Should clomifene citrate be prescribed in primary care: an in-depth interview study.

Problem

Clomifene citrate has long been considered the first-line medical treatment for fertility issues associated with polycystic ovary syndrome (PCOS). Twenty years ago, it was commonly prescribed in primary care. Currently, only 250 prescriptions are issued by GPs in England each month. Guidelines do not specifically say where clomifene should be prescribed. NICE CG156 does advise follicular tracking using transvaginal ultrasound (TVUS) during the first cycle of treatment, suggesting that management in specialist care may be more suitable. However, follicular tracking is often not practised by fertility specialists, and so the management of patients treated with clomifene may not differ much between primary care and specialist services.The aim of this study was to explore the preferences of patients, GPs and fertility specialists in terms of where clomifene is prescribed.

Approach

We conducted in-depth interviews with three cohorts: patients (n=10), fertility specialists (n=7) and GPs (n=9). Recruitment was an iterative process, guided by ongoing thematic analysis.

Findings

While all three cohorts acknowledged that receiving clomifene from the GP might be quicker and easier, there was an overall preference for an expert input and support from a fertility clinic. There was also emphasis on optimising communication and timely referral between primary and specialist care.None of the GP participants had recent experience of prescribing clomifene. Several said they would consider prescribing if robust guidelines and education were in place, however they recognised their limited exposure to fertility issues and expressed concerns about increasing workload and restricted time in consultations.

Consequences

The value of a specialist input was a common theme that resonated throughout the three cohorts. Current guidelines should be modified to standardise practice in terms of where clomifene is prescribed and how it is monitored, and to streamline the referral process from primary to specialist care for patients with PCOS-related subfertility.