• best practice guidelines
• infertility
• blood borne viruses
• chlamydia

The best practice guideline on the investigation of infertility briefly comments on appropriate microbiological investigations.¹ However, there are several issues that we feel merit further consideration.

The need to check the rubella immunity status of the female partner is highlighted. This point is also stressed by the Royal College of Obstetricians and Gynaecologists (RCOG).² Testing for blood borne viruses (antibodies to hepatitis B surface antigen, human immunodeficiency virus, and hepatitis C) is also commented upon in the best practice guideline as a general investigation and has been similarly suggested in a recent clinical review.³ However, no such guideline has been issued by either the RCOG or the British Fertility Society. Nevertheless, the Human Fertilisation and Embryology Authority has set a deadline of the end of 2004 for the screening of all women/couples participating in licensed infertility treatments (in vitro fertilisation, intracytoplasmic sperm injection, donor gamete therapy) for blood borne viruses.

The wisdom of this approach is questionable for two reasons. First, if testing of subfertile couples is part of the continuum of their care from preconception to birth, then why repeat the process when pregnant women will routinely be offered blood borne virus (and syphilis) screening during their antenatal care? Second, because the prevalence of blood borne virus infection in patients seeking infertility advice will probably be low (possibly < 1%), where is the evidence that universal blood borne virus screening is cost effective?

We believe that scarce financial resources would be better spent on a screening programme for asymptomatic chlamydia infection in the infertile population. This should be based on a chlamydia molecular amplification test, using urine, lower vaginal swabs, or endocervical swabs, and not chlamydia serology, as has been suggested previously.³ Screening for chlamydia is not mentioned in the best practice guideline but is recommended by the RCOG. This is particularly important in women who will be undergoing uterine insemination as part of their fertility investigation or treatment. In general, this will mean routinely testing women less than 25 years of age.⁴ One in 10 sexually active women in England is currently thought to be infected with chlamydia.⁵ Those identified as chlamydia positive could then be offered blood borne virus screening linked to a genitourinary counselling service.

Finally, the best practice guideline makes no comment on screening for cytomegalovirus immunity. Although not routinely recommended, cytomegalovirus IgG testing should be considered both for women who receive donor gametes (sperm or oocytes) and the donors of such gametes.