Family physicians’ attitude and practice of infertility management at primary care - Suez Canal University, Egypt

Introduction The very particular natures of infertility problem and infertility care make them different from other medical problems and services in developing countries. Even after the referral to specialists, the family physicians are expected to provide continuous support for these couples. This place the primary care service at the heart of all issues related to infertility. The aim of the work: to improve family physicians' attitude and practice about the approach to infertility management within primary care setting. Methods This study was conducted in the between June and December 2010. The study sample comprised 100 family physician trainees in the family medicine department and working in family practice centers or primary care units. They were asked to fill a questionnaire about their personal characteristics, attitude, and practice towards support, investigations, and treatment of infertile couples. Results Hundred family physicians were included in the study. They were previously received training in infertility management. Favorable attitude scores were detected among (68%) of physicians and primary care was considered a suitable place for infertility management among (77%) of participants. There was statistically significant difference regarding each of age groups, gender and years of experience with the physicians′ attitude. There was statistically significant difference regarding gender, perceiving PHC as an appropriate place to manage infertility and attitude towards processes of infertility management with the physicians′ practice. Conclusion Favorable attitude and practice were determined among the study sample. Supporting the structure of primary care and evidence-based training regarding infertility management are required to improve family physicians' attitude and practice towards infertility management.


Introduction
Infertility can be defined as the failure to achieve a pregnancy within one year of regular unprotected intercourse [1,2]. The very particular nature of infertility problem and of infertility care makes them different from other medical problems and services in developing countries. On the other hand, negative psychosocial, sociocultural, and economical consequences of childlessness are often more pronounced compared with Western societies [3,4].
Infertility is a problem of global proportions; the exact prevalence of infertility in developing countries is unknown due to a lack of registration and well-performed studies [5]. It is affecting on average 8-12 percent of couples worldwide. In some societies, however-particularly those in the "infertility belt&34; of sub-Saharan Africa as many as one-third of all couples are unable to conceive [6]. Prevalence of infertility is 10.4 % among women between 15-49 years in rural areas of Kafr ElSheikh -Egypt [7]. There is a wider prevalence range in resource-poor countries, possibly due to different country-specific factors, such as the prevalence of sexually transmitted diseases, age at delivery, and political factors [3].
In Germany, Many family physicians regard fertility counseling out of their scope of practice, although key elements in the care of involuntarily childless couples fall within the theoretical framework of family practice [8]. In United Kingdom, each general practitioner sees approximately two infertile couples each year. Despite the relative lack of opportunity to rehearse the skills of new technologies necessary to manage infertile couples, a basic understanding will assist in the general practitioners advocacy role [9]. The primary care physician who provides preventive care can initiate the diagnostic evaluation and can treat some causes of infertility [10]. The initial investigations commonly performed by general practitioners include semen analysis, serum mid-luteal progesterone and serum follicle stimulating hormone. Management strategies for the general practitioners include optimising general health, weight loss for obese infertile women, ovulation induction with clomifene and expectant management for young women with no identified cause for their delayed fertility [9].
The treating physician who is counseling the couple regarding their infertility must be familiar with the causes, investigations and the treatment options available. Even after the referral to specialists, the general practitioners are expected to provide continuous support for these couples [11]. This place the primary care service at the heart of all issues related to infertility [12].
The quality of infertility care is dependent upon adequate material resources and the appropriate use of it [13]. By following evidencebased, management protocol, infertile couples will have a good chance to start up their treatment in the proper way at early time with enough financial support through reducing money spent on unnecessary investigations [10]. The aim this study was to assess family physicians´ attitude and practice of infertility management to improve the care of infertile couple within primary care settings.

Methods
Study design: This was a cross sectional-descriptive study.

Sampling and subjects
The study was carried in Family Medicine department-Suez Canal

Results
Out of 100 family physicians, (61%) of them were in the age group of (24-29). Female physicians were more than two thirds (71%).
Most of the physicians were not qualified by Master or Diploma degree (74%). About two third of family physicians were with less than 5 years of experience (62%) and two thirds of them were working in family practice centers of Suez Canal University (66%) and in rural community (66%). 100% of the participants had no other specialty than family medicine. Table 1 shows the relationship between personal characteristics of family physicians and their attitude towards processes of infertility management in primary care. Out of 100 studied physicians, 68 ones had favorable attitude. There were statistically significant difference regarding each of age groups, gender, and years of experience with the physicians´ attitude (p < 0.05).
The majority of physicians in the age group of 30-35 and those with more than 5 years of experience had favorable attitude (85.7% and 84.2%) respectively. More than three quarters of female physicians, (77.5%) had favorable attitude.

Discussion
Out of 100 participants in the present study, 68 family physicians had favorable attitude towards processes of infertility management. Although practice of infertility management was reported by a higher percentage of family physicians than their attitude scores, the frequency of family physicians who reported that they could perform the various processes towards infertility management at primary care was better than that of their practice.
In reviewing the frequencies of favorable attitude and practices regarding supportive treatment and proposals: except for meeting the couple, most physicians reported that they could perform a large part of these processes which ranged from (80.0%) in Training was the most obvious suggestion forwarded by family physicians who practiced infertility management in primary care by approximately (75%) followed by providing supplies and laboratory support (61.3%) for each item. This was, to some extent similar in the study by Hassa et al [14], which reported, the importance of a planned post-graduate continuing education program by (70%) and improvement in laboratory investigations by (67.2%) in the recommendations section.

Limitations of the study:
The results of the study couldn´t be generalized to all primary care physicians as the study was conducted among family physician trainees in academic organization. There was a paucity of comparable studies.

Conclusion
Favorable attitude scores towards processes infertility management were determined among (68%). Favorable attitude towards PHC as an appropriate place for infertility management was found among (77%). Practice of infertility management was reported by (75%).

Competing interests
The authors declare no competing interests