Written by Dr. Phoebe Howells. Dr. Phoebe has been a doctor since 2012 with a decade of experience in Obstetrics and Gynaecology focusing on fertility. She's undertaken a clinical fellowship in Reproductive Medicine at a top London fertility clinic alongside authoring articles, sharing insights at global conferences, contributing to fertility trials for women with adenomyosis and working as the Co-Chief Medical Officer for OVUM. 

Embarking on a fertility journey can be a profound and sometimes complex experience. Whether you are just contemplating your future fertility options, in a same-sex relationship, looking to egg freeze or already eagerly trying to conceive, your GP is often your first point of contact and an invaluable resource in navigating this path. 

This blog aims to prepare you for your fertility consultation with your GP, offering insights into when you should first approach them, what to expect, and key questions to ask. Let's be honest: It can be a very stressful time. So, hopefully, after reading this, you will feel empowered to take that first step in booking the consultation and understand the next steps while making informed decisions. 

If it is taking longer to conceive than you thought, it doesn’t necessarily mean that something is wrong, but a doctor can assess and see if there is anything immediate that can be treated. They will also advise when you should be referred to an IVF clinic where further tests may be carried out.

How long is too long? How long should it take?

Remember, 8/10 couples under the age of 40 will conceive in one year, so 80% of women will get pregnant if they wait a whole year. 9/10 couples under the age of 40 will conceive in 2 years. The problem is that when you are trying to conceive, a year feels like a very long time, and every period that you have is another knock to your morale, 2 years can feel like an eternity. Remember, the National Institute of Clinical Excellence, otherwise known as ‘NICE’ recommends that you should see a doctor if

- you are under 35 years old and have been trying to conceive for 12 months

- you are over 36 years old and have been trying to conceive for 6 months

It varies with age because as you get older, you are more likely to have issues, so it is better to investigate sooner. If you are concerned that you are not getting pregnant, speak to your GP. It's better to speak to them earlier rather than later, and they can always advise you when to contact them again in the future. Of course, if you or your partner have a known problem that may be impacting your fertility, such as a problem with your fallopian tubes or your partner has a known low sperm count, then you don’t have to wait before seeing your GP. 

What to expect from the consultation

It is usually advised that you and your partner both attend the appointment. You may be asked many different questions, so getting first-hand information from the relevant person is helpful. 

What questions you may be asked, and what information to have ready.

• Information regarding your menstrual cycles, most importantly your last menstrual period and a vague knowledge of a pattern of your menstrual cycles. This will save you from getting flustered during the appointment and frantically scrolling through your diary, trying to find key events when you started bleeding. If you asked me right now, I wouldn’t remember when mine started; I wouldn't have a clue. 
• History of all previous pregnancies, including terminations and miscarriages and how they were managed. Sometimes, you may want to share this information with your GP later when alone, and it can be kept confidential, but it is important to know if you have had any procedures or complications.
• Any medical conditions, past or present
• Any surgery that you have had and any operation notes that you may have been given, if relevant to Gynaecology.
• If you have had any fertility tests so far, try and bring the results with you if you think the GP may not have access to them already. If in doubt, bring them.
• History of previous and current contraception
• Any previous sexually transmitted infections, again you may not want to share this whilst your partner is present, and this can be kept confidential. It is helpful to know if you may be offered particular tests, such as fallopian tube patency tests if this is the case.
• When your last smear was.
• If in a heterosexual relationship, how often you have intercourse and if either of you experiences any difficulty, such as erectile dysfunction or painful intercourse which can stop you from having it regularly?
• For the men, any history of groin operations or undescended testicles or any history of testicular trauma.

Reading through these questions, you may feel dread that you have to delve so deep into your personal life, embarrassed that you have to talk about your sex life, and may be worried that you will have to give information that you don’t want your partner to know about. Be reassured that everything will be confidential, there will be no judgement, and they will only ask questions important to understanding your fertility health. Believe me, after a couple of consultations, you will be happy to discuss anything. 

The Examination

Both partners (or solo parent if that’s you) will need their height and weight checked to calculate a body mass index (BMI), as reaching and maintaining a healthy weight is not only key to helping your fertility, but there are also strict cut-offs for female BMI, with the NHS only funding IVF if you have a BMI between 19-30. Not knowing this at the beginning of your journey could string you along with false hope of funded treatment, only for your dreams to be quashed when reaching the fertility clinic itself.

During the consultation, your GP may or may not want to examine you. For females, the GP may want to do a speculum examination and swabs to check for infections. They may also want to feel your tummy to see if they can feel any masses, such as fibroids, which can make your uterus enlarged. 

For men, an abnormal semen analysis may prompt a testicular exam to see the size of the testes. They may want to look for any signs of infection or lumps or swellings that could indicate a potential cause for infertility, such as a varicocele. 

What investigation might be done?

The GP may advise to carry on trying to conceive and to come back if not pregnant within a certain time frame. However, they may also advise you to have some initial tests. 

Chlamydia Screening

This is a urine or swab test, and if it comes back positive, a course of antibiotics will be prescribed. A history of sexually transmitted infections can sometimes cause blockages in your fallopian tubes, and there are different tests to check for this. These tests are called tubal patency tests. 

Blood Tests

They may take a progesterone level, which is taken 7 days before your expected period. So, in a 28-day cycle, it will be taken on day 21. Of course we don’t all have 28-day cycles, and this will be taken into account by your GP.

Follicle stimulating hormone (FSH), Luteinizing hormone (LH)  and oestradiol blood tests may be taken on days 2-4 of your cycle. These can give you some indication of your ovarian reserve. Your GP may also order blood tests to check your thyroid levels.

Anti-mullerian hormone test (AMH) is another test which gives a clearer indication of your ovarian reserve. However, it is not routinely requested by GPs. If this is not done during the initial investigations, it will absolutely be tested for when you reach the fertility clinic. A low ovarian reserve would suggest referral to the fertility specialist sooner rather than later. Your ovarian reserve declines with age, which is particularly important in those over 35. 

Ultrasound Scan

A transvaginal or transabdominal scan will give a great insight into any structural abnormalities that may be contributing to infertility. For instance, some women have differently shaped wombs that can impact fertility; they may have ovarian cysts or fibroids. All of this information is key to knowing the next steps. 

Semen Analysis 

This is a crucial test to investigate male infertility. The male partner will need to provide a fresh sample of semen directly into a sterile pot. The pot must be taken to the lab within one hour for an accurate result. The different parameters that will be checked include,

-the total concentration of sperm

-the number of motile sperm (how many are moving)

-Progressive motility (how many are moving in one direction, not just going around in circles)

- morphology (how many sperm look structurally normal with one head and one tail connected in a straight line)

If the first result is abnormal, it is usually wise to repeat in 3 months when the body has made a whole new bunch of sperm. 

These investigations' results can take one to three weeks to come back. 

Questions to Ask During Your Consultations

Which tests are needed for you, and when will you expect to get the results? 

What funding does your area provide? It is a postcode lottery, and NHS funding can be very varied and complicated. It is worth checking online which Integrated Care Board (ICB)I your address falls within and accessing their fertility treatment policy. This will let you know upfront what is and is now available in your postcode.

They will recommend you take preconception and, once pregnant, prenatal supplements. Preconception supplements are particularly important for egg health and normal fetal development. They may also suggest preconception supplements for male fertility.

Next Steps after your consultation

After collating all of the results, the GP will advise whether you need a referral to a Gynaecologist, Urologist, Fertility Specialist or other relevant specialist.

The timing of your referral to a fertility specialist will depend on all your results and the time you have already taken to conceive. It is important to know how long the NHS needs you to have been trying to conceive before NHS funding will be granted for IVF treatment. This is why checking your ICB’s fertility treatment policy is so useful.

If you are self-funding treatment, you can present directly to private Fertility clinics without a referral from the GP. However, if you use your private health insurance, you will often need a GP referral letter, so a consultation with one will still be necessary. 

Remember, a GP has approximately 7 minutes to see you. There is a lot that needs to be done, so it may not happen immediately, and they may just see an obvious cause for infertility and refer you directly to a fertility specialist without completing every other investigation.

Good luck with your journey!