Start with an open question

Start with an open-ended question to encourage Amanda to share her story.

“I can see this is really important to you. How have things been for you and Mark recently?”

Then clarify her agenda:

“What are you hoping we can achieve together today?”

This helps identify whether she wants reassurance, tests, referral, advice about timing, information about Mark’s results, or emotional support.

Time-efficient data gathering

Aim to complete data gathering by around 6–7 minutes, leaving adequate time for management.

Use focused questions to clarify:

• How long Amanda and Mark have been trying to conceive.
• Timing and frequency of intercourse.
• Menstrual cycle regularity.
• Any prior contraceptive use.
• Any previous pregnancies or fertility difficulties, if relevant.
• Any previous tests or investigations.
• What has already been tried, such as timing ovulation or lifestyle measures.
• Any red flags or risk factors.
• Mark’s health and lifestyle factors, if known.
• Emotional and relationship impact.

Avoid questions that do not directly relate to the case.

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High-yield questions

Trying to conceive

• “How long have you and Mark been trying?”
• “How often are you having sex?”
• “Have you been trying to time intercourse around ovulation?”
• “What have you already tried?”

Menstrual history

• “Are your periods regular and predictable?”
• “Have they changed recently?”
• “Have you ever had absent or very irregular periods?”

Medical and surgical history

• “Have you had any pelvic surgery?”
• “Have you ever had pelvic inflammatory disease or an STI?”
• “Do you have any known medical problems?”
• “Have either of you had previous difficulties conceiving?”

Partner factors

• “Do you know if Mark has any health issues that could affect fertility?”
• “Does he smoke, drink alcohol, use drugs, or have any concerns about testicular problems or heat exposure?”
• “Has Mark had any investigations before?”

Previous investigations

“Have either of you had any investigations before, for example blood tests or hormone checks?”

Clarify what has been done to avoid repetition and respond proportionately.

Functional, psychosocial or contextual assessment

Explore the emotional and relationship impact.

“You mentioned that this has been difficult for you and Mark. Can you tell me more about how you’re both coping?”

Ask about:

• Anxiety.
• Frustration.
• Relationship strain.
• Embarrassment.
• Pressure from family or others, if raised.
• Expectations about referral or testing.
• Whether support or counselling would be helpful.

Explore ideas, concerns and expectations

Amanda may expect early referral or investigations. Explore this gently.

“Would it help to know more about what to expect and when we would refer if it was needed?”

If she appears worried that referral is not being offered immediately:

“That’s a very common reaction when things aren’t happening as quickly as hoped, but you’re certainly not alone. Can you tell me more about what you’ve found most difficult?”

Recognise and respond to cues

Look for cues suggesting:

• Anxiety.
• Frustration.
• Embarrassment.
• Relationship strain.
• Fear that something is wrong.
• Disappointment if immediate referral is not offered.

Respond with validation:

“Trying for a baby can be a very emotional process, especially when things are taking longer than you expected.”

Useful consultation phrases

“Most couples will conceive within 12 months of trying. If it hasn’t happened by then, we can arrange further tests for both you and Mark.”

“Everything you’ve told me so far is reassuring, but I don’t want to dismiss how stressful this feels.”

“If cycles change, symptoms develop or we identify any new risk factors, we can review things earlier.”

“I can’t give Mark’s results to you without his explicit consent, but we can arrange a joint appointment or he can contact the practice directly.”

Consultation flow and signposting

1. Open with Amanda’s story and agenda.
2. Clarify how long they have been trying and intercourse frequency.
3. Explore menstrual history and ovulation-related information.
4. Ask about medical, surgical, STI and pelvic history.
5. Explore Mark’s health and lifestyle factors, if known.
6. Clarify previous tests or investigations.
7. Explore emotional, relationship and social impact.
8. Summarise and share clinical reasoning.
9. Discuss advice, options and follow-up plan.
10. Check understanding and agree next steps.

Summarising and checking understanding

Summarise as you go to stay aligned with Amanda’s agenda.

“Your periods sound regular, you and Mark are having sex regularly, and you’re both generally healthy, which is reassuring. You’re understandably worried because it’s taking longer than you expected, and you’d like to know whether tests or referral are needed now.”

Check:

• Whether the summary is accurate.
• Whether Amanda feels her main concern has been addressed.
• Whether she understands the 12-month threshold.
• Whether she knows what would trigger earlier review.

Data gathering self-check

Before moving to management, the trainee should know:

• How long Amanda and Mark have been trying.
• Frequency and timing of intercourse.
• Whether Amanda’s cycles are regular.
• Whether there are red flags requiring earlier assessment.
• Whether either partner has relevant medical or surgical history.
• Whether there has been previous PID, STI or pelvic surgery.
• What investigations or strategies have already been tried.
• What Amanda expects from the consultation.
• How this is affecting Amanda and Mark emotionally.
• Whether confidentiality issues arise around Mark’s results.

Assessment domain mapping

Data gathering

• Duration of trying to conceive.
• Menstrual and sexual history.
• Prior contraception and previous investigations.
• Female and male risk factors.
• Psychosocial and relationship impact.

Clinical management

• Explaining usual timing of fertility investigations.
• Preconception and lifestyle advice.
• Review plan at 12 months or earlier if risk factors develop.
• Confidentiality around partner results.
• Support resources and counselling where needed.

Relating to others

• Validating distress.
• Managing expectations gently.
• Using clear, non-technical explanations.
• Supporting Amanda’s agency in decision-making.

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Prioritised differential diagnosis or clinical reasoning

In a woman with regular cycles, normal sexual frequency and no red flags, differentials include:

1. Unexplained or physiological delay in conception — most likely at this stage.
2. Male factors, including lifestyle factors such as smoking, alcohol, drug use, testicular heat exposure, nutrition, age and medical conditions.
3. Ovulatory disorder — unlikely with regular, predictable periods.
4. Tubal pathology — unlikely if there is no prior PID, STI, pelvic surgery or symptoms.
5. Endometriosis — unlikely if there is no pain or dysmenorrhoea.
6. Lifestyle or concordance factors, such as stress, frequency and timing of intercourse.

Amanda has no urgent red flags for early female investigation per NICE CG156 based on the information provided.

Clinical reasoning script

“From what you’ve told me, there aren’t obvious warning signs that we need to investigate straight away. Fertility specialists usually work with couples who have been trying for a year or more, because the vast majority of couples will get pregnant within a year of trying. If it hasn’t happened by then, we can arrange tests for both of you.”

Red flags and risk assessment

Review earlier or consider earlier assessment if:

• Cycles become irregular.
• Amenorrhoea develops.
• Pelvic pain or dysmenorrhoea suggests endometriosis.
• There is a history of PID, STI or pelvic surgery.
• There are known medical problems for either partner.
• There are abnormal examination findings.
• Amanda is over 36.
• New risk factors or symptoms develop.

Decision points

Key decisions include:

• Are there red flags requiring early investigation or referral?
• Has the couple been trying for 12 months or more?
• Are intercourse frequency and timing likely to support conception?
• Are there male-factor risks that Mark should discuss with his GP?
• Does Amanda need emotional or relationship support?
• Does confidentiality prevent sharing Mark’s results?
• What follow-up point should be agreed?

Management priority

The management priority is to provide Amanda with a clear, reassuring and actionable plan:

• Continue appropriate attempts to conceive.
• Optimise preconception health.
• Address stress and relationship impact.
• Review at 12 months of trying, or earlier if new risk factors develop.
• Respect Mark’s confidentiality.

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Management options

 1. Continue regular sexual intercourse

Advise regular intercourse every 2–3 days, which maximises natural conception chances.

2. Prenatal supplements and healthy lifestyle

Discuss:

• Folic acid.
• Non-smoking.
• Healthy weight.
• Balanced diet.
• Healthy lifestyle for both partners.

3. Immunisations

Ensure both partners are up to date with relevant immunisations, including checking rubella vaccination status.

4. Stress and psychological support

Offer support for stress, relationship strain or emotional impact.

Options may include:

• Local counselling.
• Support groups.
• Couple support if needed.

5. Mark’s health and results

Offer review of Mark’s health and lifestyle, including support for quitting smoking if applicable.

If Amanda expects Mark’s result, explain:

“I understand why you’d want to know, but I can’t provide Mark’s results without his explicit consent. He can contact the practice directly, or we can arrange a joint appointment if he agrees.”

6. Follow-up plan

Arrange review at 12 months of trying, or earlier if:

• Cycles change.
• Symptoms develop.
• New risk factors are identified.
• Amanda’s distress increases and she needs further support.

7. Future investigations and referral

Explain what may be considered if pregnancy has not occurred after 12 months, including:

• Hormonal profile.
• Semen analysis.
• Tubal patency testing.
• Specialist referral where appropriate.

Make clear that these are not automatically required immediately if there are no risk factors.

8. Written resources

Offer reliable fertility information, including:

• NICE resources.
• NHS infertility information.
• NHS fertility resource leaflets or trusted websites.

Personalised plan

For Amanda, a personalised plan might include:

• Reassurance that her regular periods and absence of red flags are encouraging.
• Continued regular intercourse every 2–3 days.
• Preconception advice including folic acid and healthy lifestyle.
• Stress or couples support if wanted.
• Clear explanation of when tests would be arranged.
• Follow-up in around five months if that brings the couple to 12 months of trying.
• Earlier review if cycles change, symptoms develop or new risk factors appear.
• Clear confidentiality advice regarding Mark’s results.

Example phrase:

“I know it must feel frustrating, but the good news is that everything you’ve mentioned is reassuring and in line with what we’d hope for at this stage. Can I suggest we make a follow-up appointment for five months’ time, to reach the 12 months, and earlier if anything changes?”

Shared decision-making

Involve Amanda in the plan.

Ask:

“Would that work for you, or is there something else you’d like to discuss today?”

Check whether she wants:

• Written information.
• A planned follow-up date.
• Support for stress or relationship strain.
• Advice on involving Mark in a joint appointment.
• More explanation about investigations if needed later.

Safety-netting

Advise Amanda to seek earlier review if:

• Periods become irregular.
• Periods stop.
• New pelvic pain or dysmenorrhoea develops.
• There is a new history or disclosure of STI or pelvic infection.
• Either partner becomes aware of a relevant medical problem.
• They reach 12 months of trying without pregnancy.
• Emotional distress or relationship strain becomes difficult to manage.

Ethical, legal and safeguarding considerations

If Amanda asks for Mark’s results, explain sensitively that his results cannot be shared without his explicit consent.

This is supported by  GMC Confidentiality.

Offer alternatives:

• Mark contacts the practice directly.
• Mark provides explicit consent.
• A joint appointment is arranged.

Documentation points

Document:

• Duration of trying to conceive.
• Menstrual regularity.
• Frequency of intercourse.
• Relevant female and male risk factors discussed.
• Absence or presence of red flags.
• Previous investigations or strategies.
• Amanda’s concerns and expectations.
• Advice given about timing, lifestyle and supplements.
• Follow-up plan.
• Confidentiality discussion if Mark’s results are requested.
• Resources or support offered.

Common unsafe management plans

Avoid:

• Ordering routine fertility investigations before 12 months without risk factors.
• Referring prematurely without explaining the rationale.
• Dismissing Amanda’s distress because the timeline is still within expected range.
• Ignoring male-factor assessment.
• Sharing Mark’s results without explicit consent.
• Giving only generic reassurance without a review plan.
• Using jargon without explanation.

Follow-up and coordination with other professionals

Arrange follow-up at 12 months of trying, or earlier if new concerns arise.

Consider coordination with:

• Mark, if he consents or attends jointly.
• Fertility services if criteria are met.
• Counselling or support services if emotional or relationship impact is significant.

Learner checkpoint

Have I given Amanda a clear plan for what happens now, what happens at 12 months, and what would trigger earlier review?

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Relevant guidance areas

• Fertility assessment and treatment.
• Timing of investigations and referral.
• NHS infertility information.
• Partner confidentiality.
• Psychosocial support around fertility concerns.

NICE guidance

• NICE CG156: Fertility assessment and treatment.

 GMC, DVLA or safeguarding guidance

• GMC Confidentiality.

Patient information websites

• NHS: Infertility.
• NHS fertility resource leaflets or trusted websites, including https://www.nhs.uk/conditions/infertility.

 Key principles to remember

• Start with Amanda’s story and agenda.
• Use open questions first, then focused fertility questions.
• Ask about duration of trying, intercourse frequency, menstrual regularity and risk factors.
• Explore male-factor risks as well as female factors.
• No routine investigations before 12 months of trying unless risk factors are present.
• Explain referral thresholds clearly and positively.
• Validate emotional distress and relationship strain.
• Offer preconception and lifestyle advice.
• Do not share Mark’s results without explicit consent.
• Arrange review at 12 months, or earlier if symptoms or risk factors develop.

Transferable learning for future cases

In fertility consultations:

• Reassurance is only helpful when paired with a clear plan.
• Always explore both partners’ factors.
• Avoid premature investigation when guidance does not support it.
• Do not minimise distress just because the couple is still within an expected timeframe.
• Confidentiality applies to partner results even in a shared fertility context.
• A planned review date can reduce anxiety and improve trust.

Supervisor or examiner lens

A supervisor or examiner is likely to look for:

• Efficient, focused fertility history.
• Sensitive communication and validation.
• Recognition of absence of early investigation red flags.
• NICE-consistent explanation of 12-month review.
• Advice on intercourse frequency and preconception health.
• Consideration of Mark’s health and confidentiality.
• Clear follow-up and safety-netting.

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Final learner takeaway

In early fertility concerns, combine empathy with structure: check for red flags, support the couple, avoid premature tests, and give a clear plan for review.

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