In the JournalsPerspective

Women with difficulty conceiving often turn to generalist providers

Generalist providers are frequently the first point of care for women having problems conceiving and are in a “unique position” to advocate balanced infertility management, according to research recently published in the Journal of the American Board of Family Medicine.

Researchers noted that prevalence estimates of infertility range from 7.4% of married women of reproductive age to 15.5% who are trying to conceive.

“While the value of care before conception is well recognized, the role of a primary care provider in the diagnosis and treatment of infertility is not well studied,” Mandy W. Boltz, MD, MPH, of the department of family and preventive medicine, Office of Cooperative Reproductive Health, University of Utah, and colleagues wrote. “A better understanding of generalist providers’ role in the diagnosis and treatment of infertility may provide insight into opportunities for enhanced management of infertility in primary care settings.”

Boltz and colleagues analyzed mixed-mode questionnaire data from 867 women with primary infertility placed into a retrospective cohort through population- and fertility clinic-based sampling. The women were first asked if they saw a doctor or provider specifically for fertility-related issues. The researchers compared the likelihood of receiving in vitro fertilization (IVF) among women who first presented to a generalist provider with that of women who first presented to a fertility subspecialist, then compared time to pregnancy leading to a live birth by initial provider type.

Researchers found that 84% of the women first sought care from a generalist provider. Only 8% of women first sought care from a fertility subspecialist; these women were older and had been trying longer to conceive. In addition, women who first sought care from a general provider were less likely to receive IVF (AOR = 0.48; 95% CI, 0.28–0.82), but had similar times to pregnancy (AHR = 1.11; 95% CI, 0.8–1.53) and were equally likely to achieve pregnancy compared with women who first sought a subspecialist.

“These findings do not necessarily imply a causal relationship between first provider type and likelihood of receiving IVF. Women who seek infertility care from different types of providers likely differ beyond the factors we measured, such as cause of infertility,” Boltz and colleagues wrote.

Researchers wrote that using generalist providers as the first point of care may have several benefits for patients with infertility.

“Generalist providers who perform the initial workup and management of infertility may confer cost savings to their patients and to the health care system. They may also improve patient access to infertility care, especially for patients who, as a result of health care reform efforts, may now have increased access to primary care without increased access to subspecialty infertility care,” they wrote. “Generalist providers are uniquely positioned to promote the balanced management of infertility and may help some patients avoid unnecessary medical complications, costs, and stress associated with invasive fertility treatments.” – by Janel Miller

Disclosure: The researchers report no relevant financial disclosures.

Generalist providers are frequently the first point of care for women having problems conceiving and are in a “unique position” to advocate balanced infertility management, according to research recently published in the Journal of the American Board of Family Medicine.

Researchers noted that prevalence estimates of infertility range from 7.4% of married women of reproductive age to 15.5% who are trying to conceive.

“While the value of care before conception is well recognized, the role of a primary care provider in the diagnosis and treatment of infertility is not well studied,” Mandy W. Boltz, MD, MPH, of the department of family and preventive medicine, Office of Cooperative Reproductive Health, University of Utah, and colleagues wrote. “A better understanding of generalist providers’ role in the diagnosis and treatment of infertility may provide insight into opportunities for enhanced management of infertility in primary care settings.”

Boltz and colleagues analyzed mixed-mode questionnaire data from 867 women with primary infertility placed into a retrospective cohort through population- and fertility clinic-based sampling. The women were first asked if they saw a doctor or provider specifically for fertility-related issues. The researchers compared the likelihood of receiving in vitro fertilization (IVF) among women who first presented to a generalist provider with that of women who first presented to a fertility subspecialist, then compared time to pregnancy leading to a live birth by initial provider type.

Researchers found that 84% of the women first sought care from a generalist provider. Only 8% of women first sought care from a fertility subspecialist; these women were older and had been trying longer to conceive. In addition, women who first sought care from a general provider were less likely to receive IVF (AOR = 0.48; 95% CI, 0.28–0.82), but had similar times to pregnancy (AHR = 1.11; 95% CI, 0.8–1.53) and were equally likely to achieve pregnancy compared with women who first sought a subspecialist.

“These findings do not necessarily imply a causal relationship between first provider type and likelihood of receiving IVF. Women who seek infertility care from different types of providers likely differ beyond the factors we measured, such as cause of infertility,” Boltz and colleagues wrote.

Researchers wrote that using generalist providers as the first point of care may have several benefits for patients with infertility.

“Generalist providers who perform the initial workup and management of infertility may confer cost savings to their patients and to the health care system. They may also improve patient access to infertility care, especially for patients who, as a result of health care reform efforts, may now have increased access to primary care without increased access to subspecialty infertility care,” they wrote. “Generalist providers are uniquely positioned to promote the balanced management of infertility and may help some patients avoid unnecessary medical complications, costs, and stress associated with invasive fertility treatments.” – by Janel Miller

Disclosure: The researchers report no relevant financial disclosures.

    Perspective
    Carolyn Givens

    Carolyn Givens

    In this retrospective study of 867 women with primary infertility, women who first saw a generalist and women who first saw a subspecialist were equally likely to achieve a live birth, and there was no statistically significant difference in time to pregnancy for both groups.

    These are interesting results, yet it is important to consider the following:

    •          All the women in the study were from Utah, a population with higher female fertility and younger age at childbearing than populations of other states. A significant majority were less than 30 years of age. This makes it more difficult to generalize the conclusions.

    •          The article does not address whether the patients who conceived actually received treatment or ended up conceiving on their own, which commonly occurs, especially in young women, 1 to 3 years after first trying to conceive.

    •          The study reports lower chances of undergoing IVF if the patients saw a primary care provider first, but they don’t tell us exactly how many patients underwent IVF in either group. Although these results are reported as statistically significant, we don’t really know if they are clinically significant. We know that the patients seeking initial care with a fertility specialist were older and had been trying to conceive longer than the patients that saw a generalist first.

    In this study, 84% sought their first fertility care from a generalist. We should point out that it is very appropriate for family practitioners or OB/GYNs to initiate the patient workup with ovarian reserve testing (Cycle Day 2 or 3 Follicle Stimulating Hormone, Estradiol and an Anti-Mullerian Hormone) and prolactin, Thyroid Stimulating Hormone, and vitamin D screening, as well as semen analysis, mid-cycle pelvic ultrasound (to check endometrial thickness and rule out small polyps), and hysterosalpingogram. In addition, these physicians should consider ordering expanded genetic carrier screening panels as only then can conception of an affected fetus be avoided.

    However, we still believe that patients 32 and older who have been attempting pregnancy for at least a year should be immediately referred to a reproductive endocrinologist for treatment, simultaneous with initiating testing. These specialists are better equipped to monitor patients’ responses to treatment and to be available to do so 7 days a week. One example of this is ultrasound monitoring of patients who receive clomiphene for anovulation: monitoring of follicular development and watching for the not-uncommon side effect of clomiphene — thinning of the uterine lining and/or cervical mucus. This turns clomiphene into a contraceptive, rather than a proconceptive medication.

    As a reproductive endocrinologist, I appreciate the care and evaluation of patients referred to me by their primary care providers. Clearly there is a lot that primary care providers can do to help infertility patients, especially young patients, get on the right path to successful conception.

    • Carolyn Givens, MD
    • reproductive endocrinologist, Pacific Fertility Center, San Francisco