National Perinatal Epidemiology and Statistics Unit, School of Women's & Children's Health and Centre for Big Data Research in Health, The University of New South Wales (UNSW), Sydney, Australia.
Menzies Centre for Health Policy, University of Sydney, Sydney, Australia.
Hum Reprod. 2019 Nov 1;34(11):2173-2183. doi: 10.1093/humrep/dez172.
How did general practitioners (GPs) (family physicians) manage infertility in females and males in primary care between 2000 and 2016?
The number of GP infertility consultations for females increased 1.6 folds during the study period, with 42.9% of consultations resulting in a referral to a fertility clinic or specialist, compared to a 3-fold increase in the number of consultations for men, with 21.5% of consultations resulting in a referral.
Infertility affects one in six couples and is expected to increase with the trend to later childbearing and reports of declining sperm counts. Despite GPs often being the first contact for infertile people, very limited information is available on the management of infertility in primary care.
STUDY DESIGN, SIZE, DURATION: Data from the Bettering the Evaluation and Care of Health programme were used, which is a national study of Australian primary care (general practice) clinical activity based on 1000 ever-changing, randomly selected GPs involved in 100 000 GP-patient consultations per year between 2000 and 2016.
PARTICIPANTS/MATERIALS, SETTING, METHODS: Females and males aged 18-49 years attending GPs for the management of infertility were included in the study. Details recorded by GPs included patient characteristics, problems managed and management actions (including counselling/education, imaging, pathology, medications and referrals to specialists and fertility clinics). Analyses included trends in the rates of infertility consultations by sex of patient, descriptive and univariate analyses of patient characteristics and management actions and multivariate logistic regression to determine which patient and GP characteristics were independently associated with increased rates of infertility management and referrals.
The rate of infertility consultations per capita increased 1.6 folds for women (17.7-28.3 per 1000 women aged 18-49 years) and 3 folds for men over the time period (3.4-10.2 per 1000 men aged 18-49 years). Referral to a fertility clinic or relevant specialist occurred in 42.9% of female infertility consultations and 21.5% of male infertility consultations. After controlling for age and other patient characteristics, being aged in their 30s, not having income assistance, attending primary care in later years of the study and coming from a non-English-speaking background, were associated with an increased likelihood of infertility being managed in primary care. In female patients, holding a Commonwealth concession card (indicating low income), living in a remote area and having a female GP all indicated a lower adjusted odds of referral to a fertility clinic or specialist.
LIMITATIONS, REASONS FOR CAUTION: Data are lacking for the period of infertility and infertility diagnosis, which would provide a more complete picture of the epidemiology of treatment-seeking behaviour for infertility. Australia's universal insurance scheme provides residents with access to a GP, and therefore these findings may not be generalizable to other settings.
This study informs public policy on how infertility is managed in primary care in different patient groups. Whether the management actions taken and rates of secondary referral to a fertility clinic or specialist are appropriate warrants further investigation. The development of clinical practice guidelines for the management of infertility would provide a standardized approach to advice, investigations, treatment and referral pathways in primary care.
STUDY FUNDING/COMPETING INTEREST(S): This paper is part of a study being funded by an Australian National Health and Medical Research Council project grant APP1104543. G.C. reports that she is an employee of The University of New South Wales (UNSW) and Director of the National Perinatal Epidemiology and Statistics Unit (NPESU), UNSW. The NPESU manages the Australian and New Zealand Assisted Reproductive Technology Database on behalf of the Fertility Society of Australia. W.L. reports being a part-time paid employee and minor shareholder of Virtus Health, a fertility company. R.N. reports being a small unitholder in a fertility company, receiving grants for research from Merck and Ferring and speaker travel grants from Merck.
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在 2000 年至 2016 年期间，全科医生（家庭医生）在初级保健中如何管理女性和男性的不育症？
在此期间，女性不育症咨询的全科医生数量增加了 1.6 倍，其中 42.9%的咨询导致向生育诊所或专家转诊，而男性咨询的增加了 3 倍，其中 21.5%的咨询导致转诊。
不孕影响六分之一的夫妇，预计随着晚育趋势和精子计数下降的报告，不孕的发病率将会增加。尽管全科医生通常是不育患者的第一接触者，但关于初级保健中不育症管理的信息非常有限。
研究设计、规模、持续时间：Bettering the Evaluation and Care of Health 计划的数据被用于这项研究，该计划是一项基于澳大利亚初级保健（全科医生）临床活动的全国性研究，涉及 1000 名不断变化的、随机选择的全科医生，他们在 2000 年至 2016 年间每年参与 100000 名全科医生-患者咨询。
参与者/材料、设置、方法：本研究纳入了在全科医生处就诊以管理不育症的 18-49 岁的女性和男性。全科医生记录的详细信息包括患者特征、管理的问题和管理措施（包括咨询/教育、影像学、病理学、药物治疗以及向专家和生育诊所的转诊）。分析包括按患者性别划分的不育症咨询率的趋势、患者特征和管理措施的描述性和单变量分析，以及多变量逻辑回归，以确定哪些患者和全科医生特征与增加的不育症管理和转诊率相关。
在此期间，女性的不育症咨询率增加了 1.6 倍（每 1000 名 18-49 岁女性中 17.7-28.3 次），男性的咨询率增加了 3 倍（每 1000 名 18-49 岁男性中 3.4-10.2 次）。在女性不育症咨询中，42.9%的咨询导致向生育诊所或相关专家转诊，而男性不育症咨询中，21.5%的咨询导致转诊。在控制年龄和其他患者特征后，年龄在 30 多岁、没有收入援助、在研究后期到初级保健就诊和来自非英语国家背景的患者，更有可能在初级保健中治疗不育症。在女性患者中，持有联邦政府优惠卡（表明收入低）、居住在偏远地区和有女性全科医生，均表明向生育诊所或专家转诊的调整后几率较低。
局限性、谨慎的原因：关于不孕的时期和不孕诊断的数据缺乏，这将提供更完整的治疗寻求行为的流行病学情况。澳大利亚的全民保险计划为居民提供了获得全科医生的途径，因此这些发现可能不适用于其他环境。
这项研究为不同患者群体的初级保健中如何管理不育症提供了公共政策信息。所采取的管理措施以及向生育诊所或专家的二次转诊率是否适当，需要进一步调查。制定不育症管理的临床实践指南将为初级保健中的咨询、检查、治疗和转诊途径提供标准化方法。
研究资金/利益冲突：本文是澳大利亚国家卫生和医学研究理事会项目拨款 APP1104543 的一部分。G.C. 报告称，她是新南威尔士大学（UNSW）的员工，也是新南威尔士大学国家围产期流行病学和统计单位（NPESU）的主任。NPESU 代表澳大利亚和新西兰辅助生殖技术数据库管理机构。W.L. 报告称，她是一家生育公司的兼职带薪员工和小股东，从默克和费林获得研究赠款，并从默克获得演讲旅行赠款。R.N. 报告称自己是一家生育公司的小股东，从默克获得赠款用于研究，并从默克获得演讲旅行津贴。
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