Trying to Conceive: Subfertility Assessment

Clinical Scenario

Olivia de Rosa, 31, calls saying she needs help getting pregnant. She and her husband Marco have been trying to conceive for 12 months with regular intercourse. Her Mirena IUS was removed 12 months ago, and periods returned normally within 6 weeks. Her cycles are regular at 28-29 days and she is using ovulation predictor kits. She had a termination of pregnancy at age 24 and is privately worried this may have damaged her fertility. She is already taking folic acid.

What This Case Tests

Confirming subfertility criteria are met and initiating investigation; taking a thorough fertility history including male factor; addressing concerns about previous termination affecting fertility; knowing first-line investigations for both partners; providing evidence-based preconception advice.

Common Mistakes Trainees Make

The three most common mistakes are: investigating only the female partner (male factor contributes to approximately 30% of subfertility — semen analysis must be arranged), not asking about the previous termination or assuming it is irrelevant (Olivia may be carrying significant guilt), and providing generic advice ("just relax and it will happen") rather than structured, evidence-based management.

The Consultation Challenge

Olivia meets the NICE criteria for subfertility investigation: 12 months of regular unprotected intercourse without conception, in a woman under 36. She is well-prepared (regular cycles, ovulation tracking, folic acid) and proactive. The consultation is about initiating the appropriate workup and addressing her emotional state.

Take a comprehensive fertility history for both partners. For Olivia: menstrual cycle regularity (regular 28-29 day cycles strongly suggest ovulation), previous pregnancies and outcomes (the termination — handled sensitively), gynaecological history (STIs, pelvic surgery, cervical treatment), medical conditions (thyroid, diabetes, PCOS features), BMI and lifestyle (smoking, alcohol, exercise), and cervical screening history. For Marco: any previous children, testicular history (undescended testes, surgery, trauma, infections including mumps orchitis), medications, occupational exposures, and lifestyle factors.

First-line investigations: for Olivia — day 2-5 bloods (FSH, LH, oestradiol, thyroid function, prolactin), mid-luteal progesterone (day 21 if 28-day cycle — confirms ovulation), rubella immunity check, and chlamydia screening. For Marco — semen analysis (the single most important male investigation). If Olivia's BMI, cycles, and ovulation tests are all normal, the most likely issue may be male factor or unexplained subfertility.

The Mirena reassurance is straightforward: the evidence is clear that the hormonal IUS is fully reversible with no long-term fertility effects. Regular cycles returning within 6 weeks confirms this.

The termination conversation requires sensitivity. Olivia may not raise it herself — watch for cues or gently open the door. An uncomplicated termination does not affect future fertility. If there were no complications (infection, perforation), her termination at 24 has no bearing on her current situation. Providing this reassurance directly can be profoundly relieving.

Time check: Spend the first 4 minutes on the fertility history for both partners. By minute 7, explain the investigation plan including semen analysis. Address the termination concern between minutes 8-10. Use the final 2 minutes for preconception optimisation advice and referral timeline.

How Examiners Mark This Case

Data Gathering and Diagnosis: Examiners assess whether you take a comprehensive history covering both partners — a trainee who only investigates Olivia will miss a critical dimension. They look for: menstrual history, obstetric history (including the termination), sexual history (frequency and timing), gynaecological history, medical conditions, lifestyle factors, and — for Marco — semen analysis as the priority male investigation. Confirming that subfertility criteria are met (12 months regular unprotected intercourse) demonstrates guideline knowledge.

Clinical Management and Medical Complexity: Examiners expect a structured investigation plan for both partners: female bloods (FSH, LH, day 21 progesterone, TFTs, prolactin), chlamydia screening, rubella immunity, and semen analysis for the male partner. They look for knowledge of when to refer (after initial investigations, or immediately if there is a known cause), preconception advice (folic acid 400mcg, alcohol reduction, BMI optimisation, smoking cessation), and realistic counselling about timelines and prognosis.

Relating to Others: Examiners assess whether you address the emotional dimension of subfertility — the disappointment, the pressure, the impact on the relationship. They specifically look for whether you handle the previous termination sensitively, providing clear reassurance about its lack of impact on fertility. Olivia should leave feeling that her concerns are being taken seriously and that there is a clear, proactive plan.

Example Opening

Strong opening: "Hello Olivia, I can see you've been trying to get pregnant for a while now and want some help. First of all, you've done all the right things — regular cycles, tracking ovulation, taking folic acid. Let me ask you some questions so we can get the right investigations started for both you and Marco."

When addressing the termination: "I noticed from your records that you had a procedure when you were 24. Sometimes women worry that this might affect their ability to get pregnant later. I want to reassure you — an uncomplicated termination has no impact on future fertility, and there's good evidence for that."

Avoid: "Have you tried just relaxing? Sometimes stress can prevent conception." (Dismissive, unscientific, and invalidates the couple's experience).

How This Appears in the SCA

Subfertility assessment in primary care is a common SCA topic. Examiners assess whether you investigate both partners, know the first-line investigations, can apply the NICE referral criteria, and address the emotional and psychosocial dimensions of infertility — including sensitive history like previous terminations.

Key Statistic

Approximately 1 in 7 couples experience difficulty conceiving. Male factor contributes to approximately 30% of cases, female factor 30%, combined factors 30%, and unexplained 10%. At age 31 with regular cycles, the prognosis for conception is good — approximately 90% of couples in this age group conceive within 2 years.

Relevant Guidelines

• NICE CG156: Fertility problems — assessment and treatment
• NICE preconception care recommendations.

Frequently Asked Questions

When does a couple meet the criteria for subfertility investigation?

NICE defines subfertility as failure to conceive after 12 months of regular unprotected intercourse. Investigation should be offered at this point for women of any age. For women over 36, or with known risk factors (irregular cycles, previous pelvic surgery, known endometriosis), earlier investigation after 6 months may be appropriate. Immediate referral is warranted if there is a known cause of infertility in either partner.

Why must I investigate the male partner as well?

Male factor contributes to approximately 30% of subfertility cases, and combined male-female factors account for another 30%. Semen analysis is the single most important male investigation and should be arranged alongside female investigations. A trainee who only investigates the female partner demonstrates incomplete clinical knowledge and will lose marks.

Does previous IUS (Mirena) use affect fertility?

No. The hormonal IUS is fully reversible with no evidence of long-term fertility effects. Fertility typically returns immediately upon removal, with regular cycles resuming within weeks for most women. In Olivia's case, her regular 28-29 day cycles returning within 6 weeks of removal confirm normal ovarian function. This is a common patient concern that merits direct reassurance.

Does a previous uncomplicated termination affect future fertility?

No. Multiple large studies confirm that an uncomplicated termination — whether medical or surgical — does not affect future fertility, conception rates, or pregnancy outcomes. The only scenario where fertility could be affected is if there was a rare complication such as uterine perforation or infection leading to pelvic inflammatory disease. Address this concern directly and clearly — many women carry unnecessary guilt.

What preconception advice should I give alongside investigations?

Folic acid 400mcg daily (already taking), reduce alcohol to minimum, stop smoking if applicable, optimise BMI (18.5-24.9 for both partners), ensure rubella immunity, review medications for teratogenic potential, and advise regular intercourse every 2-3 days throughout the cycle rather than timing around ovulation kits (which can create pressure and reduce spontaneity). Vitamin D supplementation 10mcg daily is also recommended.