Female fertility investigations: The holistic approach in the primary care setting

Introduction: Infertility is a disease that affects one in 6 people of reproductive age globally and is increasingly encountered in primary care centres. A comprehensive, holistic approach to initial assessment of female and male infertility is crucial, and this manuscript outlines a systematic framework for general practitioners to assess infertility from the female perspective. We propose that early, holistic approach to female infertility investigations and counselling can reduce the need for physically, emotionally, and financially taxing therapies such as medically assisted reproduction (MAR) and even help couples achieve spontaneous pregnancies while awaiting specialist review. The evaluation of male infertility, though equally important, falls outside the scope of this discussion. Materials and Methods: A comprehensive literature review was performed using national and international articles, guidelines, and scientific publications. Findings were analysed and collated to develop a practical, systematic approach to the initial female infertility investigations suitable for use in primary care. Results: A 3-tiered, evidence-based assessment framework was developed, encompassing all aspects of initial investigations performed in a primary care setting. For ease of understanding, this manuscript presents a pragmatic approach to thinking about and pursuing the female infertility investigations by asking 3 questions: (1) Does the female have an ovulatory disorder? (2) Is the female anatomy allowing normal function and a pregnancy? (3) Are there other female factors preventing a pregnancy? Emphasis is placed on identification of reversible risk factors for female infertility, with the aim to optimise natural conception and streamline referral and management by fertility specialists. Conclusion: Comprehensive female investigations and management in the primary care setting, alongside the exclusion of male factor infertility, can be a means to achieve pregnancy spontaneously without the need for MAR. If onward referral to fertility specialists and MAR is needed, this thorough assessment will enable early counselling of patients as regards to expected ovarian response, egg quality, likelihood of pregnancy, and risks of MAR. This structured and holistic approach empowers both general clinicians and fertility specialists to deliver personalised care to optimise reproductive outcomes, addressing the ever-growing pandemic of infertility.