Fertility History Taking – OSCE Guide

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Fertility history taking is an important skill that touches on many areas of medicine. This guide provides a structured approach to taking a fertility history in an OSCE setting.

When taking a fertility history, you are likely speaking to an individual or couple struggling to conceive. This is an understandably anxiety-inducing experience for them. As with all history taking, it is important to be constantly aware and sensitive to a patient’s emotions.

The context of the conversation is probably either a fertility clinic or primary practice. Being aware of the context will guide how open your initial questions are. 

This guide addresses history taking for both biological male and female patients. For completion, you may need to take a fertility history for any partners involved in the conception journey.  You should check whether the patient is comfortable with their history being taken in front of their partner or whether they’d prefer to answer your questions alone.


What is infertility?

A couple is considered ‘subfertile’ if they have not conceived after a year of regular, unprotected intercourse.

Most couples are not thought to be strictly infertile because every month they still have a chance of conceiving although this may be a lower chance than what is normal.1


Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Explain that you’d like to take a history from the patient.

Gain consent to proceed with history taking.

General communication skills

It is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).

Some general communication skills which apply to all patient consultations include:

  • Demonstrating empathy in response to patient cues: both verbal and non-verbal
  • Active listening: through body language and your verbal responses to what the patient has said
  • An appropriate level of eye contact throughout the consultation
  • Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair)
  • Making sure not to interrupt the patient throughout the consultation
  • Establishing rapport (e.g. asking the patient how they are and offering them a seat)
  • Signposting: this involves explaining to the patient what you have discussed so far and what you plan to discuss next
  • Summarising at regular intervals
You might also be interested in our OSCE Flashcard Collection which contains over 2000 flashcards that cover clinical examination, procedures, communication skills and data interpretation.

Conception history

It is good practice to use open questioning to explore the patient’s conception history. Here is an example of what you can say to start the consultation:

  • “I gather you have been having some difficulty recently getting pregnant. Can you tell me some more about this?”

Provide the patient with enough time to answer and avoid interrupting them.

Facilitate the patient to expand if required:

  • “Can you tell me a bit more about that? If that’s ok.”

More specifically, you need to find out how long the patient has been trying to conceive. This is defined as regular, unprotected sex.2 You should ask about their previous forms of contraception including when they stopped using it and how long they were using it. 

Open vs closed questions

History taking typically involves a combination of open and closed questions. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis.

Ideas, concerns, and expectations

A key component of history taking involves exploring a patient’s ideasconcerns and expectations (often referred to as ICE) to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation. 

The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. This will help ensure your consultation is more naturalpatient-centred and not overly formulaic.

It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below.

Ideas

Explore the patient’s ideas about the current issue:

  • “What do you think the problem is?”
  • “What are your thoughts about what is happening?”
  • “It’s clear that you’ve given this a lot of thought and it would be helpful to hear what you think might be going on.”

Concerns

Explore the patient’s current concerns:

  • “Is there anything, in particular, that’s worrying you?”
  • “What’s your number one concern regarding this problem at the moment?”
  • “What’s the worst thing you were thinking it might be?”

Expectations

Ask what the patient hopes to gain from the consultation:

  • “What were you hoping I’d be able to do for you today?”
  • “What would ideally need to happen for you to feel today’s consultation was a success?”
  • “What do you think might be the best plan of action?”

Summarising

Throughout the history taking process, it is good to summarise at regular intervals to ensure you have understood the patient correctly.

Summarise what the patient has told you about their conception history. This allows you to check your understanding of the patient’s history and provides an opportunity for the patient to correct any inaccurate information.

Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically summarise as you move through the rest of the history.

Signposting

Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare for what is coming next.

Signposting examples

Explain what you have covered so far“Ok, so we’ve talked about your concerns and what you’re hoping we achieve today.”

Signposting can help prepare patients for subjects that might be especially sensitive.

Explain what you plan to cover next“Next, I’d like to talk about any past pregnancies if that’s ok. I know this can be a difficult subject so please just take your time and we can come back to it if you wish.”


Pregnancy history

As mentioned above, remember to be sensitive to a patient’s emotions, especially when discussing topics such as previous pregnancies.

You need to find out if the patient has had any pregnancies with a current partner or previous partners. You need to note the date they became pregnant, how they became pregnant (was it a natural conception or was treatment involved) and how long the gestation lasted.  

You need to ask about the outcome of any pregnancies such as biochemical pregnancy (miscarriage within the first 2-3 weeks of conception), miscarriage, termination of pregnancy (TOP) and the method of termination (surgical or medical), ectopic pregnancy, preterm birth, term birth as well as if it was a stillbirth or live birth.

If the patient has delivered any babies, you need to know the mode of delivery (i.e. vaginal or caesarean) and the baby’s health outcome.

Primary vs secondary failure to conceive

A primary failure to conceive means the female patient has never conceived before. A secondary failure to conceive means that the patient has conceived previously, irrespective of how the pregnancy developed, but is now struggling to conceive again.1


Menstrual history

You need to ask if the patient has a regular menstrual cycle. How often do they have periods and how many days do they normally bleed for? 

Ask when the patient’s last menstrual period (LMP) was, noting the day it started and ended, and how much pain they normally experience during their menstrual cycle.


Sexual history

Inquire as to how often the patient is having unprotected sex and if they experience any pain and/or bleeding during or after.

You should ask if they have had any previous sexually transmitted infections (STIs) and what treatment they received. You should also check if they have had any investigations for STIs. 


Systemic enquiry

systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant to fertility. A systemic enquiry may also identify symptoms that the patient has forgotten to mention.

Deciding on which symptoms to ask about depends on what the patient has already told you and your level of experience.

Some examples of symptoms you could screen for in each system include:

  • Systemic: fevers, fatigue
  • Respiratory: dyspnoea, cough, sputum, wheeze, haemoptysis, pleuritic chest pain
  • Gastrointestinal: dyspepsia, nausea, vomiting, dysphagia, abdominal pain
  • Genitourinary: oliguria, polyuria
  • Neurological: visual changes, motor or sensory disturbances, headache
  • Musculoskeletal: chest wall pain
  • Dermatological: rashes, ulcers
Polycystic ovary syndrome

When taking a fertility history, it’s essential that you identify risk factors for common causes of infertility as you work through the patient’s history (e.g. past medical history, family history, social history). Polycystic ovary syndrome (PCOS) is a common cause of infertility.3

Important PCOS symptoms include:

  • Infrequent menstrual periods, no menstrual periods and/or irregular bleeding
  • Inability to become pregnant
  • Increased hair growth on the face, chest, stomach, back, thumbs, and/or toes (hirsutism)
  • Weight gain (usually around the waist)
  • Acne, oily skin and/or dandruff
  • Male pattern baldness and/or thinning hair
  • Skin tags and/or small excess flaps of skin in the armpits and/or neck 4

Past medical history

Make note of the patient’s height and weight, then calculate their BMI. 

Ask if the patient has any medical conditions: 

  • “Do you have any medical conditions?”
  • “Are you currently seeing a doctor or specialist regularly?”
  • “Have you experienced any significant physical trauma?”

If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospital admissions.

Ask if the patient has previously undergone any surgery or procedures (e.g. vasectomy or any abdominal or pelvic surgery):

  • “Have you ever previously undergone any operations or procedures?”
  • “When was the operation/procedure and why was it performed?”

Smears

Make a note of the patient’s smear history, including the date of the examination and what the result was.

Vaccinations

Inquire as to whether the patient has received their measles, mumps, and rubella (MMR) vaccine. This is because rubella is extremely dangerous in pregnancy.5

You should also ask whether the patient has had their COVID vaccine (and if so, how many) and note any vaccinations for travelling.

Allergies

Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis).

Conditions for pregnancy

When taking a fertility history, it is worth keeping in mind the four basic conditions required for pregnancy:1

  1. An egg must be produced: failure to release an egg is known as ‘anovulation’
  2. Adequate sperm must be released: as part of further investigations, a sperm sample may be needed
  3. The sperm and the egg must form an embryo: sexual, cervical, and/or problems with the fallopian tube may prevent the sperm from reaching the egg
  4. The embryo must implant: the incidence of defective implantation is not known

Drug history

You should ask if the patient is currently taking any prescribed medications or over-the-counter remedies:

  • “Are you currently taking any prescribed medications or over-the-counter treatments?”
Folic acid

Folic acid is recommended for women trying for a baby and during the first 3 months of their pregnancy to help the baby’s brain and spine develop.6 This can be taken with an over the counter pre-pregnancy supplement that contains at least 400 micrograms of folic acid. 

Risk factors for neural tube defects include:

  • History, or family history, of neural tube defect in either partner
  • The woman is taking anti-epileptic medication
  • Maternal co-morbidities: diabetes, sickle cell anaemia, thalassaemia/thalassaemia trait
  • Maternal BMI >30 

If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form and route of administration.

Ask the patient if they’re currently experiencing any side effects from their medication:

  • “Have you noticed any side effects from the medication you currently take?”

Family history

Ask the patient if there is any family history of genetic problems:

  • “Are you aware of any genetic problems in your family?”
  • “Were you, your parents, and/or siblings born with any medical problems?” 

Particularly important conditions to screen for are haemoglobinopathies (such as sickle cell anaemia and thalassaemia)

Ask if there is a family history of early menopause (less than 45 years old):

  • “At what age did your mum conceive you and any of your siblings? Are you aware of whether she has experienced menopause and at what age?”

Social history

Explore the patient’s social history to both understand their social context and identify potential infertility risk factors.

Smoking

Record the patient’s smoking history, including the type and amount of tobacco used. Also, ask the patient about vaping.

Calculate the number of ‘pack-years’ the patient has smoked for to determine their cardiovascular risk profile:

  • pack-years = [number of years smoked] x [average number of packs smoked per day]
  • one pack is equal to 20 cigarettes

See our smoking cessation guide for more details.

Alcohol

Record the frequencytype and volume of alcohol consumed on a weekly basis.

See our alcohol history taking guide for more information.

Recreational drug use

Ask the patient if they use recreational drugs and if so, determine the type of drugs used and their frequency of use.

Recreational drugs may be the underlying cause of a patient’s presentation with fertility problems. For instance, anabolic steroids can impair male fertility.

Diet

Ask the patient what their diet looks like on an average day and/or week. For men, you may want to ask how much soy they consume (for instance, in protein shakes). Although controversial, there is some evidence to suggest that high soy intake could cause cases of lower sperm count.

Exercise

Inquire as to whether the patient regularly exercises, including the frequency and exercise type.

Occupation

Ask about the patient’s current occupation:

  • Assess the patient’s level of activity in their occupation. Sedentary jobs have been linked with an increased risk of sperm abnormality. 7

Partner history

You will need to take full history on any partner the patient is planning to get pregnant with. However, it may be the case that the patient is planning to become pregnant without a partner (e.g through IVF).

If the patient does have a partner, you will need to confirm the partner’s name, medical record number, age and occupation.


Closing the consultation

Summarise the key points back to the patient.

Ask the patient if they have any questions or concerns that have not been addressed.

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.


Reviewer

Dr Matt Prior MBBS PhD MRCOG

Consultant and Subspecialist in Reproductive Medicine

Founder of The Big Fertility Project


Editor

Dr Chris Jefferies


References

  1. Impey, Lawrence and Child, Tim. Obstetrics & Gynaecology. Fifth ed. Published in 2017.
  2. NHS. Overview: Infertility. Published in 2020. Available from: [LINK]
  3. NHS. Causes: Infertility. Published in 2020. Available from: [LINK]
  4. Gloucestershire Hospital, NHS Foundation Trust. Polycystic ovarian syndrome (PCOS). Published in 2018. Available from: [LINK]
  5. NHS. Thinking of getting pregnant? Published in 2011. Available from: [LINK]
  6. NHS. Pregnancy, breastfeeding and fertility while taking folic acid. Published in 2022. Available from: [LINK]
  7. K, Jakubik J, Kups M, Rosiak-Gill A, Kurzawa R, Kurpisz M, Fraczek M, Piasecka M. The impact of sedentary work on sperm nuclear DNA integrity. Published in 2019. Folia Histochem Cytobiol. 57(1):15-22.

 

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