Referral Form for Fertility Assessment Only CRITERIA BASED ACCESS – Patients from the BNSSG Clinical Commissioning Group area only Patient 1 Name Male Female Address Post Code Date of Birth NHS Number Patient 2 Name Male Female Address Post Code Date of Birth NHS Number Criteria for Referral for Assessment by Fertility Services The Access to Fertility Assessment and Treatments Policy is available on the relevant CCG website. In order to refer a couple for assessment by the Fertility to relevant questions Services, couples must answer “Yes” below. the couple do not qualify for routinely funded fertility assessment or treatment and Any “No” responses will mean that funding approval must therefore be secured from the Individual Funding Request (IFR) Panel prior to referral. A copy of this form should be completed and forwarded on with an IFR application. Please note: Recurrent miscarriage is not an indication for patients to access Fertility Services although, if appropriate, patients may be referred for gynaecological investigations rather than fertility services and treatments. Prospective fathers with a BMI of over 29.9 kg/m2 should be offered a referral to weight management services to reduce their weight, as obesity can impact on fertility. For couples in a heterosexual relationship - The couple have failed to conceive after regular 1.a Yes / No unprotected sexual intercourse for two years. Patients may be referred outside this timeframe if there is a known condition which is likely N/A to affect the fertility of either partner, for example: severe oligomenorrhoea previous testicular surgery) oncology treatment is likely to compromise the fertility of either the prospective mother or father Heterosexual couples who have failed to conceive after regular unprotected sexual intercourse for more than one year but less than two years and where the prospective mother will be older than 18 weeks before her fortieth birthday may also be referred. For same sex couples - insemination on at least 10 cycles at an HFEA licenced centre, over a Yes / No 1.b period of 2 years, has failed to lead to a pregnancy. N/A The couple have been in a stable relationship for two years or more. 2. Yes / No The prospective mother is aged less than 18 weeks before her 40th birthday at assessment. 3. Yes / No Yes / No The prospective father in a heterosexual relationship is aged 54 years or less. 4. N/A Neither partner in a heterosexual relationship has been sterilised in the past even if it has been 5.a Yes / No reversed.
Referral Form for Fertility Assessment Only – CRITERIA BASED ACCESS Patients from the BNSSG Clinical Commissioning Group area only Patient 1 Name Male Female Address Post Code Date of Birth NHS Number Patient 2 Name Male Female Address Post Code Date of Birth NHS Number Criteria for Referral for Assessment by Fertility Services The Access to Fertility Assessment and Treatments Policy is available on the relevant CCG website. In order to refer a couple for assessment by the Fertility Services, couples must answer “Yes” to relevant questions below. Any “No” responses will mean that the couple do not qualify for routinely funded fertility assessment or treatment and funding approval must therefore be secured from the Individual Funding Request (IFR) Panel prior to referral. A copy of this form should be completed and forwarded on with an IFR application. Please note: Recurrent miscarriage is not an indication for patients to access Fertility Services although, if appropriate, patients may be referred for gynaecological investigations rather than fertility services and treatments. Prospective fathers with a BMI of over 29.9 kg/m2 should be offered a referral to weight management services to reduce their weight, as obesity can impact on fertility. 1.a For couples in a heterosexual relationship - The couple have failed to conceive after regular unprotected sexual intercourse for two years. Patients may be referred outside this timeframe if there is a known condition which is likely to affect the fertility of either partner, for example: severe oligomenorrhoea previous testicular surgery) oncology treatment is likely to compromise the fertility of either the prospective mother or father Heterosexual couples who have failed to conceive after regular unprotected sexual intercourse for more than one year but less than two years and where the prospective mother will be older than 18 weeks before her fortieth birthday may also be referred. Yes / No N/A 1.b For same sex couples - insemination on at least 10 cycles at an HFEA licenced centre, over a period of 2 years, has failed to lead to a pregnancy. Yes / No N/A 2. The couple have been in a stable relationship for two years or more. Yes / No 3. The prospective mother is aged less than 18 weeks before her 40th birthday at assessment. Yes / No 4. The prospective father in a heterosexual relationship is aged 54 years or less. Yes / No N/A 5.a Neither partner in a heterosexual relationship has been sterilised in the past even if it has been reversed. Yes / No
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