Infertility Management in Women and Men Attending Primary Care

Patient Characteristics, Management Actions and Referrals

Georgina M. Chambers; Christopher Harrison; James Raymer; Ann Kristin Petersen Raymer; Helena Britt; Michael Chapman; William Ledger; Robert J. Norman

Disclosures

Hum Reprod. 2019;34(11):2173-2183. 

In This Article

Abstract and Introduction

Abstract

Study Question: How did general practitioners (GPs) (family physicians) manage infertility in females and males in primary care between 2000 and 2016?

Summary Answer: The number of GP infertility consultations for females increased 1.6 folds during the study period, with 42.9% of consultations resulting in a referral to a fertility clinic or specialist, compared to a 3-fold increase in the number of consultations for men, with 21.5% of consultations resulting in a referral.

What is Known Already: Infertility affects one in six couples and is expected to increase with the trend to later childbearing and reports of declining sperm counts. Despite GPs often being the first contact for infertile people, very limited information is available on the management of infertility in primary care.

Study Design, Size, Duration: Data from the Bettering the Evaluation and Care of Health programme were used, which is a national study of Australian primary care (general practice) clinical activity based on 1000 ever-changing, randomly selected GPs involved in 100 000 GP–patient consultations per year between 2000 and 2016.

Participants/Materials, Setting, Methods: Females and males aged 18–49 years attending GPs for the management of infertility were included in the study. Details recorded by GPs included patient characteristics, problems managed and management actions (including counselling/education, imaging, pathology, medications and referrals to specialists and fertility clinics). Analyses included trends in the rates of infertility consultations by sex of patient, descriptive and univariate analyses of patient characteristics and management actions and multivariate logistic regression to determine which patient and GP characteristics were independently associated with increased rates of infertility management and referrals.

Main Results and the Role of Chance: The rate of infertility consultations per capita increased 1.6 folds for women (17.7–28.3 per 1000 women aged 18–49 years) and 3 folds for men over the time period (3.4–10.2 per 1000 men aged 18–49 years). Referral to a fertility clinic or relevant specialist occurred in 42.9% of female infertility consultations and 21.5% of male infertility consultations. After controlling for age and other patient characteristics, being aged in their 30s, not having income assistance, attending primary care in later years of the study and coming from a non-English-speaking background, were associated with an increased likelihood of infertility being managed in primary care. In female patients, holding a Commonwealth concession card (indicating low income), living in a remote area and having a female GP all indicated a lower adjusted odds of referral to a fertility clinic or specialist.

Limitations, Reasons for Caution: Data are lacking for the period of infertility and infertility diagnosis, which would provide a more complete picture of the epidemiology of treatment-seeking behaviour for infertility. Australia's universal insurance scheme provides residents with access to a GP, and therefore these findings may not be generalizable to other settings.

Wider Implications of the Findings: This study informs public policy on how infertility is managed in primary care in different patient groups. Whether the management actions taken and rates of secondary referral to a fertility clinic or specialist are appropriate warrants further investigation. The development of clinical practice guidelines for the management of infertility would provide a standardized approach to advice, investigations, treatment and referral pathways in primary care.

Study Funding/Competing Interest(S): This paper is part of a study being funded by an Australian National Health and Medical Research Council project grant APP1104543. G.C. reports that she is an employee of The University of New South Wales (UNSW) and Director of the National Perinatal Epidemiology and Statistics Unit (NPESU), UNSW. The NPESU manages the Australian and New Zealand Assisted Reproductive Technology Database on behalf of the Fertility Society of Australia. W.L. reports being a part-time paid employee and minor shareholder of Virtus Health, a fertility company. R.N. reports being a small unitholder in a fertility company, receiving grants for research from Merck and Ferring and speaker travel grants from Merck.

Introduction

Infertility affects one in six couples and over 180 million people worldwide (Inhorn and Patrizio, 2015; Loxton and Lucke, 2009), causing significant personal suffering and representing an important public health problem. The trend to later childbearing seen worldwide (de Graaff et al., 2011), rising rates of obesity (Pantasri and Norman, 2014) and a decline in sperm counts in developed countries (Levine et al., 2017), all point to increasing demand for the medical management of infertility.

The treatment of infertility has been revolutionized over the past 40 years by ART, such as IVF, with an estimated 1.5 million cycles performed each year worldwide (Dyer et al., 2016). A similar number of more traditional fertility treatments, such as ovulation induction and artificial insemination, are also performed each year (Kulkarni et al., 2013). However, before such treatments can be offered, patients in many countries are generally managed in primary care (general practice) by general practitioners (GPs) (family physicians) before being referred to a IVF/fertility clinic or relevant specialist (e.g. gynaecologist or urologist) gynaecologist.

Previous studies indicate that only approximately one in two women who suffer from infertility—generally considered to be the failure to conceive after 12 months of unprotected timed intercourse—seek medical assistance to become pregnant (Boivin et al., 2007; Oakley et al., 2008; Datta et al., 2016). For example, in a recent survey of US women suffering from infertility, only 42% consulted their doctor about ways of becoming pregnant (Greil et al., 2016), and in surveys of Australian women between 58% and 71% of women suffering from infertility sought assistance (Herbert et al., 2009; Marino et al., 2011).

Relatively good data on fertility treatments provided outside of primary care exists in national ART registries (Adamson et al., 2018; Centers for Disease Control and Prevention (CDC) et al., 2018; Fitzgerald et al., 2018; Human Fertilisation and Embryology Authority (HFEA), 2018 and medical claims datasets. However, there is very little information on the management of infertility in the primary care setting by GPs. In Australia, GPs are the first port of call in the health care system with almost all consultations being self-referred and GPs acting as gatekeepers to other health care services. There are over 36 000 GPs in Australia representing approximately 150 GPs per 100 000 population (Royal Australian College of General Practitioners, 2018). Australia's universal health insurance scheme, Medicare, which is mainly funded through a levy on taxpayers, covers all or part of the cost charged by GPs for services provided. GPs can either bill Medicare directly for the total Medicare benefit for consultations or can charge patients an additional fee, which the patient must pay as an out-of-pocket expense.

Given that primary care is the most important access point for reproductive care and education, understanding the treatment-seeking behaviours and first-line management actions of infertility in primary care is important for improving outcomes for couples and individuals wishing to have children. Therefore, the objective of this study is to examine the management of infertility over recent years in Australian primary care.

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