Management of infertility: one stop clinic may offer solution

Editor—In their review of the management of infertility Cahill and Wardle report that most investigations to establish a cause of subfertility are simple to undertake.¹ In our experience, these investigations are protracted for many couples, requiring several outpatient visits and often inpatient laparoscopy for the female partner. At a time of understandable stress for the couple, the assessment process can be frustrating for all concerned.

Since February 2000 we have attempted to rationalise the investigation of infertility using a “one stop” approach as used for conditions such as dyspepsia and menorrhagia (A Taylor et al, meeting of the British Society for Gynaecological Endoscopy, Portsmouth, May 2002). Couples who fulfilled our selection criteria were invited to the one stop fertility clinic.

History, examination, and review of blood tests previously organised were followed by pelvic ultrasonography (to look for polycystic ovaries, adnexal masses, and uterine fibroids), hysteroscopy (to look for endometrial polyps, submucous fibroids, and uterine anomalies), and culdoscopy with hydrotubation (to look for adhesions, endometriosis, and tubal disease).

Culdoscopy (telescopic examination of the pouch of Douglas via the posterior fornix) was first introduced to gynaecological practice in 1941 but was superseded by laparoscopy.² Recently a refined version using narrow instruments and saline irrigation to investigate infertility has been reintroduced and carried out under local anaesthesia.³ This technique allows for clear visualisation of the pouch of Douglas and adnexa, as well as assessment of tubal patency by hydrotubation. Although culdoscopy is more invasive than ultrasonography in the female partner,⁴ it can exclude pelvic endometriosis and adhesions, which are important causes of infertility.

To date, 130 of the 211 (61%) couples referred to the clinic met our selection criteria, and 87 of this group have been seen. Of these, 70 patients (80%) completed the three diagnostic procedures successfully and 26 patients (30%) were found to have pelvic pathology. The average time for the three procedures was 41 (SD 17) minutes. The investigations were well tolerated, and there were no serious complications. Patient feedback was positive, the availability of immediate results being particularly appreciated.

While a one stop approach is not suitable for all couples, and not all couples opt for outpatient investigation, we believe that a one stop fertility clinic offers a rational, efficient, and potentially cost effective alternative to the traditional investigation of infertility.