April 28th, 2017

by Brienne Poole

Over one million women in the United States have reported issues with infertility [1]. Infertility is defined as the inability to conceive after >12 consecutive months of unprotected sexual intercourse, and it can cause major distress for couples attempting to achieve pregnancy. Many women present to their primary care clinician for fertility care and some choose to consult specialists in reproductive endocrinology. Although both types of clinicians can assist women in achieving a healthy pregnancy, the role of generalists in fertility care is less well studied.

A recent study published in the Journal of the American Board of Family Medicine sought to better understand the role of the generalist clinician in the diagnosis and treatment of infertility [2]. The researchers retrospectively looked at the types of clinicians women with infertility first saw for fertility care (generalist vs. sub-specialist). They then examined associations between the type of clinician seen, the likelihood of receiving in vitro fertilization (IVF), and the time to pregnancy resulting in live birth. The results of this investigation are outlined below.

Where do women seek infertility care?

The majority of women in the study (84%) presented first to a generalist (i.e. family physician, ob/gyn, physician assistant, midwife, or nurse practitioner), while 8% reported seeing a fertility sub-specialist first. Women who chose to see a sub-specialist first tended to be older and had been trying to conceive longer.

Interestingly, the chances of achieving pregnancy resulting in live birth were equal between women who saw generalists first and women who saw sub-specialists first.

This data emphasizes the fact that most women are looking to their primary care clinicians for guidance with infertility. It is important that these health care professionals are familiar with and are comfortable treating a variety of infertility issues.

Likelihood of receiving IVF based on clinician type

Women who presented to a generalist first were significantly less likely to receive IVF in this study. The odds of receiving IVF for patients seeing a sub-specialist were 58% more than those seeing a generalist. This comparison was still true after factoring in age and length of time attempting to conceive.

The significance of these findings is that women who see primary care clinicians first may avoid having to undergo IVF treatments, which are costly and can have substantial risks, including obstetric complications, preterm delivery, and low birthweight infants [3].

However, we cannot say that there is a causal relationship between type of clinician and likelihood of IVF as women presenting to sub-specialists may have different etiologies for their infertility.

Time to pregnancy based on clinician type

There was no statistically significant difference in time to pregnancy between patients presenting to generalists first vs. sub-specialists first. Among the women who achieved live birth in the study, the median time to pregnancy was 35 months for those seeing generalists first and 31 months for those seeing fertility sub-specialists first.

Conclusions

The results of this study suggest that an overwhelming majority of patients with primary infertility first seek out guidance from a primary care physician or generalist.

Additionally, presenting first to a generalist clinician was associated with a decreased likelihood of receiving IVF and yet a similar time to pregnancy leading to a live birth.

This study used a large population- and clinic-based cohort which makes the data more applicable to the general population of infertile women seeking treatment. However, the women in this sample had a younger average age of childbearing compared to the general US population (23.9 years old) and 76% identified as Latter-Day Saint. Further research needs to be done comparing outcomes in fertility care among samples more similar to the general US population.

Discussion

Primary care clinicians are positioned to provide comprehensive, longitudinal care for patients presenting with infertility concerns. Beginning fertility care with generalists may be more cost-effective and prevent unnecessary medical complications associated with invasive fertility treatments. Primary care clinicians should be prepared to deliver thorough, evidence-based care for women pursuing treatment for infertility. One way to provide more systematic care to infertility patients would be for generalists to receive training in FABM charting and related treatment options.

Sources

1. Boltz MW, Sanders JN, Simonsen SE, Stanford JB. Fertility Treatment, Use of in Vitro Fertilization, and Time to Live Birth Based on Initial Clinician Type. J Am Board Fam Med. 2017 Mar-Apr;30(2):230-238. https://www.jabfm.org/content/30/2/230.full.pdf+html?sid=a4cfbf7e-db3a-454a-8888-6966bb24ed72
2. Centers for Disease Control and Prevention. Key Statistics from the National Survey of Family Growth. 2013. https://www.cdc.gov/nchs/fastats/infertility.htm.
3. Sunderam, S. Centers for Disease Control and Prevention. Assisted Reproductive Technology Surveillance – United States. 2013. https://www.cdc.gov/mmwr/preview/mmwrhtml/ss6411a1.htm?s_cid=ss6411a1_w.