woman talking to doctor

If you are trying to conceive, there will be different stages you go through on the journey. While the GP may be your first port of call, further investigations normally require a referral from your GP to a fertility clinic, gynaecologist, or fertility specialist. This blog post forms part of the conversation on the Fertility Podcast all about that next step with our resident expert Dr James Nicopollus.

What is Secondary Care and what should you expect?

Your secondary care referral is where your fertility will be looked at in more detail. You might have a scan, discuss further available investigations such as HyCoSy or HSG, and maybe some more blood tests. Secondary Care is not IVF, but it is the next stage in considering why you are struggling to conceive. It is important to note that even if you are not entitled to IVF if you have another child, for example, you are still entitled to a referral to see a specialist.

Getting a referral does not mean that the GP cannot help in any way, but often through Secondary Care, there are better tests which can be done and more expert care available. It is important to have as much as information available as possible when considering fertility struggles.

How to access Secondary Care

To get a referral to secondary care, you need to see your GP. If you are finding it difficult to get a referral, be persistent. The NICE guidelines state clearly that this is what you are entitled too, however some healthcare trust will have their own local polices. Check the fertility policies for your local area and then have a discussion with your GP. If this information is unclear, you can contact your local trust commissioners or PALS for clarification. Also consider how long you have been trying to conceive. If you are over 35 and have been trying for 6 months, or under 35 and have been trying for a year, the GP should be using this timeframe as a basis for referrals and not any longer. If a referral is taking longer, don’t be afraid to go back to your GP.

Seeing a gynaecologist

When you get referred to secondary care, it is likely that you will see a gynaecologist. Ideally you want to see a gynaecologist with a special interest in fertility. Sadly, there can be a wait to see specialists due to delays from the GP referral to secondary care, and then again from secondary care to IVF if that is needed. The pandemic has resulted in a further increase in delays.

You can seek private healthcare opinions, but ideally referrals should happen through the NHS and there are lots of good NHS fertility centres.

What happens at the referral?

When you do get referred to a fertility clinic, you will probably find that they will try and cover all bases and do more blood tests. Even if you have had tests done with your GP such as a semen analysis, repeated tests are likely to ensure results are accurate.

Another key test is a scan. Scans can check egg reserves by observing how many follicles you have. The more follicles you have is a better fertility indicator. Scans can also help rule out any pelvic issues such as thyroids, polyps, or endometrioma which could be impacting on your fertility. A scan can really give you a lot of information in one test.

Tubal patency checks

If the sperm and egg reserve results are coming back as fine, and you are ovulating regularly, which can be checked with a progesterone test, in secondary care you can also have a tubal patency check to see if your tubes are open.

A laparoscopy is a procedure which can check this, but the procedure is done under general anaesthetic and uses a camera to look inside your abdomen.

This isn’t always done though, especially if all other results are fine and you’ve not previously had a sexually transmitted infection, and you are otherwise healthy because it is a more invasive procedure and tends to be more common if you are displaying symptoms of conditions such as endometriosis.

More commonly, a HyCoSy or HSG test will be done, which is a scan using special dye to screen the fallopian tubes.

What else can affect the pelvic area?

The importance of doing a scan such as a HyCoSy or HSG is also to detect any other pelvic issues. Sexually transmitted infections such as chlamydia can be silent, so tests are really important to exclude them.

If you have previously had any surgery on the pelvic area such as a complex appendix procedure or ruptured appendix, these could cause adhesions and perhaps impact on tubal patency.

If there is evidence of painful periods or intercourse, then a laparoscopy should be considered to check for endometriosis.

Sperm health and genetic material

If after going through testing procedures and there is still no sign of why fertility struggles are occurring, an investigation into the sperm genetic material should be considered. Unfortunately, this is not widely available, but sperm DNA fragmentation can be used to show if there is any genetic issues with the sperm. The test looks at how the genetic material is packaged in the sperm. If everything is packaged normally, this shouldn’t impact fertility, but if there is some unravelling of the genetic material this can impact on natural fertility as well as IVF and IUI. ICSI treatment is an option to try and overcome this.

Unexplained infertility

There are instances where all test results are inconclusive, and it is understandable that this has an emotional impact. When you don’t have a diagnosis, but are still having no success conceiving, the next step would be to go to the fertility clinic for fertility treatment. Here will be the place where treatment options are explained such as IVF/ICSI, IUI and continuing trying to conceive naturally, with the success rates outlined for treatments.

Going through the Secondary Care journey

Everyone’s experience of the Secondary Care journey varies so much. Different clinics and trusts offering different services and tests and it is important not to compare your experience to someone else. Sometimes funding limitations can impact tests and you may feel like you are not receiving full guidance. The best thing to do is to be as well-informed as you can be from reliable sources and always have a list of questions to ask your consultant.

Going through a fertility journey is emotional and there is no question which you shouldn’t feel able to ask. You may find that fertility coaching helps you. Get in touch if you would like to find out more.