The standardised Welsh Health Specialised Services Committee referral form must be used for all patients referred to the assisted reproduction services held at Wales Fertility Institute.
There is an individual referral form for diagnostic Andrology service which can be found under Andrology Referrals below
Many patients will have already attended their GP surgery for healthy lifestyle advice prior to attempting conception. The eligibility criteria for treatment indicates the following:
• BMI for the female partner must be between 19 and 30
• Both partners must be non-smoking at the time of treatment.
It is likely that patients will seek advice from their GPs with regards to weight loss and smoking cessation in order to ensure they are eligible to be offered treatment.
The following criteria are set by the Welsh Health Specialised Services Committee.
In Vitro Fertilisation (IVF) or Intra Cytoplasmic Sperm Injection (ICSI)
A full cycle of IVF treatment, with or without ICSI, should comprise one episode of ovarian stimulation and the transfer of any resultant fresh and frozen embryo(s). This will include the storage of any frozen embryos for one year following egg collection. Patients will be advised at the start of the treatment that this is the level of service that is available on the NHS and that the NHS will not fund storage following this period. Patients will be counselled, and agree that storage of any frozen embryos following this period will need to be funded by themselves, or allowed to perish.
Women who are aged less than 40 years and who meet the access criteria are entitled to up to two cycles of IVF with or without ICSI as long as the treatment remains clinically appropriate. However if the woman reaches the age of 40 during the first cycle of treatment they will not be entitled to a second cycle of IVF. Women aged between 40 and 42 years who meet the access riteria are entitled to one cycle of IVF with or without ICSI provided the following 3 criteria are also fulfilled:
• they have never previously had IVF treatment
• there is no evidence of low ovarian reserve
• there has been a discussion of the additional implications of IVF and pregnancy at this age.
IVF on the NHS is available for couples who do not have any living children (biological or adopted) or where one of the partners does not have any living children (biological or adopted). For single women/men – that the woman/man does not have any living children (biological or adopted).
Body Mass Index [BMI]
The female partner must have a body mass index of between at least 19 and up to and including 30. Patients outside this range will not be added to the waiting list and should be referred back to their referring clinician and/or general practitioner for management where required.
Sub-fertility is not the result of a sterilisation procedure in either partner/single woman/single man (this does not include conditions where sterilisation occurs as a result of another medical problem). Couples/single women/single men who have undertaken a reversal should not be referred for treatment.
Where either of the couple/single woman/single man smokes the patient is not eligible. Only patients who agree to take part in a supported programme of smoking cessation will be accepted on the IVF treatment waiting list and must be non-smoking at the time of treatment.
History of previous treatment
For single patients, three or more IVF cycles by the patient will exclude any further NHS IVF treatment. For couples, three or more IVF cycles by either partner will exclude any further NHS IVF treatment. Previous cycles whether NHS or privately funded will be taken into account.
Subfertility must be demonstrated before there can be access to NHS funded IVF treatment. Subfertility for heterosexual couples is defined as inability to conceive after 2 years unprotected intercourse or a fertility problem demonstrated at investigation. Subfertility for same sex couples/single women/single men is defined as no live birth following insemination at or just prior to the known time of ovulation on at least six non-stimulated cycles or a fertility problem demonstrated at investigation. For same sex couples/single women/single men, the non-stimulated cycles may be achieved through a private arrangement or through NHS-provided IUI with donor sperm. Intra-uterine insemination (IUI) is not funded by WHSSC.
Funding for IUI is the responsibility of the Health Boards. Where donor sperm is needed to undertake IUI, the donated sperm will be funded by WHSSC, but not the IUI procedure. In women aged 40-42 years there is also no evidence of low ovarian reserve.
Diagnostic semen analysis referrals:
Patients being referred for semen analysis should be provided with the relevant completed referral form and specific pot provided by Wales Fertility Institute to all referrers. Patients will be asked to contact the Unit directly to make a mutually convenient appointment.
• The sample should be delivered to the Unit within 2 hours of being produced.
• The patients should also be informed that the result will be forwarded to the GP surgery within 7 to 10 days following analysis of sample.
• No results will be given via the telephone for confidentiality reasons.
• Unfortunately samples that do not have the relevant information completed will not be analysed.
• Patients who attend the Institute without a scheduled appointment will not be seen.
• For referrals to the assisted reproduction service, all fields in the form must be completed in order that the Institute has information on the full basic preliminary investigations which should be undertaken at primary care level.
• Unfortunately if the referral information is not complete or accurate we will be unable to accept the referral at the Institute.
Referral for consideration of sperm storage:
If you wish to arrange sperm storage for one of your oncology patients you will need to follow the procedure below.
• Advise the patient that we will be contacting him soon in order to book his first appointment for sperm storage.
• Please email us the patient’s name, date of birth and hospital number, as well as his contact details, so that we can arrange the appointment with him.
• The patient needs to be tested for the following:
• HIV 1 and 2 (Anti-HIV – 1, 2)
• Hepatitis B (HBsAg/Anti-HBc)
• Hepatitis C (Anti-HCV-Ab)
• TPHA & VDRL
• Urethral swab for gonorrhoea
• Urine test for chlamydia
• HTLV- 1 and 2 antibody testing
• Virology screening results are only valid if obtained no more than 15 days prior to sperm storage.
• Ensure that you post/fax or email us the above virology screening results.
• You will also need to post/fax or email us a referral letter.
• Provide the patient with a copy of our Sperm Freezing Brochure, which will give the patient background information on sperm freezing procedures at IVF Wales and the practical aspects and risks of freezing sperm.
• Check if patient has a partner.
• Provide the patient with a copy of the HFEA_CD_FORM. This form will also need to be completed by the patient’s partner.
• Provide the patient with a copy of the HFEA_GS_FORM.
• If the patient has a partner, provide the patient with a copy of the HFEA_MT_FORM.
• Inform the patient that he will need to bring the forms above to his first sperm storage appointment.
• Inform the patient that he will need to bring photo ID (ie driving licence or passport) to his first sperm storage appointment, as well as photo ID for his partner.
The Embryology Team
Wales Fertility Institute
C1 link corridor
University Hospital of Wales
Tel: 029 20 74 3558
Fax: 029 20 74 5158 (FAO Embryology Team)