Perspectives on the Management of Infertility in Primary Care: A Survey of Healthcare Providers in a Regional Health Care System in Southwest Virginia

Research Article

Austin J Reprod Med Infertil. 2016; 3(1): 1035.

Perspectives on the Management of Infertility in Primary Care: A Survey of Healthcare Providers in a Regional Health Care System in Southwest Virginia

Gentry AL¹*, Pagidas K¹ and Johnson I²

¹Department of Obstetrics and Gynecology, University of Louisville School of Medicine, USA

²Department of Obstetrics and Gynecology, Virginia Tech Carilion School of Medicine, USA

*Corresponding author: Adrienne L. Gentry, Department of Obstetrics and Gynecology, University of Louisville School of Medicine, 550 Chestnut St. Louisville, KY 40202, USA

Received: May 25, 2016; Accepted: July 05, 2016; Published: July 07, 2016

Abstract

Purpose: The objective of this study is to identify current practice patterns of the primary care providers in the Carilion Clinic system for the evaluation, management, and referral of patients with infertility.

Methods: A 15 question survey was emailed to primary care physicians, physician assistants, and nurse practitioners in the Carilion Clinic system. The survey included a demographic analysis of the practice, and provided questions in regards to practice patterns in the evaluation, treatment, and referral of an infertile couple. The inclusion criteria were all PCPs (family medicine, internal medicine). Exclusion criteria included any other field of medicine

Results: Twenty-five percent of PCPs in the Carilion network answered the survey. Majority of responders were family medicine (80%), and physicians (80%). Fifty-five percent were female and thirty percent have been practicing medicine for more than 20 years. Half of PCPs were comfortable initiating the diagnostic evaluation of the infertile couple and of these, seventy three percent order diagnostic testing. Less than half (42%) of providers refer patients greater than age 35 that present with infertility for more than 6 months.

Conclusion: This survey provides insight into the variation of practice patterns of infertility by primary care providers (PCPs). Although half of PCPs that answered our survey are comfortable initiating the evaluation of the infertile couple, they are not following the current referral guidelines. This can lead to delayed diagnosis, and decreased time to achieve pregnancy. Based on these results, an educational model may be beneficial for PCPs that are interested in the evaluation of the infertile couple.

Keywords: Infertility; Primary care providers; Clomiphene

Introduction

Approximately 10-15 percent of couples will experience infertility during their reproductive years. While the majority of women see an OBGYN for annual gynecological exams, some women that live in rural areas, and/or with limited access to care, seek gynecological care from a primary care provider. However, there may be an increase in the utilization of primary care providers within inner cities secondary to health care reform and the fact that women’s preventive health care must be covered. Surprisingly, there is limited data in regards to the percent of women that receive their well women care also known as an annual gynecological exam from a family medicine and/or internal medicine provider versus an OBGYN.

These primary care providers are often the first resource for women and couples for fertility counseling and, thus serve a critical role in the identification of women and couples experiencing difficulty conceiving. They also play an important role in the initial evaluation of the infertile couple.

Interestingly, after review of multiple academic primary care residency programs that have posted their residency curriculum on their website within the United States, they report that infertility education is part of their curriculum; albeit brief and superficial in scope. Furthermore, multiple primary care textbooks review the evaluation and initial work up of the infertility couple, including that of the American Academy of Family Physicians (AAFP).

Depending on the country, some primary care providers believe that infertility should be a part of their practice and desire it to be a part of their residency education [1,3]; however, others do not believe it should be a scope of their practice [2]. Interestingly, a study that was published in 1992 in Israel stated that primary care providers and general gynecologists should not be evaluating and treating the infertile couple [4]. This is likely due to the limited resources that were available and the novel concept of infertility at that time. Later in 2003, Smith et al. stated that general practitioners have the ability to treat couples with infertility with the idea of preventing some referrals to subspecialists; however, more guidelines would need to be developed [5].

Of the studies that had a positive outlook on primary care providers evaluating and treating infertile couples, the majority of them agreed that further education and algorithms would provide more competent providers, earlier evaluation and diagnosis, and more satisfied patients.

Despite the numerous surveys and work done in other countries in regards to primary care providers attitudes towards evaluation and treatment of the infertile couple, there is a paucity of information in the literature regarding the practice patterns of primary care providers in the United States. The objective of this study is to identify current practice patterns of the primary care providers in the Carilion Clinic system for the evaluation, management, and referral of patients with infertility.

Methods

A 15 question survey was developed. Two hundred and forty three primary care providers were identified within the Carilion Clinic system by searching public emails within the Carilion server. The primary care providers were comprised of physicians, resident physicians, physician assistants, and nurse practitioners. The survey was reviewed and approved by the Virginia Tech -Carilion School of Medicine IRB. Carilion Clinic is a hospital system in Western Virginia serving a population of approximately one million people. Surveys were sent via email on three different occasions between December 2013 through March 2014. Data were collected and analyzed using Survey Monkey.

The survey included a demographic analysis of the practice, and provided questions in regards to practice patterns in:

1) The evaluation of an infertile couple; 2) Treatment of an infertile couple; 3) Diagnosis and Referral of an infertile couple. (Insert Survey)

The questions asked for the three categories were:

1) The evaluation of an infertile couple

a) I am comfortable initiating the diagnostic evaluation of patient that present with infertility

b) Do you order diagnostic testing for patients that present with infertility

c) If you answered yes to the above question, what tests do you order?

2) Treatment of an infertile couple

a) I perform ovulation induction with clomiphene citrate in my practice.

b) Dose of clomiphene citrate that I feel comfortable prescribing is ­

3) Diagnosis and Referral of an infertile couple.

a) I routinely refer patients less than 35 years old that present with infertility for more than one year.

b) I routinely refer patients less than 35 years old that present with infertility for more than two years.

c) I routinely refer patients 35 and older that present with infertility for more than 6 months.

d) I routinely refer patients 35 and older that present with infertility for more than 1 year.

e) I refer my patients with infertility to (OBGYN, REI, other)

Answers to the questions were either yes/no, multiple choice or 5-point Likert scale depending on the question being asked. The inclusion criteria were all primary care providers (family medicine, internal medicine, general practitioners), regardless of age, sex, gender, and ethnic characteristic. Exclusion criteria included any other field of medicine.

Results

The e-mailed survey was completed by 60 out of 243 primary care providers (25%). Three of the email addresses were undeliverable. Table 1 provides a demographic summary of the respondents. Less than half (44%) of providers were between the ages of 31-45, and 34% were between the ages of 46-60. Only, five percent of providers were older than 60 years of age. Just over half (55%) of the providers were female. Rural health care providers made up 33% of the respondents, suburban practitioners made up 47%, and 18% of the providers practice in inner cities. Recently trained providers (less than 5 years) were 37% of the responders, whereas 30 percent had practiced medicine for more than 20 years.