Fertility preservation provision in the NHS in Scotland: guidance

Annex C

Suggested Template for referrals to fertility preservation treatment

To be used/adapted by ACUs to ensure fertility services have the information required for a correct referral.

Fertility preservation referral form

1. Criteria for NHS treatment

Please confirm that your patient meets these criteria:

• Patient is resident in Scotland
• Storing eggs or embryos: BMI under 35
• Age before 40th birthday if storing eggs, before 53rd birthday if storing sperm
• No existing biological children/not a legal parent unless with a partner that does not have a biological child/is not a legal parent.
• Not previously sterilised
• Where it is clinically judged that there is evidence that the risk is greater than 30% chance of fertility lost through therapy
• Gender Identity: the patient has been assessed and referred as eligible to access treatment under the Gender Identity Healthcare Protocol.
• Oncology: treatment is with intention to cure, or long-term survival

Fitness: Patient is fit to travel for the Cryostorage appointment Yes/No

Patient is fit for procedures including anaesthetic/sedation Yes/No

Or Patient is able to produce a sperm sample by masturbation

2. Referrer details Date of referral:

Consultant/ Specialist nurse:

Contact no:

Email address:

Hospital/Department:

3. Patient details

Name:

CHI:

Address:

Contact no (preferably mobile):

Type of preservation:

Eggs Sperm Embryos

If embryos, partner’s name and DOB:

4. Reason for referral

Date of referral to fertility preservation service:

Diagnosis:

1 Cancer 2 Non-cancer medical reason 3 Transgender 4 Armed forces 5 Other

Date of diagnosis:

Type of cancer (ICD code):

C18 Colon

C40 Bone and articular cartilage – limbs only

C41 Bone and articular cartilage - non-limb/ not specified

C50 Breast

C53 Cervix uteri

C56 Ovary

C62 Testis

C71 Brain/CNS

C81 Hodgkin lymphoma

C82 Non-Hodgkin lymphoma – follicular lymphoma

C83 Non-Hodgkin lymphoma – non-follicular lymphoma

C84 Non-Hodgkin lymphoma – mature T/NK-cell lymphoma

C85.9 Non-Hodgkin lymphoma – unspecified

C91 Lymphoid leukaemia

C92 Myeloid leukaemia

Type of medical condition (ICD code):

M32 Systemic Lupus Erythematosus

M05 Rheumatoid arthritis – seropositive

M06 Rheumatoid arthritis – other

M07 Psoriatic and enteropathic arthropathies

M45 Ankylosing Spondilitis

G35 Multiple sclerosis

D56 Thalassaemia

D57 Sickle cell disorders

D60 Acquired pure red cell aplasia

D61 Other aplastic anaemias (including Fanconi anaemia)

K50 Crohn’s Disease

K51 Ulcerative Colitis

N80 Endometriosis

Q96 Turner Syndrome

Q99.2 Fragile X

E74.2 Galactosaemia

Planned treatment:

1 Surgery

2 Radiotherapy

3 Chemotherapy

4 Radiotherapy and chemotherapy

5 Surgery and chemotherapy

6 Surgery and radiotherapy

7 Surgery, radiotherapy and chemotherapy

Please specify chemotherapy regimen:

Please specify estimate of pelvic radiotherapy dose:

Previous treatment (outline regimen):

Predicted reduction in fertility after current planned treatment:

<10%

10-30%

30-70%

>70%

Unknown

Date of anticipated treatment starting:

Relevant Past Medical History:

Current medication:

Any current coagulation/thrombosis issues?

Any other relevant information?

If storing eggs LMP: Average cycle length:

Current contraception:

5. Additional patient information

Age: BMI:

Confirm the patient is post-pubertal Yes / No

Relationship status:

Existing children (please delete): No / Yes

Travelled overseas within the last 2 years Yes / No

6. Medical practitioner’s statement:

I certify that the person named in Section 3 of this form is, or is likely to become prematurely infertile.

Name: Signature: Date:

Virology screening is required prior to referral.

This consists of testing for hepatitis B (HBV) and C (HCV) viruses and human immunodeficiency viruses (HIV 1 and 2). These tests do not preclude referral.

Please confirm that this has been undertaken

To refer, email/phone this referral form to the appropriate Assisted Reproduction unit:

Aberdeen: gram.aberdeenfertility@nhs.scot (within Grampian fertility preservation referrals should come via service requests)

Dundee: Tay.acusecretarial@nhs.scot Tel: 01382 496475

Edinburgh: loth.assistedconceptionunit@nhs.scot; please follow up with phone call to 0131 242 2445/6

Glasgow: ggc.preservation.acs@nhs.scot Tel: 0141 2115674