Infertility was back in the news in June when the Human Fertilisation and Embryology Authority (HFEA) released figures showing an upsurge in older women demanding fertility treatment. Last year there were 6,174 treatment cycles among women aged 40-45 using their own eggs. In 1991, the comparable figure was just 596 cycles.

Infertility is the most common reason, after pregnancy, for women aged 20 to 45 to see their GP, according to the HFEA. The Royal College of Obstetrics and Gynaecology says that one in six couples experiences infertility, which NICE defines as a failure to conceive after regular unprotected sexual intercourse for two years. As well as those with infertility, many patients with sub-fertility will seek help in primary care.

Bill Ledger, professor of obstetrics and gynaecology at the University of Sheffield, has predicted that the prevalence of infertility could double over the next 10 years. Much of this is being caused by our changing society: people are waiting longer to get married (with the average age now 36 for men and 33 for women) and are delaying the decision to start a family.

The rising prevalence of obesity will also affect fertility and the rise in sexually transmitted diseases will add to more tubal infertility. Sperm quality may also be falling.

Professor Ledger, who is also head of the Centre for Reproductive Medicine and Fertility at the Royal Hallamshire Hospital in Sheffield, says: 'The evidence is that infertility is becoming more common so general practice will see more couples with these problems over the next decade than at present.'

The result for nurses could be an increased role in this field of practice. At present, practice nurses carry out the initial assessments at a GP's request. This involves taking blood to test midluteal serum progesterone, luteinising hormone and follicle-stimulating hormone.

Practical advice
Alison McTavish, nurse manager at Aberdeen Fertility Centre, says some practice nurses are also involved in giving injections to women undergoing fertility treatment because a local surgery is more convenient for many patients than going to a tertiary centre. 'It means the practice nurse has more contact with the infertile patient than the GP, so they ought to have a good understanding of treatments,' she says.

As infertility becomes more common, nurses may find that they are asked questions more frequently, often from those who are presenting with an unrelated symptom.

NICE recommends that couples try to get pregnant for a year before investigations start, but many will feel that is too long to wait.

Heidi Birch, director of nursing services at the nurse-led Midlands Fertility, says nurses can expect to be asked about tests that are privately available, as patients may have read about these. For example, there are over-the-counter tests such as Plan Ahead, which measures a woman's ovarian reserve and there are DIY sperm count tests that can be performed at home.

Ms Birch says that many patients are happy to pay for tests to eliminate some of their anxiety, so it is important for practice nurses to understand what these are. 'We get quite a few requests for these tests,' she affirms. That's normally because the GP says "wait and come back if you're not pregnant". It's a stressful time; couples don't necessarily want delays at that point.'

Emotional support
As well as looking for practical advice, patients may also need emotional support during their difficult journey. Jane Denton, a founder member of the RCN fertility nurses group, acknowledges that this can be a tall order for practice nurses, who may not have the time or the expertise to meet patients' needs.

This is one of the reasons why Ms Denton, who is director of the Multiple Births Foundation, believes there should be dedicated fertility nurses based in the community. They could hold clinics across a region, taking referrals from primary care practitioners, and liaise between primary, secondary and tertiary care.

Ms Denton says that work would need to be done to identify the training and competencies required for such a role, but believes it would be cost-effective and beneficial to patients and health professionals.

'At this stage, the idea is only "blue sky thinking", but there are many merits in it,' she says. 'A lot of people could be given a great deal of help that could resolve their problems at a much earlier stage.'

In the meantime, there is still is a great deal that practice nurses can do to develop their role. Debbie Barber, a nurse consultant at the Oxford Fertility Unit and member of the RCN fertility nurse group, says nurses could run pre-conception health classes.

These could cover the lifestyle issues that can impact on fertility, like smoking and weight, as well as helping couples work out the best times of the month to have sex.

New distance-learning course
The RCN is to launch a two-module distance learning course at the University of Greenwich, south-east London, in September. The first module alone would be enough for practice nurses interested in starting pre-conception clinics, according to Ms Barber, who argues that 'the potential for primary care involvement in infertility is huge'. She points out that GPs already offer services like minor surgery.

Fertility nurse Wendy Eustace, who runs Fertility Essentials, a community-based, organisation which takes private patients (see case study, page 41) believes that fertility problems are more common than statistics suggest. She says many couples would welcome pre-conception advice.

'We see people who have been trying to have a baby for years and have never seen anyone about it. Every month becomes very pressured. It's important to get the right information and practice nurses are well-placed to provide this.'

- Specialist fertility nurses Wendy Eustace and Fiona Wynn work in the community to provide preconception health advice to couples who are worried about their fertility.

The pair, who have nearly 20 years' fertility experience between them, set up Fertility Essentials in January. They work from a GP practice in Peterborough.

A couple can expect to have two one-and-a-half-hour consultations, with either nurse. Most are face-to-face although some are by phone if the patients live far away.

During the first meeting, the nurse takes a full history and asks 150 questions to build a detailed picture of the couple. This is written into a report, which includes recommendations specific to the couple that aims to maximise their chances of getting pregnant.

The second visit focuses on menstrual cycle awareness and helps a couple to work out when they are most fertile so that they can plan sexual intercourse.

Wendy says: 'Most couples think that they're making love at the right time of the month but, when we look at the cycle, the majority are not.'

Each consultation costs £95. Some GPs pay for their patients to access the service from their practice budget.

'We're trying to see people early, when they're really anxious,' says Ms Wynn, who used to run the fertility clinic at Guys and St Thomas' Hospital, London. 'It avoids them having to spend months or years trying.'

If the patients wish, the nurses can give advice on the appropriate tests, which they can then arrange.

'A lot of the people we see are slightly older and are starting to worry about the quality of their eggs.Every month can become pressured and the consultations ease some of their concerns,' explains Ms Eustace.

The nurses see an average of two couples each per week and since the start of the year, have helped dozens get pregnant. The first baby conceived as a result of Fertility Essentials has just been born.

Infertility: the facts

Primary care nurses can help couples with fertility problems by explaining that their fertility can be affected detrimentally by:

• Excess alcohol intake in women and men.
• Smoking by women and men (there is an association with reduced semen quality although the impact on male fertility is uncertain).
• A BMI of more than 29 for men and women - reducing weight by even 10 per cent can boost fertility.
• A BMI of less than 19 for women as it may result in irregular menstruation.
• A number of prescription, over-the-counter and recreational drugs.
• Sexually transmitted diseases, e.g. genital tract infection with chlamydia is a risk factor for subsequent tubal infertility in women.
• Age - female fertility declines with age although the effect of age on male fertility is less clear.
•  Psychosexual problems which may mean frequent intercourse - every two to three days - is difficult.
• Previous serious illness including abdominal operations, mumps and pelvic inflammatory disease.

Resources
Fertility Essentials www.fertilityessentials.co.uk.