General Practitioners

A Guide for Family Doctors

At ReproMed Ireland, we understand that as a GP you are generally the initial point of contact for patients with questions regarding their fertility.  We have put together some useful information to help you provide patients with the best possible understanding and guidance. You can also refer your patient direct from this page or you can find us on Socrates E- referral and Healthlink.

Primary management of infertility by General Practitioners

The scope of this webpage is to assist GP’s with necessary information for their day to day practice, and provide an easy referral pathway of their subfertile patients for the next steps when needed. The best way is to divide patients into those that can be treated in general practice and patients that should be referred to ReproMed.

Definition:

Infertility is the inability to achieve an ongoing pregnancy after 12 months of regular unprotected intercourse (defined as 2 or more times per week). 84% of couples will conceive in the first year. The probabilities of conceiving reduce with time trying and age.

  • Around 50-60% of couples will achieve pregnancy in the first 6 months of trying
  • 84% within one year
  • 90% within 2 years

There is a drop in fertility associated with maternal age. The reasons are an increase in the percentage of aneuploid embryos, mainly originating from meiotic alterations in the egg associated to age. Please refer to our Algorithm.

Common causes of infertility

The main causes of infertility have changed in the last 30 years. What used to be the main cause (tubal obstruction) is now reduced to 10-15%. When analyzing the frequency of causes one needs to divide the subfertile population in couples with a female patient younger or older than 35 years of age.

In the younger population the causes of infertility are divided into:

  • 40% female causes (tubal obstruction, ovulatory dysfunction, uterine abnormalities)
  • 40% male causes (poor motility or number of sperm, anejaculation, impotence)
  • 20% unexplained

In the population with the female older than 35, this ratio changes and the female causes become more common.

Ovulatory dysfunction: The hall mark of ovulatory dysfunction in the absence of regular menstrual cycles defined as cycles between 21-35 days with a variation between cycles of no more than 7 days. These can be divided in 3 groups according to WHO:

  • WHO I: hypogonadotropic hypogonadism
  • WHO II: PCOS
  • WHO III: hypergonadotropic hypogonadism

Tubal pathology: tubal obstruction or dysfunction has become less frequent with the introduction of screening and early treatment of STIs. What used to be the main cause of infertility is now reduced to 10-15% (some studies refer a prevalence as low as 6%). Other causes include endometriosis, previous pelvic surgery, smoking (by alteration of cilliar motility).

Semen alterations: There are causes of semen alterations for which to investigate. These are previous surgeries (orchidopexia, hernia repair), adult mumps, certain genetic or chromosomal alterations (cystic fibrosis, Klinefelter’s disease) but most of the times no diagnosis will be found. Also consider male general health including smoking, excessive alcohol intake, and obesity.

When to refer the patient to ReproMed?

The main reason for the drop in fertility with age is explained by the increase in the aneuploidy of embryos. This is usually associated with a natural reduction in the ovarian reserve with aggravates the prognosis and time available for treatment. For this reason the recommendations to refer patients change with age.

  1. No success after 12 months of unprotected sex for women 35 or younger, and 6 months for women older than 35
  2. Recurrent pregnancy loss (2 or more miscarriages)
  3. Premature ovarian failure
  4. Genetic or chromosomal conditions
  5. Abnormal sperm parameters (low sperm concentration or motility) refer to algorithm
  6. A sensible approach could be an AMH of <15 pmol/L in patients between 30-35 y.o.a. who want more than one more child to consider the possibility of egg freezing.

Who to treat?

The primary treatment of infertility by GPs should be focused on ovulation induction with  timed sexual intercourse. This type of treatment involves the stimulation of ovulation in anovulatory patients and then intercourse during a specified period. This treatment is not useful in patients who are ovulating, as a coital frequency of 2-3 times per week ensures the presence of spermatozoa during ovulation each month.

(Please refer to the algorithm and protocol that you will find in this webpage)

IMPORTANT:  in couples in which the female has regular menses (is ovulating) and have a coital frequency of 2-3 ovulation induction should not be recommended

Infertile couples in which the female has regular menses and appropriate coital frequency should be referred for evaluation and treatment to a ReproMed.

Counselling

ReproMed has a counselling service for specialised infertility advice and support.

Private Health Insurance

VHI customers may avail of a number benefits exclusively with ReproMed.

Patient Resources

We offer a range of support services and information to assist your patients in their fertility journey. These range from our unique ReproMed personalised video medical consenting resources which outline the patient journey in a robust format. This will explain the intricacies of treatment and is the way forward for future medical consenting. We also offer a patient portal for easy access to all their details, with treatment plan updated regularly to de-stress the fertility journey and increase the patient support we offer.

Dr. Hans Arce is our Medical Director and consultant in ReproMed Ireland. He graduated from Universidad Peruana Cayetano Heredia in Lima, Peru. He prides himself for his practical approach to problems but specially the importance of the human emotional side his patients have to go through in this very difficult journey. He also works really hard to deliver to his patients the most evidence based treatments he has in hand.
Results from new Calcium Ionophore treatment offered by Repromed are promising.