A fertility conversation can begin in the most ordinary of consultations in primary care. A patient may be attending for cervical screening, a medication review or another routine appointment when they mention that they have been trying to conceive and nothing has happened. Sometimes they are only just beginning to think about pregnancy and want to know whether there is anything they should be doing first.
For the patient, that conversation may come after months of worry or uncertainty. For the healthcare professional, particularly if fertility is not an area they deal with every day, it can raise a number of questions. What should I ask? Are there any investigations I can start? Is there anything in the history I should be concerned about? When should this patient be referred?
Fertility is a specialist area, but the first conversation often happens in primary care. Practice nurses, GPs and other primary care healthcare professionals are therefore in a valuable position to provide good preconception advice, recognise when something may need further investigation and help patients access specialist care at the right time.
Some of the most useful fertility conversations happen before a patient has experienced any difficulty conceiving.
We spend a great deal of time educating people about preventing pregnancy, but considerably less time talking about fertility itself. Many people reach the point of wanting to start a family without a particularly clear understanding of their menstrual cycle, when conception is most likely or how their general health may affect pregnancy and fertility.
A preconception consultation is a good opportunity to look at the wider picture.
This might include discussing medical history and existing health conditions, current medication, smoking, alcohol, weight, diet and lifestyle. Menstrual cycle regularity is important, as is understanding the couple’s circumstances and the health of both partners. Preconception advice should also include folic acid supplementation, in line with current guidance.
For couples trying to conceive naturally, current NICE guidance NG257: Fertility problems: assessment and treatment advises regular intercourse every two to three days to optimise the chance of pregnancy.
Where rubella vaccination history is uncertain, it may also be appropriate to check rubella status and offer vaccination if required, with advice to avoid pregnancy for at least one month following vaccination.
These may sound like relatively simple conversations, but they can make a real difference. They can also identify factors that warrant further assessment sooner rather than later.
One area where our understanding of fertility care continues to develop is male fertility.
Historically, fertility investigations have often centred heavily on the female partner. Yet male factors are an important part of fertility assessment, and both partners should be considered from the outset where appropriate.
Relevant questions for the male partner might include medical history, previous testicular problems, medication, smoking, lifestyle and occupation. Semen analysis is also an important part of the initial assessment of possible male factor fertility problems.
This can create a very practical challenge in primary care. Arranging a semen analysis may be straightforward; receiving an abnormal result and trying to explain its significance to an understandably anxious patient can feel rather different.
An abnormal semen analysis does not necessarily provide a definitive answer. Repeat testing is usually recommended to confirm an abnormal result, with the timing guided by the nature of the abnormality, local pathways and specialist advice.
This is one of those situations where knowing your local fertility pathway and where to seek further advice is invaluable. Primary care professionals do not need to become specialists in semen analysis, but it helps to understand what the next step should be.
For further information on male fertility and semen analysis, clinicians can refer to NICE NG257 and the Royal College of Nursing’s resources on male fertility, alongside their local fertility referral pathway.
Age can be a difficult fertility conversation to have, but it is an important one.
There is still a gap between public perception and the biological reality of fertility. Stories of people becoming pregnant in their late 30s or 40s are common, but patients may not know whether assisted conception, donor eggs or other fertility treatment played a part.
Female fertility declines with age, and that has implications for how quickly patients should be assessed and referred.
For people under 36 with no known or suspected cause of infertility, current NICE guidance recommends further clinical assessment and investigation if pregnancy has not occurred after one year of regular unprotected intercourse. This may include appropriate initial investigations in primary care, depending on local pathways, alongside referral for specialist fertility assessment.
Specialist referral should be offered at presentation where the person trying to become pregnant is aged 36 or over, or where either partner has a known or suspected clinical cause of infertility or a history of factors that may predispose them to fertility problems.
So, while a period of trying to conceive before further investigation is appropriate for many younger patients, it is important not to apply the same timeframe to everyone.
These conversations need to be handled sensitively. Giving honest information about age and fertility is not about frightening patients; it is about giving them the information they need while there is still time to consider their options.
The length of time someone has been trying to conceive is only part of the picture. Sometimes the history gives us clues that there may already be an underlying reason why conception is proving difficult.
For women and people with female reproductive organs, conditions to consider include endometriosis, polyendocrine metabolic ovarian syndrome (PMOS, previously known as PCOS), premature ovarian insufficiency (POI), tubal disease and other relevant reproductive or gynaecological conditions.
The clues will vary.
Very irregular or absent periods may suggest that ovulation is not occurring regularly and should prompt us to think about conditions such as PMOS. Symptoms such as significant dysmenorrhoea, chronic pelvic pain or pain during or after sex may raise suspicion of endometriosis.
POI is another important consideration, particularly in someone under 40 who develops irregular or absent periods alongside symptoms of oestrogen deficiency, such as hot flushes or night sweats. A previous diagnosis of POI, ovarian surgery, chemotherapy or radiotherapy is also clearly relevant to fertility.
It is also worth thinking about the fallopian tubes. A history of pelvic inflammatory disease, chlamydia, ectopic pregnancy or pelvic or abdominal surgery may increase the possibility of tubal damage and should form part of the fertility history.
Other known gynaecological conditions, including uterine abnormalities or adenomyosis, may also be relevant depending on the individual’s symptoms and history.
None of these conditions automatically means that someone will be unable to conceive. Many people with endometriosis or PMOS, for example, will become pregnant without fertility treatment. However, a known or suspected cause of infertility should change the way we think about timing.
Current NICE guidance recommends specialist referral at presentation where either partner has a known or suspected clinical cause of infertility or a history of factors that may predispose them to fertility problems.
This is why a good history is so valuable. Before ordering a long list of fertility tests, consider whether there is already something in the patient’s menstrual, reproductive, gynaecological, medical or surgical history that suggests they may need earlier assessment.
What can be initiated before referral will depend on the patient’s individual circumstances, local services, referral pathways and the clinician’s role.
A good history should always come first.
For women and others with female reproductive organs, asking about the frequency and regularity of menstrual cycles can provide useful information about whether ovulation is likely to be occurring. If cycles are regular and monthly, ovulation is likely. During fertility investigations, serum progesterone testing is used to help confirm ovulation. The timing of the test is important. Although serum progesterone is often referred to as a ‘day 21’ test, this assumes a 28-day menstrual cycle. In practice, it should be timed to the mid-luteal phase; for example, in a longer cycle it may need to be taken later.
Where cycles are irregular, serum gonadotrophins (FSH and LH) should also be measured as part of the investigation.
For the male partner, semen analysis forms an important part of the initial assessment.
Further investigations should be guided by the clinical history and presentation. Thyroid function testing, for example, is appropriate where symptoms suggest thyroid disease.
The aim is not to complete every possible investigation before referral. It is to start the appropriate assessment, identify anything that may alter the pathway and make sure specialist input is sought when it is needed.
A fertility assessment should not become a checklist of investigations.
Work, lifestyle, relationships and the practical realities of someone’s life can all be relevant.
A couple may understand when conception is most likely, but shift work, military deployment, frequent travel or spending long periods apart may make trying to conceive more challenging in practice.
Smoking is another important factor. It is likely to reduce fertility in women and is associated with reduced semen quality in men. Weight can also be relevant: a higher BMI is associated with reduced fertility, while low body weight can affect ovulation in some women.
These conversations are an opportunity to identify factors that may be influencing fertility and to offer practical, evidence-based advice where appropriate. Even relatively small changes may help optimise general health and reproductive health while investigations or referral are underway.
Patients sometimes arrive at the consultation with the assumption that difficulty conceiving will eventually mean IVF.
In reality, fertility care is much more individual than that.
The treatment offered will depend on the underlying issue, and IVF is only one of a number of possible approaches. It can be an enormously important treatment for some patients, but it does not overcome every cause of infertility and it cannot remove the effect that age has on reproductive potential.
There may also be difficult practical conversations around access to treatment. NHS-funded fertility treatment and eligibility criteria vary across the UK. In England, access is determined locally by Integrated Care Boards (ICBs), so criteria and the number of funded treatment cycles may differ depending on where a patient lives. Clinicians should therefore be familiar with their local fertility pathway and funding criteria. Some patients may choose to explore private care because of waiting times or because they do not meet local NHS funding criteria.
For anyone exploring treatment privately, the Human Fertilisation and Embryology Authority (HFEA) is a particularly useful source of impartial information. It regulates UK fertility clinics and provides information to help patients understand treatments and compare licensed clinics.
Perhaps one of the most important parts of fertility care has nothing to do with investigations.
Fertility difficulties can affect almost every aspect of someone’s life. Patients may spend months or years navigating uncertainty, repeated appointments, treatment, financial pressures and difficult decisions.
For many people, there can also be a profound sense of grief and loss. This may follow pregnancy loss or unsuccessful fertility treatment, but it can also come from the loss of an expected future, the loss of control over something they had assumed would happen naturally, or the decision to stop treatment.
Those patients may no longer be under a fertility service, but they have not necessarily stopped living with the experience.
They may come back into primary care months or years later for something entirely unrelated, and the emotional impact may still be significant.
NICE recognises this and recommends that counselling is offered before, during and after fertility investigation and treatment, irrespective of the outcome.
Primary care professionals have an important part to play here too. We may not be providing specialist fertility counselling, but we can listen, acknowledge what someone has been through and make sure they know where further support is available.
Fertility is an area where patients can very quickly find themselves overwhelmed by information.
A few minutes of research online can lead to supplements, tests, specialist diets, alternative therapies, private treatments, social media accounts and countless personal stories. Some of it will be useful. Some will have little evidence behind it. Some may be commercially driven.
It is particularly difficult to judge the quality of that information when you are already anxious and desperate to find something that might help.
We do not need to know the answer to every fertility question ourselves, but we can give patients reliable places to start.
Useful sources include:
Clinicians should also be familiar with their local NHS fertility services, referral pathways and funding criteria, as these can vary across the UK.
Sometimes good fertility care in primary care is simply recognising the concern, asking the right questions and helping the patient find the right next step.
Fertility can be a complex area, particularly when it is not something you encounter every day in practice. Knowing what to ask, what can reasonably be done in primary care and when specialist input is needed can make these conversations easier for both clinicians and patients.
We recently explored these issues in our Fertility Care in Primary Care Lunchtime Health News session, where women’s health and fertility nurse consultant and educator Kate Pleace joined Clinical Trainer Alys Bunce for an informal discussion about fertility care in everyday primary care.
The conversation covered common presentations, preconception health, initial assessment and investigations, male fertility, age, referral, treatment pathways and the emotional impact of fertility difficulties.
The 45 minute session was recorded live in July 2026 and is available to watch free on demand below.
For anyone who would like a broader introduction to the subject, our 1 day Fertility Care in Primary Care course also looks in more detail at supporting patients who present with fertility-related questions.
Click below to find out more and register your interest, or contact us if you would like to arrange a bespoke session for your team.
Our ‘Fertility Care in Primary Care’ course supports healthcare professionals with pre-conception advice, fertility assessment, investigations and referral pathways.
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