Quality statement 2: Referral for specialist consultation

Quality statement

People are referred for specialist consultation if the woman has not conceived after 1 year of intercourse or after 6 cycles of artificial insemination, or earlier in certain circumstances.

Rationale

Over 80% of women aged under 40 years will conceive within 1 year if they have regular unprotected vaginal intercourse at and around the time of ovulation. If they do not conceive after 1 year, or after 6 cycles of artificial insemination, they should be referred to specialist services to decide if more support is needed. Women aged 36 years or over and people with a known clinical cause or history of predisposing infertility factors should be offered an earlier referral (before 1 year) because of the impact of these factors on fertility. Delays in referral to specialist services can have a negative impact on patient care and treatment outcomes.

Quality measures

Structure

Evidence of local arrangements to ensure that referral pathways are in place for specialist consultation when women have not conceived after 1 year of intercourse or after 6 cycles of artificial insemination, or earlier in certain circumstances.

Data source: Local data collection.

Process

a) Proportion of people (women aged 35 years or under and men) who are referred for specialist consultation if the woman has not conceived after 1 year of intercourse or after 6 cycles of artificial insemination, when there is no known clinical cause or history of predisposing factors for infertility in the woman or man.

Numerator – the number in the denominator who are referred for specialist consultation.

Denominator – the number of people (women aged 35 years or under and men) who have not conceived after 1 year of intercourse or after 6 cycles of artificial insemination and there is no known clinical cause or history of predisposing factors for infertility in the woman or man.

Data source: Local data collection. Data can be collected using the NICE clinical audit tool for fertility: people concerned about delays in conception: audit standard 3.

b) Proportion of people who are referred for specialist consultation within 1 year of identification of fertility problems when there is a known clinical cause in the woman or man, a history of predisposing factors for infertility or the woman is aged 36 years or older.

Numerator – the number in the denominator who are referred for specialist consultation within 1 year of identification of fertility problems.

Denominator – the number of people who have not conceived and have a known clinical cause, a history of predisposing factors for infertility or the woman is aged 36 years or older.

Data source: Local data collection. Data can be collected using the NICE clinical audit tool for fertility: people concerned about delays in conception: audit standard 4.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (primary care, secondary care and specialist fertility services) ensure that referral pathways are in place so that people who have not conceived are referred for specialist consultation after 1 year of intercourse or 6 cycles of artificial insemination, or earlier depending on the presence of known infertility factors and the age of the woman.

Healthcare professionals refer people for specialist consultation if they have not conceived after 1 year of intercourse or 6 cycles of artificial insemination, or earlier depending on the presence of known infertility factors and the age of the woman.

Commissioners (clinical commissioning groups and NHS England area teams) ensure that there is sufficient capacity within specialist services and that agreed pathways and referral criteria are in place for people who have not conceived to be referred for specialist consultation after 1 year of intercourse or 6 cycles of artificial insemination, or earlier depending on the presence of known infertility factors and the age of the woman.

What the quality statement means for patients

People finding it difficult to get pregnant are referred for specialist advice and tests if they have been trying for a year or longer or have had 6 cycles of artificial insemination (which is the direct insertion of sperm into a woman's womb or the neck of the womb). If they have a known problem that might affect their fertility or the woman is aged 36 years or older, they should be referred earlier.

Source guidance

  • Fertility (2013) NICE guideline CG156, recommendations 1.2.13.5, 1.2.13.6 and 1.2.13.7 (key priorities for implementation).

Definitions of terms used in this quality statement

Circumstances for earlier referral

An earlier referral should be offered if there is a known clinical cause of infertility in the woman or man, a history of predisposing factors for infertility (such as amenorrhoea, oligomenorrhoea, pelvic inflammatory disease or undescended testes) or the woman is aged 36 years or over. [Fertility (NICE guideline CG156), recommendation 1.2.13.7]

Specialist consultation

Assessment, investigation or treatment in secondary or tertiary care services (for example, urology departments, gynaecology departments or fertility clinics). [Expert opinion]