Infertility/RPL
ADULT
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If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.
- Ectopic pregnancy
- Ruptured haemorrhagic ovarian cyst
- Torsion of uterine appendages (ovarian)
- Acute/severe pelvic pain
- Significant or uncontrolled vaginal bleeding
- Severe infection
- Abscess intra pelvis or PID
- Bartholin's abscess / acute painful enlargement of a Bartholin's gland/cyst
- Acute trauma including vulva/vaginal lacerations, haematoma and/or penetrating injuries
- Post-operative complications within 6 weeks including wound infection, wound breakdown, vaginal bleeding/discharge, retained products of conception post-op, abdominal pain
- Urinary retention
- Acute urinary obstruction
- Unstable molar pregnancy
- Inevitable and / or incomplete abortion
- Hyperemesis gravidarum
- Ascites, secondary to known underlying gynaecological oncology
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| Category 1 (appointment within 30 calendar days) |
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| Category 2 (appointment within 90 calendar days) |
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| Category 3 (appointment within 365 calendar days) |
(Definition: - infertility is the failure to achieve pregnancy after 12 months or more of regular unprotected intercourse) |
Please insert the below information and minimum referral criteria into referral
1. Reason for request Indicate on the referral
- To establish a diagnosis
- For treatment or intervention
- For advice and management
- For specialist to take over management
- Reassurance for GP/second opinion
- For a specified test/investigation the GP can't order, or the patient can't afford or access
- Reassurance for the patient/family
- For other reason (e.g. rapidly accelerating disease progression)
- Clinical judgement indicates a referral for specialist review is necessary
2. Essential referral information Referral will be returned without this
Essential Referral Information (for Infertility and RPL)
- History of:
- previous pregnancies, STIs and PID, surgery, endometriosis
- other medical conditions
- Include the following information about partner
- age and health, reproductive history, testicular conditions, semen analysis
- a referral letter for the partner is required
- Weight/ BMI
- STI screen result – endocervical swab or first catch urine for chlamydia +/- gonorrhoea NAA
- FBC group and antibodies rubella IgG varicella IgG, syphillis serology, HBV/HCV/HIV serology results
- FSH, LH (Day 2-5), prolactin, TSH if cycle prolonged and/or irregular
- Pelvic USS (TVS preferable)
- If PCOS is suspected include the following:
- Free androgen index (FAI) or Free Testosterone
- Fasting blood glucose result
- Lipids, TSH results
Infertility – additional Essential Referral Information
- Day 21 serum progesterone level (7 days before the next expected period)
First trimester RPL – additional Essential Referral Information
- Thrombophilia screen, antiphospholipid syndrome (APS)
- Autoimmune screen
- Coeliac serology – serum deamidated gliadin peptide (DGP), tTG Ab
- Antinuclear antibodies (ANA) only if personal or family history indicates higher risk of autoimmune disease
- Karyotype for both parents
Second trimester RPL – additional Essential Referral Information
- Hysterosalpingogram (HSG) or hystero-sonogram
- US with cervical length
3. Additional referral information Useful for processing the referral
- BMI
- Anti-mullerian hormone (AMH)
- History of marijuana use (including partner)
- Fasting blood glucose, testosterone and free androgen index test for those likely to have PCOS
- Hysterosalpingography (HSG) or saline infusion USS (sonohysterography)
4. Request
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Patient's Demographic Details
- Full name (including aliases)
- Date of birth
- Residential and postal address
- Telephone contact number/s – home, mobile and alternative
- Medicare number (where eligible)
- Name of the parent or caregiver (if appropriate)
- Preferred language and interpreter requirements
- Identifies as Aboriginal and/or Torres Strait Islander
Referring Practitioner Details
- Full name
- Full address
- Contact details – telephone, fax, email
- Provider number
- Date of referral
- Signature
Relevant clinical information about the condition
- Presenting symptoms (evolution and duration)
- Physical findings
- Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
- Body Mass Index (BMI)
- Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
- Current medications and dosages
- Drug allergies
- Alcohol, tobacco and other drugs use
Reason for request
- To establish a diagnosis
- For treatment or intervention
- For advice and management
- For specialist to take over management
- Reassurance for GP/second opinion
- For a specified test/investigation the GP can't order, or the patient can't afford or access
- Reassurance for the patient/family
- For other reason (e.g. rapidly accelerating disease progression)
- Clinical judgement indicates a referral for specialist review is necessary
Clinical modifiers
- Impact on employment
- Impact on education
- Impact on home
- Impact on activities of daily living
- Impact on ability to care for others
- Impact on personal frailty or safety
- Identifies as Aboriginal and/or Torres Strait Islander
Other relevant information
- Willingness to have surgery (where surgery is a likely intervention)
- Choice to be treated as a public or private patient
- Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)
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If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.
- Please note that where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.
- A change in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.
- Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.
Last updated: 7 December 2020
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