RRM Fertility Consult Template

Clinician Specialty: General Practitioner HPC: Patient is a 32-year-old female presenting with primary infertility, having been trying to conceive for 18 months. She reports regular menstrual cycles but has noticed increased premenstrual symptoms recently. She denies any significant pain during menstruation or intercourse. She is seeking guidance on further investigations and potential fertility treatment options. GP: G1 P0 TTC: 18 months Previous fertility treatments: None reported. Medications: * Folic Acid 400mcg, once daily, for preconception health. * Vitamin D 1000 IU, once daily, for general health. Allergies: * Penicillin, rash. Phx: History of mild asthma, well-controlled with as-needed salbutamol. No other significant past medical history. Menstrual Hx: Menarche 13 years Period length 5 days Period pattern Day 1: H, Day 2: H, Day 3: M, Day 4: L, Day 5: VL. Occasionally brown bleeding (B) on Day 6. total cycle length 28 days any fertile mucus Clear, stretchy mucus observed around day 14-15 of cycle, wet sensation. luteal phase length 13 days bleeding in the cycle other than menstruation None reported. Endometriosis screen: Pain with periods: Severity 3/10, mainly on days 1-2. Described as dull cramping, relieved by paracetamol. Pain on intercourse: Denies pain with intercourse. Pain in other times of cycle: None. Bladder pain or symptoms with period: None. bowel pain with menstruation or other times: None. analgesia needed - what taken and how often: Paracetamol 500mg, 1-2 tablets twice daily on days 1-2 of menses. PMS: Symptoms include irritability, bloating, and breast tenderness for 3-4 days prior to menses, resolving with onset of bleeding. PCOS screen: Hirsutism: None. Acne: Mild facial acne since age 16, typically worse around menses. Uses over-the-counter topical treatments. No significant severity or triggers identified. Prolactin screen: Ni allergy- (cheap jewelry rash): None. Dermagraphism: None. skin issues/ rashes/ warts: None. thrush: Occasional history of thrush, treated with over-the-counter antifungals. galactorrhoea: None. Insulin Resistance Screen: Weight history: Stable weight for the past 5 years. Reports a healthy BMI, no significant fluctuations. central distribution: No central fat distribution noted. skin tags: None. Social: Diet: Balanced diet, consumes moderate carbohydrates. Prioritises whole foods and lean proteins. Lifestyle: exercise: Exercises 3-4 times per week (mix of cycling and strength training) for 45-60 minutes per session. alcohol: Occasional social drinking, 1-2 units per week. smoking: Never smoked. CST: 1 November 2023, normal results. Mamograms: Not applicable for age. Fhx: Diabetes: Maternal grandmother type 2 diabetes. PCOS: No family history. Endometriosis: Maternal aunt with endometriosis. Thyroid problems: No family history. Autoimmune: No family history. Other: No other significant family medical history. Partner- SFA seminal fluid analysis done before/ results: Seminal fluid analysis performed 3 months prior, results were within normal limits for concentration, motility, and morphology. Investigations done to date: * 15 September 2024: Day 3 FSH, LH, Oestradiol - all within normal range. * 22 September 2024: Day 21 Progesterone - indicated ovulation. A: 32-year-old female with primary infertility for 18 months. Initial investigations suggest ovulatory cycles and normal male factor. Patient reports regular cycles with mild PMS and no significant endometriosis symptoms. Family history of endometriosis in a maternal aunt. Further investigations are warranted to identify potential contributing factors to infertility. Plan: * antenatal screen: Complete routine antenatal blood screen (full blood count, blood group, rhesus status, antibody screen, rubella, varicella, hepatitis B, C, HIV, syphilis). * hormone profile: Repeat hormone profile including thyroid function tests and prolactin. * infectious cervix screen: Chlamydia and gonorrhoea PCR. * ultrasound: Pelvic ultrasound to assess uterine morphology, ovarian reserve, and rule out any structural abnormalities or endometriomas. * charting: Advise continued ovulation tracking (e.g., basal body temperature, ovulation predictor kits). * referrals: Referral to a fertility specialist for comprehensive assessment and management plan.