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Sir,

In their editorial ‘NICE fertility guideline: good news for infertile couples, but who pays the bill?’1 Thornton and Bhattacharya point out that although the guideline is an important step forward, to succeed it will need an appropriate level of funding.

We expect funding to gradually improve over the coming years so in the meantime it is essential that those managing patients with fertility problems use the money that is available effectively.

The full NICE clinical guideline2 was released in February 2004. In coming to their conclusions, the members of the guideline development group include economic analysis to assess cost effectiveness so we should expect clear guidance on the best way to use the specific investigations recommended.

In the section written for people with fertility problems (page 144, Appendix A), the guide states that ‘if you have been trying to get pregnant for more than one year or your periods do not occur often’ you should be offered a blood test taken ‘about 21 days after the first day of the last period’. In the main body of the guideline aimed at clinical staff (page 42), the guideline does qualify this advice by referring to the ‘midluteal phase’ or the need to perform the sample later if the woman's cycle is irregular. But it fails to state and emphasize the need to make it clear to the woman that she must keep a record of the date of the period after the sample is given.

We asked 34 Specialist Registrars attending a regional obstetrics and gynaecology training day what instructions they would give to a patient with an irregular long cycle. Only 12 trainees (35.3%) stated that the sample of interest should be taken about seven days before a period.

The new guideline does make the point that women with regular monthly menstrual cycles in the range 26 to 36 days are likely to be ovulating (page 42). Women with irregular cycles usually have polycystic ovaries,3 but the great majority of these will still ovulate. All too often, misinterpretation of mistimed samples leads to inappropriate ovulation induction, delayed referral to assisted conception and unnecessary anxiety.

We strongly believe that reference to the date of the previous menstrual period rather than to the next has always been detrimental to the management of women with a fertility problem and regret that the NICE guideline missed the opportunity to rectify this widespread and costly misunderstanding.

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