Can family practice help with fertility issues?

Can Family Practice Help with Fertility Issues?

Yes, family practice providers should offer basic infertility care as part of core family planning services, including initial evaluation, fertility counseling, and appropriate referrals to specialists when needed. 1

Scope of Family Practice in Fertility Care

Family practice providers play a critical role as the primary access point for reproductive care and can manage initial fertility assessments before specialist referral is necessary. 1 The CDC explicitly recommends that basic infertility services be integrated into family planning practice, following guidelines from ACOG, ASRM, and the American Urological Association. 1

When to Initiate Fertility Evaluation

Standard definition: Failure to achieve pregnancy after 12 months of regular unprotected intercourse warrants evaluation. 1, 2

Earlier evaluation (after 6 months) is justified for: 1, 2

• Women aged >35 years (due to age-related fertility decline)
• History of oligo-amenorrhea (infrequent menstruation)
• Known or suspected uterine/tubal disease or endometriosis
• Male partner with known subfertility or risk factors

What Family Practice Can Provide

Pre-Fertility Counseling for Couples Not Yet Meeting Infertility Criteria

Fertility maximization education includes: 1

• Teaching about the 6-day fertile window ending on ovulation day, characterized by slippery, stretchy cervical mucus
• Advising vaginal intercourse every 1-2 days beginning soon after menstrual period ends for women with regular cycles
• Discussing ovulation prediction methods (over-the-counter kits, digital apps, cycle beads)
• Counseling that fertility rates are lower in very thin or obese women and those consuming >5 cups of caffeine daily
• Strongly discouraging smoking, alcohol, recreational drugs, and most commercial vaginal lubricants as these reduce fertility

Basic Infertility Evaluation for Women

Medical history should specifically assess: 1

• Duration of attempting pregnancy, coital frequency and timing
• Past surgeries (indications and outcomes), previous hospitalizations
• Medical conditions associated with reproductive failure (thyroid disorders, hirsutism, endocrine disorders)
• Gravidity, parity, pregnancy outcomes and complications
• Menstrual history: age at menarche, cycle length/characteristics, dysmenorrhea severity
• Sexual history including pelvic inflammatory disease and STD exposure

Physical examination must include: 1

• Height, weight, BMI calculation
• Thyroid examination for enlargement, nodules, or tenderness
• Clinical breast examination and assessment for androgen excess signs
• Pelvic examination assessing for: vaginal/cervical abnormalities, uterine size/shape/position/mobility, adnexal masses or tenderness, cul-de-sac abnormalities

Referral for further diagnostic testing when indicated: 1

• Serum progesterone levels, FSH/LH levels
• Thyroid function tests, prolactin levels
• Endometrial biopsy, transvaginal ultrasound
• Hysterosalpingography, laparoscopy
• Clomiphene citrate trial (may be initiated by specialists)

Basic Infertility Evaluation for Men

Medical history should include: 1

• Systemic medical illnesses (diabetes mellitus)
• Prior surgeries, past infections
• All medications (prescription and nonprescription) and allergies
• Contraception methods, coital frequency/timing
• Duration of infertility, prior fertility history
• Sexual history and gonadal toxin exposure (including heat)
• Female partner's history of pelvic inflammatory disease and STDs
• Sexual dysfunction problems

Physical examination focuses on: 1

• Penis examination including urethral meatus location
• Testicular palpation and size measurement
• Vas deferens and epididymis presence and consistency
• Varicocele presence
• Secondary sex characteristics
• Digital rectal examination

Semen analysis is the first and most simple screen for male fertility. 1 If abnormal, refer for second semen analysis, endocrine evaluation, post-ejaculate urinalysis, or other necessary testing and treatment.

Critical Point: Simultaneous Evaluation

Both partners should be evaluated simultaneously from the outset, as male factor contributes to approximately 50% of infertility cases. 2 Family practice providers can reasonably obtain the male partner's medical history and order semen analysis, though referral to a male reproductive medicine specialist is also appropriate. 3

Preconception Health Services

Family practice should integrate preconception health services for couples attempting pregnancy, which improves pregnancy outcomes and reduces adverse events like low birthweight, premature birth, and infant mortality. 1 This includes:

• Identifying and modifying biomedical, behavioral, and social risks
• STD screening (including HIV) and vaccinations
• Folic acid supplementation counseling
• Addressing lifestyle factors (smoking cessation, alcohol avoidance, weight optimization)

Psychological Support and Counseling

ACOG emphasizes addressing the emotional and educational needs of infertility patients. 1 Family practice providers should consider referring clients for psychological support, infertility support groups, or family counseling, as infertility significantly impacts psychological wellbeing and relationships. 4

When to Refer to Specialists

Immediate referral is warranted when: 1

• Abnormal findings on initial evaluation require advanced diagnostic procedures
• Treatment beyond basic counseling is needed
• Women are >40 years old (more immediate evaluation and treatment needed)
• Known conditions causing infertility are present

Common Pitfalls to Avoid

• Don't delay evaluation in women >35 years: The 6-month threshold (not 12 months) applies due to age-related fertility decline 1, 2
• Don't overlook male factor: Approximately 50% of infertility involves male factors, so always evaluate both partners simultaneously 2, 3
• Don't assume lifestyle changes alone will suffice: While important, couples with true infertility (meeting time criteria) need formal evaluation, not just lifestyle counseling 1
• Don't miss underlying pathology: Conditions like PCOS (most common cause of anovulatory infertility affecting ≥7% of women), thyroid disorders, and tubal disease require specific diagnosis 2

Bottom Line

Family practice providers are not only capable of helping with fertility issues but are explicitly recommended to provide basic infertility services as part of comprehensive family planning care. 1 This includes initial evaluation, fertility optimization counseling, basic diagnostic workup, and timely referral to reproductive specialists when indicated. The key is knowing when basic care is sufficient versus when specialist referral is needed—generally after completing initial history, physical examination, and first-line testing. 1