When should I consider referring a patient for specialist fertility assessment in cases of unexplained infertility?

Consider referring a patient for specialist fertility assessment in cases of unexplained infertility if:

• The woman is of reproductive age and has not conceived after 1 year of regular (every 2–3 days) unprotected sexual intercourse, with no known cause of infertility identified. Both partners should be assessed together at this point.
• Earlier referral is warranted if the woman is aged 36 years or over, due to the age-related decline in fertility.
• There is a known clinical cause of infertility or a history of predisposing factors for infertility, even if unexplained infertility is suspected.
• The couple has undergone 12 cycles of artificial insemination (6 or more by intrauterine insemination) without conception.
• There are concerns about fertility in people with chronic viral infections such as hepatitis B, hepatitis C, or HIV, who should be referred to centres with appropriate expertise.

These recommendations align with NICE guidance on fertility problems: assessment and treatment, which advises starting investigations after 1 year of trying to conceive, or earlier if risk factors or advanced maternal age are present, to enable timely specialist assessment and management.

Additionally, counselling should be offered before, during, and after investigation and treatment regardless of outcome, as infertility and its management can cause psychological stress.

Referral to specialist fertility services allows for further investigations such as tubal patency tests in women and detailed semen analysis in men, and consideration of appropriate treatments including assisted reproduction techniques.

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