medical questions, tell me how you've both been coping with this — it can be really hard."

"Have either of you ever had a pelvic infection or chlamydia? I ask everyone because it's one of the most common causes we can look for."

"Are your periods regular? That helps me understand whether you're ovulating."

"What's your main concern coming in today? Is it about investigations, funding, or understanding what might be happening?"

Deductions

Only asking female partner questions — male factor missed
Not asking STI/PID history — tubal factor missed
Starting investigations without asking duration (not yet at threshold)
Not asking about folic acid — pre-conception basic
No ICE — missing couple's real agenda (often funding anxiety)

🔴 Red

Female history only • no male factor questions • no STI/PID • no ICE • investigations before 12m threshold

🟠 Amber

Both partners asked • STI history • ICE superficial • folic acid missed • no psychosocial

🟢 Green

Both partners • STI/PID asked • ICE all 3 • BMI/smoking/alcohol • folic acid confirmed • empathy for emotional burden

Step 2

Triage Engine — Emergency · Urgent · Routine

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Most infertility presentations are routine — but ectopic risk, galactorrhoea, suspected testicular malignancy, and sodium valproate use all require urgent action before investigation begins.

🔴 Emergency

999 or Same-Day Hospital

Immediate

Suspected ectopic pregnancyPositive hCG + pelvic pain + haemodynamic instability → 999
Ovarian hyperstimulation syndrome (OHSS)After ovulation induction or IVF: abdominal distension, oliguria, dyspnoea → hospital admission

🟠 Urgent

Same Day / 2-Week Wait

Days

Suspected testicular malignancyPainless testicular mass → urgent USS + 2WW urology
Galactorrhoea (hyperprolactinaemia)Prolactin level + pituitary MRI; treatable cause of anovulation
Sodium valproate in woman of childbearing potentialUrgent specialist review; switch AED; document pregnancy prevention programme
Suicidal ideation following failed cycle or long infertility durationSame-day mental health referral; safety plan
Positive pregnancy test in woman with tubal disease historySame-day EPAU referral to exclude ectopic

🟢 Routine

GP-managed

Planned

Infertility >12 months (<35) or >6 months (≥35)Initiate NICE CG156 investigation pathway; both partners assessed
Pre-conception optimisationFolic acid, rubella immunity, BMI, smoking, alcohol, medications review
Expectant management counselling84% conceive year 1; 92% year 2; lifestyle optimisation first
IVF pathway discussion and referralAfter investigations or directly if criteria met; check local NHS eligibility

🎓 SCA Checkpoint — Step 2Tasks

🔴 Red

Valproate not flagged • galactorrhoea dismissed • ectopic risk not addressed in tubal disease patient

🟢 Green

Ectopic risk addressed • valproate flagged • galactorrhoea leads to prolactin • threshold timing correct

Step 3

Do I Need This Examination?

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Examination in infertility is targeted. BMI calculation is mandatory for IVF eligibility. Pelvic examination is needed if symptoms suggest endometriosis or pelvic pathology. Testicular examination is essential if male factor is suspected.

Examination	Why it matters	Finding that changes management	Changes?
BMI (height + weight)	BMI <19 = hypothalamic anovulation; BMI >30 = PCOS risk, anovulation, IVF contraindicated until weight loss. NICE: advise BMI 19–30 for optimal IVF outcomes.BMI >35 = most NHS ICBs will not fund IVF; advise weight reduction first.	BMI >30 = weight loss advice before referral; BMI <19 = eating disorder screen	YES — IVF eligibility
Pelvic examination (female)	Required if dysmenorrhoea, dyspareunia, or pelvic pain present — may reveal endometriosis nodules, uterine tenderness (PID), or ovarian mass.Routine pelvic examination is not required for every infertility patient without symptoms.	Fixed uterus / nodular utero-sacral ligaments = endometriosis; adnexal mass = urgent USS	Context: symptoms
Testicular examination (male)	Testicular volume (small testes = impaired spermatogenesis), varicocele (impalpable in lying position; palpable standing), epididymal cysts, tenderness.Painless solid testicular mass → urgent testicular USS and 2WW urology.	Varicocele = urology referral; testicular mass = 2WW USS; small soft testes = Klinefelter's screen	YES — referral route
Thyroid examination	Hypothyroidism causes menstrual irregularity and anovulation. Goitre or clinical hypothyroidism signs mandate TSH check.TSH >2.5 mIU/L is associated with reduced IVF success; treat to TSH <2.5 pre-conception.	Clinical hypothyroidism = TSH urgently; treat before IVF referral	Context: symptoms
Signs of hyperandrogenism (acne, hirsutism)	Acne, hirsutism, alopecia, and acanthosis nigricans suggest PCOS or congenital adrenal hyperplasia. These findings direct the investigation pathway to androgens and LH:FSH ratio.Acanthosis nigricans = insulin resistance; consider fasting glucose and HbA1c alongside hormonal screen.	Hirsutism + irregular cycles = PCOS workup; virilisation = 17-OH progesterone for CAH	YES — DDx

🎓 SCA Checkpoint — Step 3Tasks

🔴 Red

No BMI • testicular mass not examined • no endometriosis examination when symptoms present

🟢 Green

BMI calculated • targeted pelvic exam if symptoms • testicular exam mentioned for male factor • IVF eligibility considered

Step 4

Do I Need This Investigation?

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NICE CG156 specifies a core investigation set for both partners. The GP initiates all these tests before or at the point of referral. Investigations answer three questions: (1) Is she ovulating? (2) Is there a uterine/tubal factor? (3) Is the semen analysis normal? The answers direct the referral pathway.

Investigation	Clinical question it answers	Abnormal result and management change
Progesterone (day 21 of 28-day cycle)	Is she ovulating? Mid-luteal progesterone >30 nmol/L confirms ovulation. For irregular cycles: measure 7 days before expected next period. Repeat if borderline.	<30 nmol/L = probable anovulation; <16 nmol/L = definite anovulation; check TSH, prolactin, LH:FSH for cause
FSH, LH, oestradiol (day 2–5 cycle)	Is ovarian reserve adequate? Is this a pituitary cause? High FSH/LH + low oestradiol = ovarian failure/POI. Low FSH + low LH = hypogonadotrophic hypogonadism (hypothalamic cause). High LH:FSH ratio (>2:1) = PCOS.	FSH >10 IU/L = reduced ovarian reserve; FSH >30 = POI; LH:FSH >2 = PCOS; all LH:FSH low = hypothalamic
AMH (anti-Müllerian hormone)	What is the ovarian reserve? AMH reflects the number of antral follicles and predicts response to ovarian stimulation in IVF. Does not predict chance of natural conception. Used for IVF planning.	AMH <5 pmol/L = very poor reserve; poor IVF response predicted; AMH >30 pmol/L = PCOS / OHSS risk
Semen analysis (WHO 2021 criteria)	Is male factor contributing? Volume ≥1.4mL; concentration ≥16M/mL; total motility ≥42%; progressive motility ≥30%; morphology (Kruger) ≥4% normal forms. Any abnormality = repeat after 3 months.	Severe oligospermia = ICSI; azoospermia = surgical sperm retrieval ± specialist; normal twice = male factor excluded
TSH	Is hypothyroidism causing anovulation or impaired implantation? TSH should be <2.5 mIU/L pre-conception and in IVF cycles for optimal outcomes.	TSH >4 = treat before IVF; TSH 2.5–4 = discuss treatment; subclinical hypothyroidism reduces IVF success
Prolactin	Is hyperprolactinaemia suppressing GnRH and causing anovulation? Galactorrhoea, headache, visual field defect suggest prolactinoma.	Prolactin >1000 mIU/L = investigate (hypothyroid? prolactinoma?); MRI pituitary; dopamine agonist (cabergoline)
Rubella immunity	Is she immune to rubella? Non-immune women should be vaccinated before conception. Do not administer MMR if already pregnant (live vaccine).	Non-immune = offer MMR; avoid conception for 1 month post-MMR; repeat serology after
Chlamydia screening (NAAT)	Is asymptomatic chlamydia present? Screening before any uterine instrumentation (HSG, IUI, IVF egg collection) prevents ascending PID.	Positive = treat both partners with azithromycin 1g stat; trace contacts; delay uterine instrumentation until clear
Pelvic USS + antral follicle count	Are there structural uterine, ovarian, or tubal causes? USS identifies polycystic ovaries (PCOS criteria), uterine fibroids, endometrial polyps, hydrosalpinx, ovarian cysts.	Hydrosalpinx = salpingectomy before IVF (doubles success rate); fibroids >6cm = myomectomy discussion; PCOS = ovarian induction protocol
Hysterosalpingography (HSG) or HyCoSy	Are the fallopian tubes patent? Tubal occlusion requires IVF as primary treatment (bypasses tubes). HSG also identifies uterine septum and Asherman's syndrome.	Unilateral block = IVF; bilateral block = IVF; hydrosalpinx on HSG = laparoscopic salpingectomy before IVF

🎓 SCA Checkpoint — Step 4TasksGlobal Skills

Investigation phrases

"I'd like to check a progesterone level in the second half of your cycle to confirm you're ovulating, and we need a semen analysis for your partner."

"I'd also like to check your rubella immunity and do a chlamydia screen before any further procedures."

Deductions

Only ordering female investigations — semen analysis mandatory
Progesterone on wrong day (must be mid-luteal; day 21 for 28-day cycle)
Not checking rubella or chlamydia before uterine instrumentation

🔴 Red

No semen analysis • wrong cycle day progesterone • no chlamydia screen

🟢 Green

Both partner investigations • correct timing • TSH + prolactin • rubella immunity • chlamydia screen

Step 5

Reaching a Diagnosis & DDx — Explained in Plain Language

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The GP does not diagnose the cause of infertility in primary care — but initiates the pathway that will. Explaining the investigation results in plain language and helping the couple understand what different diagnoses mean for their treatment options is a core GP skill.

🗣️ Explaining unexplained infertility in plain language

"In about 1 in 4 couples, we can't find a clear reason after all the tests — this is called 'unexplained infertility'. That doesn't mean nothing is wrong; it means the tests we have can't identify the cause. The good news is that many couples with unexplained infertility do go on to conceive, either naturally or with IVF."

A — GP-managed / refer via routine pathway

Unexplained infertility

Normal investigations bilaterally. NICE: offer IUI (up to 6 cycles) or IVF (3 NHS cycles if eligible) after 2 years unexplained infertility or in women ≥35 after 12 months.

Anovulatory infertility (PCOS)

Irregular cycles + LH:FSH >2 + PCO on USS. First-line: weight loss + ovulation induction with letrozole or clomifene; refer to fertility clinic.

B — Specialist input needed

Male factor (oligospermia / azoospermia)

Repeat semen analysis 3 months apart. Severe oligospermia or azoospermia = andrology/urology referral; ICSI; surgical sperm retrieval if obstructive azoospermia.

Tubal factor (PID history, HSG block)

IVF is primary treatment bypassing tubes; hydrosalpinx = laparoscopic salpingectomy before IVF to double success rate. Refer to fertility clinic.

C — Urgent / concurrent diagnosis

Premature ovarian insufficiency (POI)

FSH >30 x2 + low oestradiol in woman <40. Irreversible in most cases. Fertility counselling; egg donation; HRT for bone/CVD protection. Refer to POI specialist.

Testicular malignancy

Painless testicular mass = 2WW USS immediately. Sperm cryopreservation before chemotherapy. Oncology & fertility co-management.

🎓 SCA Checkpoint — Step 5TasksRelating to OthersGlobal Skills

🔴 Red

Tubal factor = IVF not mentioned • POI not escalated • testicular mass not flagged • diagnosis given without explanation

🟢 Green

Diagnosis explained plainly • IVF/ICSI/IUI distinction made • NHS eligibility discussed • emotional impact of diagnosis acknowledged

Step 6

If Referral Is Needed — What the GP Does Before & During

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NICE CG156: refer couples with infertility >12 months (<35) or >6 months (≥35) or immediately if known cause is present. The GP should complete investigations before referral where possible to avoid delays at the fertility clinic. Local NHS IVF eligibility criteria must be checked as they vary by ICB.

Scenario	Urgency	GP action before referral	What GP must NOT do
Infertility >12 months (unexplained)	Routine	Initiate all NICE core investigations before referral; optimise lifestyle (BMI, smoking, alcohol); confirm IVF NHS eligibility locally; check rubella immunity + chlamydia	Delay referral until after all investigations completed if patient ≥35 — age is a time-critical factor
Woman ≥35: infertility >6 months	4–6 weeks	Refer earlier and initiate investigations simultaneously; do not wait 12 months; AMH + AFC urgently to assess ovarian reserve	Apply 12-month rule to woman ≥35 — NICE CG156 explicitly recommends 6-month threshold
POI diagnosed (FSH >30, <40 yrs)	Urgent	Start HRT immediately; fertility counselling; specialist POI clinic; DEXA; karyotype if <30; psychological support; discuss egg donation	Delay HRT pending specialist — every month without oestrogen causes bone loss; delay fertility counselling
Male azoospermia	4–6 weeks	Repeat semen analysis; karyotype; FSH/testosterone; refer to andrology — obstructive vs non-obstructive distinction; sperm banking if treatment planned	Dismiss as "nothing can be done" — surgical sperm retrieval (TESA/MESA) + ICSI is effective for obstructive azoospermia
Suspected endometriosis	Routine	Refer to gynaecology for laparoscopy; laparoscopic excision improves spontaneous conception rates; do not delay referral	Empirically prescribe GnRH analogues in primary care; this suppresses ovulation and delays fertility further

🎓 SCA Checkpoint — Step 6Tasks

🔴 Red

12m rule applied to ≥35 yr woman • POI HRT delayed • azoospermia dismissed • investigations not initiated before referral

🟢 Green

Age-appropriate referral threshold • investigations initiated simultaneously • POI treated promptly • NHS eligibility discussed

Step 7

Management — Expectation · Lifestyle · Ovulation Induction · Drug Cards · Psychosocial Support · Follow-Up

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7A — Setting expectations: validate → explain → agree a plan

🤝

The couple need three things from this consultation: explanation, a plan, and hope

Validate

Name the duration and burden explicitly. Don't minimise or rush past 14 months of trying.

"Fourteen months of trying is a significant amount of time, and I want to make sure we take this seriously and get things moving today."

Explain

Give the statistics honestly. Most couples do conceive with investigation and treatment — but timelines are real.

"The good news is that with the right investigations, we can often find out why and put together a plan. Most couples in your situation do go on to have a family, though it may take time."

Agree a plan

Today should end with specific actions: investigations booked, lifestyle changes started, referral initiated if indicated.

"Before you leave today I'd like to have arranged the blood tests, the semen analysis appointment, and a referral if we're at that stage — so you leave with something concrete."

7B — Lifestyle modifications: mechanism + evidence

💔

Folic Acid

400 mcg OD (5mg if high risk)

Mechanism

Prevents neural tube defects (NTD): spina bifida, anencephaly. Folate supports DNA synthesis and methionine metabolism. Neural tube closes at day 26–28 — before most women know they are pregnant.

Practical

Start 3 months before conception; continue until 12 weeks pregnant. 5mg for epilepsy, diabetes, BMI >30, previous NTD, thalassaemia. BHIVA guidelines recommend 5mg for HIV.

Reduces NTD risk by 70%

⚖️

BMI Optimisation

BMI 19–30 for optimal fertility

Mechanism

BMI <19: hypothalamic GnRH suppression causes anovulation. BMI >30: insulin resistance drives androgen excess, disrupts follicular development, impairs implantation. Obese women have 30% lower IVF success rates.

Practical

5–10% weight loss restores ovulation in 55% of overweight anovulatory women. Refer to structured weight management programme (NHS Tier 3 if BMI >35). Delay IVF until BMI <30 for most NHS ICBs.

5-10% weight loss restores ovulation in 55%

🚬

Smoking Cessation

Stop completely — both partners

Mechanism

Smoking causes DNA damage in oocytes and sperm, reduces ovarian reserve (AMH lower in smokers), impairs implantation via endometrial receptivity changes, and doubles miscarriage risk. IVF outcomes significantly worse in smokers.

Practical

NHS Stop Smoking Service: varenceline (first-line), NRT (safe in TTC), bupropion. Both partners should stop. Most NHS ICBs require non-smoking for IVF funding.

Improves AMH; IVF success rates comparable to non-smokers within 12 months

🧔

Alcohol Reduction

Female <5 units/wk; male <14 units/wk

Mechanism

Female: alcohol impairs follicular development, implantation, and embryo quality; reduces IVF success rate at >5 units/week. Male: alcohol >14 units/week reduces testosterone, sperm count and motility.

Practical

Advise abstinence in early pregnancy (no safe level). Brief intervention using AUDIT-C score; referral to alcohol services if dependent. NICE: women trying to conceive should ideally avoid alcohol.

Reduces alcohol improves IVF outcomes; abstinence in pregnancy

🏃

Exercise (moderate)

150 min/week; avoid excessive

Mechanism

Moderate exercise improves insulin sensitivity (PCOS), maintains healthy BMI, reduces stress hormones. Extreme exercise (>7 hours intense/week) suppresses GnRH — hypothalamic anovulation in athletes.

Practical

Target: 150 min/week moderate activity. Advise reducing extreme exercise if hypothalamic anovulation suspected (low BMI, loss of period with heavy training).

Moderate exercise improves PCOS ovulation; avoid excessive for hypothalamic anovulation

🌞

Vitamin D & Supplements

10 mcg VD3/day; avoid high-dose Vit A

Mechanism

Vitamin D deficiency is associated with implantation failure and reduced IVF success. Excess vitamin A (retinol) is teratogenic — avoid liver, liver products, and high-dose supplements. Vitamin C and E antioxidants may support sperm quality.

Practical

Advise 10 mcg vitamin D daily throughout TTC and pregnancy. Avoid supplements with high retinol. No evidence for CoQ10 or DHEA in primary care, though used in fertility units.

Vitamin D deficiency correction may improve implantation rates

7C — Medication selector & drug reference cards

Infertility context selector — guides drug card focus

Anovulation / PCOS (ovulation induction) Male factor (semen quality) IVF / IUI cycle support Hyperprolactinaemia Pre-conception supplementation PCOS + insulin resistance

Guidance

Select the clinical context above for targeted drug card guidance.

Clomifene Citrate

Clomid 50mg — ovulation induction in anovulatory infertility

✓ First-line (PCOS anovulation)

Ovulation induction50mg days 2–6; max 100mg; max 6 cycles

✓ Use when

Anovulatory infertility (PCOS) + BMI <30 + no tubal / severe male factor

Initiate in fertility clinic; not recommended in primary care without monitoring

✗ Avoid if

Tubal pathology — no benefit; IVF needed

Ovarian cyst present (USS first)

Liver disease; abnormal uterine bleeding undiagnosed

⚠ Side effects

Multiple pregnancy (8–10% twins); ovarian hyperstimulation; visual disturbance (stop immediately); hot flushes

🔬 Monitor

Follicle tracking USS on day 10–12 to confirm ovulation and check OHSS risk; progesterone day 21 to confirm ovulation; do not exceed 6 cycles

💬 Counselling

"This tablet helps your body to ovulate. Take it from day 2 to day 6 of your cycle. Twin pregnancy risk is around 1 in 10. If you get visual disturbances, stop and contact us immediately."

SCA pearl: Clomifene is NOT prescribed in primary care without fertility clinic involvement and USS monitoring. Mentioning this limitation, and that it requires monitoring, demonstrates accurate clinical knowledge in the SCA.

Letrozole (Femara)

Off-label for ovulation induction; superior to clomifene in PCOS

✓ Preferred (PCOS + BMI >30)

Ovulation induction2.5–5mg days 2–6

✓ Use when

PCOS anovulation — higher live birth rate than clomifene in PCOS (NEJM PPCOS trial)

BMI >30 with PCOS: better ovulation rates than clomifene in this group

Clomifene failure (no ovulation at 100mg) — switch to letrozole

✗ Avoid if

Pregnancy (teratogen in animal models; off-label for ovulation induction in UK)

Liver impairment; must be prescribed within fertility clinic context

⚠ Side effects

Lower multiple pregnancy rate than clomifene (2–3%); hot flushes; headache; fatigue

💬 Counselling

"This is a tablet we use to help ovulation. It's actually licensed for breast cancer treatment but is widely used for fertility — the evidence for it is better than the older tablet (clomifene) for your type of irregular ovulation."

SCA pearl: NICE CG156 (2023 update) recommends letrozole over clomifene as first-line ovulation induction in PCOS. Knowing this change from prior guidance demonstrates up-to-date clinical knowledge — a scored Tasks item.

Gonadotrophins (FSH / hMG)

Gonal-F; Menopur; Bemfola; Pergoveris — IVF / IUI stimulation

✓ IVF stimulation

IVF / IUI75–225 IU SC; fertility clinic protocol

✓ Use when

IVF / ICSI ovarian stimulation — fertility clinic prescribes and monitors

Hypogonadotrophic hypogonadism — replaces absent endogenous FSH/LH

IUI cycle stimulation (low dose) to produce 1–2 dominant follicles

✗ Avoid if

Without ultrasound monitoring — OHSS risk; multiple pregnancy risk is high without monitoring

PCOS: high OHSS risk; careful dose titration and USS monitoring essential

⚠ Side effects

OHSS: abdominal distension, nausea, oliguria, ascites, pleural effusion — severe OHSS = hospital admission

Multiple pregnancy; injection site reactions

💬 Counselling

"These injections stimulate your ovaries to produce eggs for IVF. You'll be monitored with regular scans. If you get significant abdominal bloating, reduced urine output, or difficulty breathing after the injections, contact the fertility unit immediately."

SCA pearl: OHSS is the most serious complication of ovarian stimulation. Knowing the warning symptoms (bloating, reduced urine, breathlessness) and that it requires urgent contact with the fertility unit — not just GP — is a scored safety knowledge item.

Metformin (Glucophage)

500mg–2500mg/day in divided doses — insulin sensitiser in PCOS

✓ PCOS + insulin resistance

PCOS adjunct500mg OD → titrate to 1500–2500mg/day

✓ Use when

PCOS with insulin resistance (fasting glucose >6.1; HbA1c ≥42; acanthosis nigricans)

Adjunct to letrozole or clomifene in PCOS — improves ovulation rates

Prevention of OHSS risk in PCOS women undergoing IVF

✗ Avoid if

eGFR <30 mL/min/1.73m² (lactic acidosis risk)

Iodinated contrast within 48 hours; hepatic impairment; alcohol excess

⚠ Side effects

GI intolerance (nausea, diarrhoea) — minimise by slow titration and taking with food; use modified-release formulation if poorly tolerated

Vitamin B12 deficiency with long-term use; check B12 annually

💬 Counselling

"Metformin helps your body respond better to insulin, which in your case is contributing to the irregular periods. Start with one tablet a day with food and build up slowly to reduce the stomach side effects."

SCA pearl: Metformin is not a first-line ovulation inducer — it is an insulin sensitiser that improves ovulation rates as an adjunct. NICE CG156 (2023): do not offer metformin alone for ovulation induction in PCOS; use with letrozole or clomifene.

Progesterone Luteal Support

Cyclogest 400mg pessaries; Utrogestan 200mg; Crinone 8% gel

✓ IVF luteal support

IVF cycleFrom egg collection; fertility clinic prescribes

✓ Use when

Luteal phase support after IVF/ICSI egg collection — replaces progesterone suppressed by GnRH analogue protocol

Recurrent implantation failure — some evidence for progesterone supplementation in natural cycle

✗ Avoid if

Undiagnosed vaginal bleeding; thrombophlebitis; hormone-sensitive neoplasia

⚠ Side effects

Vaginal: local irritation, discharge. Oral: drowsiness (take at bedtime), headache, bloating

💬 Counselling

"These pessaries support the lining of the womb to help the embryo implant. Use them from egg collection day as the clinic advises and continue until the pregnancy test. They may cause some vaginal discharge — that's normal."

SCA pearl: Progesterone luteal support is routine post-IVF and is prescribed/managed by the fertility clinic. The GP role is to know it exists, recognise it on a medication list, and not discontinue it without specialist advice during early pregnancy.

Folic Acid & Pre-Conception Supplements

Folic acid 400mcg OD standard; 5mg if high risk; Vitamin D 10mcg OD

✓ All couples TTC

Pre-conception400mcg folic acid (5mg high risk); start 3 months before

✓ Always recommend

Folic acid 400mcg OD: all women trying to conceive; start 3 months before and continue to 12 weeks

5mg folic acid: epilepsy, diabetes, BMI >30, previous NTD, thalassaemia, HIV on certain antiretrovirals

Vitamin D 10mcg OD: all pregnant and breastfeeding women; TTC recommended in UK (autumn/winter)

✗ Caution

Avoid retinol (vitamin A) supplements and liver — teratogenic in high doses

Avoid high-dose vitamin A in combined supplements; check individual supplement contents

⚠ Notes

No evidence for omega-3, CoQ10, DHEA supplements in primary care infertility; advise diet-first approach

Iodine: RCOG recommends 150mcg iodine supplement in TTC and pregnancy (UK population iodine deficiency common)

💬 Counselling

"Folic acid is one of the most important things you can take — it protects against spinal problems in the baby right from the very start. Start now even before you're pregnant. Also take a vitamin D supplement, especially through autumn and winter."

SCA pearl: Folic acid counselling is a mandatory Tasks item in any infertility or pre-conception SCA station. Standard dose 400mcg; high-risk 5mg (epilepsy, diabetes, obesity, previous NTD). Failure to mention it scores a deduction.

7D — Psychosocial support: specific referrals, not generic advice

🤝

Infertility psychological support — NICE CG156 mandated elements

🎓

Counselling: NICE mandated

NICE CG156: licensed fertility clinics must offer counselling to all people undergoing treatment. GP should refer to NHS fertility counselling at the time of fertility clinic referral — not as an afterthought after failed cycles.

"There's specific counselling available through the fertility service which many couples find really helpful — I'll make sure that's part of your referral."

👴

Relationship support

Medicalised sex and blame attribution strain relationships. Relate and BICA (British Infertility Counselling Association) offer specialist couples counselling for infertility. NICE CG156 endorses this.

"This process puts a lot of pressure on relationships — if you'd find it helpful, there's specialist couples support specifically for people going through fertility treatment."

📚

Information resources

Fertility Network UK (patient charity); HFEA website (licensed clinics, treatment info); Donor Conception Network (for donor treatment pathways). GP should direct patients to reliable sources, not self-directed social media.

"I'd recommend looking at the Fertility Network UK website — it's a patient charity with really good, balanced information."

💥

NHS eligibility discussion

NHS IVF eligibility varies by local ICB. Most require: age <40 (female), <3 previous IVF cycles, no existing children (in some areas), non-smoker, BMI 19–30, duration criteria. The GP must be honest about local eligibility and not raise false hopes.

"I want to be honest with you about what's available on the NHS locally — the rules vary and I want to make sure I give you an accurate picture."

7E — Safety-netting

⚠ Three scenario-specific phrases

Next appointment Review investigation results; adjust plan; referral if not yet initiated

After referral Fertility clinic will manage; GP role: ongoing emotional support, medication reconciliation, pre-natal booking

Immediately Ectopic symptoms with positive test; OHSS signs; suicidal ideation

🎓 SCA Checkpoint — Step 7 (Final)TasksRelating to OthersGlobal Skills

Closing phrases

"Before you leave today, let's make sure we've arranged the blood tests and semen analysis — so you're not leaving empty-handed."

"Are you taking folic acid? That's one of the most important things right now."

"If you get a positive test and any one-sided pain, please go straight to A&E."

"The NHS pathway can take time — I want to be honest about that while keeping the process moving."

Final deductions

No folic acid mention — mandatory pre-conception item
No ectopic warning for tubal factor patient
Not acknowledging NHS IVF eligibility/timelines honestly
No psychological support offered
No investigations arranged at close of consultation

🔴 Red

No folic acid • no ectopic warning • only female investigated • no referral threshold discussed • no psychosocial support

🟠 Amber

Both partners • folic acid • referral discussed • emotional impact acknowledged but support not offered

🟢 Green

Both partners investigated • folic acid confirmed • ectopic warning • OHSS safety-net • counselling offered • NHS eligibility honest • investigations booked today

"We've been trying for over a year now and nothing's happening. I've been tracking my cycle obsessively and my partner had a vasectomy reversal three years ago. We've been reading about IVF online and we're worried about whether we'd qualify on the NHS."

Who you are (female partner)

Emma, 31, nurse. Regular cycles (28 days). No previous pregnancies. One episode of chlamydia treated 5 years ago — will not volunteer unless asked. BMI 26. Non-smoker. Drinks 8 units/week (stress-related). Taking folic acid 400mcg OD (started 2 months ago). PHQ-9 score would be 12 (moderate depression).

Who you are (male partner)

James, 33, IT consultant. Vasectomy reversal 3 years ago. No other children. BMI 31. Drinks 18 units/week. Cyclist (3 hours/day). Works from home — laptop on lap for hours. No other medical history. No medications. Has not had semen analysis.

Hidden agenda

You're terrified the IVF won't be funded on the NHS because you've heard the rules are strict. You feel guilty about the chlamydia but won't bring it up. James blames himself for the vasectomy reversal. You're both exhausted and your relationship is under strain. Emma is considering stopping trying.

If asked directly about STI history

Emma: "Yes, I had chlamydia when I was 26. It was treated. I never had PID as far as I know."
James: No STI history
Emma: "I didn't know that could affect the tubes — is that why this is happening?"

"Are we likely to get IVF on the NHS? We can't afford to do it privately and I'm scared we're going to be told we don't qualify."

Resolution: Accept the plan if the doctor: (1) Addresses both partners and initiates both partner investigations; (2) Asks about STI/PID history without judgment; (3) Explains NHS IVF eligibility honestly (local ICB rules vary); (4) Arranges ectopic safety-netting given PID history; (5) Discusses James's alcohol and cycling as modifiable male factors; (6) Confirms folic acid and offers psychological support.

🏥

Clinic Quick Reference

Infertility — Clinical Decision Framework

NICE CG156 (2023)

▼expand

🚦 1 — Triage & Thresholds

🔴 Immediate action

Ectopic pregnancy signs • OHSS • Testicular mass (2WW USS) • Valproate in woman of childbearing potential • Suicidal ideation

🟠 Urgent (4–6 wks)

Woman ≥35: 6-month threshold • Galactorrhoea (prolactin + MRI) • POI (FSH>30) • Azoospermia (andrology)

🟢 Routine

<35: after 12 months • ≥35: after 6 months • Initiate all NICE core investigations • NHS eligibility check

📊 2 — Key Numbers

12 months

Investigate threshold (<35)

6 months

Investigate threshold (≥35)

84%

Conceive within 1 year

92%

Conceive within 2 years

1 in 7

UK couples affected

Day 21

Progesterone (28-day cycle)

3 cycles

NHS IVF (NICE recommendation)

<35 yrs

NHS IVF age limit (most ICBs)

📊 3 — NICE Core Investigations (both partners)

👶 Female

Progesterone day 21 (ovulation) • FSH/LH/E2 day 2–5 • AMH (ovarian reserve) • TSH • Prolactin • Rubella immunity • Chlamydia NAAT • Pelvic USS (AFC) • HSG / HyCoSy (tubal patency)

👴 Male

Semen analysis (WHO 2021) • Repeat if abnormal (3 months apart) • FSH/testosterone if azoospermia • Karyotype if severe oligospermia • Testicular USS if mass

🔴 Red flags: Ectopic symptoms • OHSS • Testicular mass • Valproate in woman TTC • Suicidal ideation

🛡️ Safeguarding: Reproductive coercion • Donor conception welfare of child • Infertility-related mental health crisis

🎓

SCA Exam Quick Reference

SCA Consultation Blueprint

Tasks · Relating to Others · Global Skills · RAG guide

▼expand

🕐 12-Minute Flow

0–2 min

Empathy first

"Before the questions, tell me how you've both been coping with this."

ROGS

✗ Starting with "when did you start trying?"

2–5 min

Both partner history

"Have either of you had a pelvic infection or chlamydia? I ask everyone."

TasksGS

✗ Female only • ✗ No STI/PID history

5–7 min

ICE + lifestyle

"What's your biggest worry? Funding? What might be causing it?"

✗ No ICE • ✗ No smoking/alcohol check

7–10 min

Investigations + plan

"Today I'd like to arrange a blood test to confirm ovulation and a sperm test for your partner."

Tasks

✗ Female investigations only • ✗ No folic acid check

10–12 min

Safety-net + close

"Positive test + pain = A&E same day. How are you both feeling?"

TasksROGS

✗ No ectopic warning • ✗ No mood check

🔴🟠🟢 RAG Scoring

Tasks

🟢

Both partners investigated • folic acid • correct threshold • ectopic warning • counselling offered

🟠

Female investigations • folic acid • threshold correct • no OHSS/ectopic safety-net

🔴

Female only • no folic acid • 12m threshold for ≥35 • no referral • no safety-net

Relating to Others

🟢

Empathy first • ICE all 3 • both partners • STI non-judgmental • hope honest • counselling

🔴

No empathy • no ICE • female only • STI judgmental • dismissive of funding concern

💬 Key Phrases

Open

"Before the questions, tell me how you've both been coping."

STI

"Have either of you had a pelvic infection or chlamydia? I ask everyone."

Folic acid

"Are you taking folic acid? That's one of the most important things right now."

NHS honest

"The NHS rules vary by area — I want to give you an accurate picture, not false hope."

Ectopic

"Positive test + pain = A&E same day — mention your PID history."

"You leave today with investigations booked — let's make sure that happens before you go."

🚫 9 Danger Zones

✗

Female history only
→ Male factor = 30% of cases; semen analysis mandatory

✗

12-month rule applied to woman ≥35
→ NICE CG156: 6-month threshold for ≥35; refer earlier

✗

No folic acid check
→ Pre-conception mandatory; 400mcg standard; 5mg if high risk

✗

No STI/PID history
→ Chlamydia is leading preventable cause of tubal infertility

✗

No ectopic warning with tubal history
→ Positive test + pain = A&E; this is a mandatory safety-net

✗

Valproate not flagged
→ MHRA 2023: urgent specialist review; no TTC without pregnancy prevention programme

✗

No psychological support offered
→ NICE CG156 mandates counselling as part of any licensed treatment

✗

Overselling NHS IVF eligibility
→ Local ICB criteria vary; be honest; do not promise 3 cycles universally

✗

No concrete actions at end of consultation
→ Patient should leave with investigations booked, not just promised

Infertility · GP Clinical Reasoning Framework v2 · NICE CG156 Fertility problems: assessment and treatment (2013, updated 2023) · NICE CKS Infertility (2023) · HFEA Code of Practice 9th Edition · WHO Semen Analysis Reference Values 2021

v2: Clinical stem · Open Q first · ICE in all modes · Psychosocial (1D + 7D) · Both-partner approach · Safeguarding (1B) · Expectation management (7A) · SCA RAG checkpoints after every step · SCA Scorecard as standalone section · Dual tailored summaries

Teaching clinicians why each step matters — not just what to do · Always consult current BNF/NICE CKS/HFEA guidance · Clinical judgement takes precedence over any framework

Infertility

Red Flags in infertility history

Safeguarding Considerations

🛡️ Reproductive coercion

👴 Child safeguarding (existing children)

🧠 Mental health crisis

🕊 Vulnerability in donor conception

🛡️ Grief and identity

👴 Relationship strain

📚 Social and cultural pressure

💥 Financial and occupational stress

🧠 Mental health impact

🌼 Folic acid and pre-conception health

999 or Same-Day Hospital

Same Day / 2-Week Wait

GP-managed

Unexplained infertility

Anovulatory infertility (PCOS)

Male factor (oligospermia / azoospermia)

Tubal factor (PID history, HSG block)

Premature ovarian insufficiency (POI)

Testicular malignancy

Validate

Explain

Agree a plan

Infertility context selector — guides drug card focus

Counselling: NICE mandated

Relationship support

Information resources

NHS eligibility discussion

⚠ Three scenario-specific phrases

🎭 Patient actor brief — click to practise

Who you are (female partner)

Who you are (male partner)

Hidden agenda

If asked directly about STI history