Podcast Review: Primary Care Knowledge Boost – Assisted conception

'Ideally, women should get pregnant in their 20s,' says retired gynaecologist, Dr Cheryl Fitzgerald, in my ear. I sit up in my seat on the train, feeling a little tense.

'Early 30s is fine,' I breathe a sigh of relief. Dr Fitzgerald, who is an expert in subfertility, continues 'As soon as you get to your mid-30s, then actually the chance of getting pregnant starts to go down very significantly.'

I eat my meal deal as Dr Fitzgerald explains why female age is so important when it comes to subfertility, suddenly aware of my egg cells withering with every passing mouthful.

When I tuned in to the Primary Care Knowledge Boost podcast about managing subfertility in general practice, I didn't expect it to strike a personal chord. After all, 'Assisted Conception – Managing Subfertility in General Practice' is an educational podcast aimed at GPs, giving practical guidance on what to do for patients who are struggling to get pregnant. Dr Fitzgerald talks to two GPs from Manchester, answering their many questions about subfertility – including what causes it, when to suspect it, and what treatment options are available to those hoping to have a child.

The bottom line is that there aren't that many treatment options available. And even when there are options, these seem to be vastly outnumbered by reasons why a patient may not be able to access them. Eligibility for IVF treatment on the NHS depends on factors that are either impossible to control – such as age, and having a child already – or extremely difficult to change – like BMI, and the postcode you happen to live in (see BioNews 1165, 1324a, 1324b and 1326).

Dr Fitzgerald is well aware that the system feels unjust, which is why she emphasises the need for GPs not to build up false expectations for patients.

'It's really important for GPs to say: "I do not know whether you will be able to access treatment,"' she says. As she repeats this for the second time, you sense a slight exasperation in her voice. She recalls that, even when she worked in an IVF unit, she struggled to memorise the complex web of treatment eligibility criteria (see BioNews 1193).

'It's often very complicated and there are some areas that have funny little quirks,' she says. 'Funny little quirks' is perhaps not the best term for things like being ineligible for IVF treatment as a woman in a same-sex couple, if you're unlucky enough to live in a postcode where it isn't funded by the NHS. 

But this is one verbal mishap among otherwise very sound, pragmatic advice. When the GP hosts ask about investigations they should do for a couple who have been trying to get pregnant for over a year, Dr Fitzgerald is refreshingly frank, saying 'quite honestly, I wouldn't really be bothered about any investigations'. She explains that, in a case like this where the patients display clear clinical signs of subfertility, the most important thing is to refer them as early as possible to secondary care. Once there, they will get a full work-up of investigations done anyway.

Rather than getting bogged down in specialist tests, Dr Fitzgerald advises GPs to focus on optimising management of existing health problems, such as diabetes and epilepsy, as well as advising patients to take the right supplements, and avoid smoking or excessive alcohol.

That's not to say, however, that patients who want to get pregnant can never have a glass of wine, or a cup of coffee. It's a nice moment when Dr Fitzgerald is asked what lifestyle advice GPs should give to their patients, and she deflects the question without dismissing it, saying that 'actually a lot of this is about taking pressure off couples'. She says that the stress caused by subfertility tends to be equivalent to that of a cancer diagnosis, and therefore urges GPs to provide reassurance where it's due.   

For me, the highlight of the podcast is when Dr Fitzgerald once again mentions the importance of female age for maximising fertility, but this time acknowledges that this narrative may be misconstrued as anti-feminist. Stories of celebrities having babies in their 40s may give women a false sense of security, she says, since it is rarely disclosed that many of these pregnancies are achieved with donor eggs.

'I think it is profoundly anti-feminist not to give women the information. I think they need to know and then they can make a choice.'

As someone who would like to have the option of having children one day, I appreciate Dr Fitzgerald's candidness. I came away with perhaps a bleaker outlook on subfertility than before – the ticking of my biological clock sounding a little louder, accompanied by frustration at the disparities in access to free IVF treatment.

But Dr Fitzgerald is merely the bearer of bad news. And she's right – we can only make informed choices if we are well-informed.