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The general practitioner is likely to be the first port of call for a woman with questions or worries about her fertility. It is important to be confident in providing initial advice and guidance regarding fertility, and to know when further investigations or referral to secondary care is warranted.

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The most likely reason for a woman to consult related to fertility is difficulty conceiving. Most women can be reassured that the vast majority of couples (84%) will conceive within a year of having regular unprotected intercourse.

Pre-conception advice is important for all women trying to conceive. Women should be advised to limit alcohol intake to no more than one or two units once or twice per week. They should be advised to commence daily oral folic acid and informed of the benefits of this in reducing the incidence of neural tube defects in babies.

Women should be encouraged to stop smoking, and ensure a healthy, balanced diet. For women who are overweight or obese, weight loss can contribute to increased chance of conception.

Couples should be advised to aim to have sex every two to three days, and that there is no added benefit to having sex every day or more than once per day.

It may be useful for a couple to track the woman’s menstrual cycle, to ensure they are having intercourse around the time of ovulation.

A woman under the age of 35 who has failed to conceive after two years of regular intercourse should be offered further assessment. The GP should take a thorough history, including details of any previous pregnancies, her menstrual cycle, the frequency and timing of intercourse and any medical conditions and regular medications that may be relevant.

In a woman with regular menses, the preliminary investigation is mid-luteal progesterone, which, where raised, likely confirms ovulation is occurring. In a woman with irregular cycles, which, in most cases indicates an ovulatory disorder such as polycystic ovary syndrome (PCOS), additional blood tests may be helpful. These may include follicle-stimulating hormone (FSH), luteinising hormone (LH), oestradiol, thyroid function tests and prolactin. Where such tests are normal, further investigation for male factor infertility or imaging for female factor infertility may be considered.

Investigations should be considered earlier in a woman over the age of 35. Depending on the results of these investigations, referral to secondary care for assisted conception may be necessary.

Toward the end of the reproductive life, women may consult with the GP regarding menopause and cessation of fertility. Women can be advised that menopause is diagnosed in a woman over the age of 50 who is not taking any hormonal contraceptives when she has not had a menstrual period for over one year.

In women aged 40­–50 not on hormonal contraception, the absence of menstrual periods for over two years is considered menopause. For women using hormonal contraception, or still having menstrual bleeding, natural loss of fertility is assumed to occur at the age of 55. For women using certain contraceptives, an FSH level can assist in diagnoses of menopause.

In summary, an understanding of the menstrual cycle, reproductive lifespan, and the expected process and timescale for conception are essential for any GP consulting with women with questions about their fertility.

Dr Samantha Miller, MBChB

Read another article like this one: Managing women’s sexual health in primary care

References

1. Fertility Network UK (2016). Fertility treatment: What the GP needs to know. https://fertilitynetworkuk.org/wp-content/uploads/2016/08/FACTSHEET-Funding-Information-for-GPs-June-2016.pdf
2. Australian Journal of General Practice (2020). Assessment of female fertility in the general practice setting. https://www1.racgp.org.au/ajgp/2020/june/female-fertility-in-general-practice-setting
3. Faculty of Sexual and Reproductive Health (FSRH) (2019). Contraception for Women Aged Over 40 Years https://www.fsrh.org/documents/fsrh-guidance-contraception-for-women-aged-over-40-years-2017/fsrh-guideline-contraception-aged-over-40-sep-2019.pdf
4. Department of Health, State Government of Victoria, Australia (2021). Better Health Channel: Age and Fertility. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/age-and-fertility#bhc-content
5. Department of Health, State Government of Victoria, Australia (2021). Better Health Channel: Age and Fertility. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/infertility-in-women
6. Trying to get pregnant (2020). https://www.nhs.uk/pregnancy/trying-for-a-baby/trying-to-get-pregnant/
7. How long does it take to get pregnant? (2018). https://www.nhs.uk/pregnancy/trying-for-a-baby/how-long-it-takes-to-get-pregnant/