Woman in A Same-sex Relationship Requesting Assisted Conception Referral — Free SCA Practice Case
Woman in a same-sex relationship requesting assisted conception referral
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Full Name
Emily Chen
Age
31 years
Consultation Type
VideoAge
31
Situation
Video Consultation.
Reason for Encounter
"Patient and her wife are planning to start a family. Requesting a referral to the fertility clinic."
Medical Records
- ●PMH: Nil significant.
- ●Medications: None.
- ●Allergies: NKDA.
Recent Notes
- ●Last Year: Routine cervical smear (Normal/HPV Negative). Up to date with routine immunizations.
Patient Script
For the friend playing the patient role
Character Overview: You are Emily. You and your wife, Sarah (32), have been married for three years and are ready to start a family. You are excited and assume that because you physically cannot conceive without medical intervention, the NHS will step in and provide Intrauterine Insemination (IUI) or IVF right away. To speed things up, you and Sarah have already been trying at home for the last 4 months using sperm donated by a male friend, using a plastic syringe. You haven't caught pregnant yet, so you decided it's time to get professional NHS help. You are completely unaware of the NHS funding criteria (which usually requires same-sex couples to pay for 6 private clinic cycles first). When the doctor explains this, you will feel deeply discriminated against and become angry. You will not volunteer the at-home insemination details unless the doctor specifically asks exactly how you have been trying. Consultation Flow & Responses:
- ●The Opening
- ●If the doctor asks an open question: "Hi Doctor! Sarah and I have decided it's finally time to start our family. We're so excited. We've been trying a bit at home, but we haven't had any luck, so we'd like you to refer us to the NHS fertility clinic for IUI or IVF."
- ●Data Gathering (The Layers)
- ●Layer 1: Pre-conceptual Health Screen:
- ●"I'm the one who is going to carry the baby first. I'm very healthy, I go to the gym, and my BMI is about 22."
- ●"Neither of us smoke. I only drink occasionally."
- ●"I haven't started taking folic acid yet, do I need to start that now?"
- ●Layer 2: The Fertility History & At-Home Insemination (The Medical Trap):
- ●If asked exactly how long/how they have been trying: "We've been trying for about 4 months. A good friend of ours offered to be the donor. He comes over when I'm ovulating, provides a sample in a sterile cup, and we use a syringe."
- ●Layer 3: Donor Screening (Infection & Legal Risks):
- ●If asked if the friend has been medically screened: "Screened? Well, no, not officially by a doctor. He's a healthy guy, we've known him for years. He doesn't have any diseases."
- ●Layer 4: ICE (The Core Revelation) - ONLY REVEAL IF ASKED:
- ●If the doctor asks: "What were you hoping the clinic would do for you today?"
- ●Reaction (The Reveal): "Well, since the at-home thing isn't working, we expect to be referred to the NHS clinic to use proper donor sperm and get IUI. Since we're a same-sex couple, we obviously have a biological barrier to getting pregnant, so we need medical help."
ICE — Ideas, Concerns, Expectations
(Actor guidance: Emily does not volunteer these perspectives unprompted. They surface only when the candidate directly explores her thinking, worries, or hopes.)
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Ideas: Emily hasn't really thought about why the at-home insemination hasn't worked — she assumes it's simply because doing it at home with a syringe isn't as effective as a proper clinical procedure. She doesn't suspect any underlying fertility problem with herself. "I think it's just because we're doing it at home without proper equipment — I'm sure if it was done properly in a clinic, it would work."
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Concerns: Emily's main worry is that the process of starting a family will be unfairly difficult and expensive because she is in a same-sex relationship. She is also quietly anxious that the longer it takes, the more strain it will put on her and Sarah's relationship — they have been building up to this for a long time. "I just worry that the whole system is stacked against us because we're two women. And Sarah and I have been dreaming about this for years — I don't want it to turn into something stressful that comes between us."
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Expectations: Emily wants a straightforward NHS referral for IUI with anonymous donor sperm. She expects the GP to facilitate this without barriers, and she wants to leave the consultation feeling that things are moving forward. "I just want to get the ball rolling — get referred, get on a waiting list, and feel like we're actually making progress."
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Negotiation & Collaborative Management Plan
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If the Doctor explains the NHS requires 6 self-funded (private) IUI cycles first:
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Reaction: Shocked and angry. "Wait, what? Are you saying we have to pay thousands of pounds privately before the NHS will even look at us? That is incredibly unfair! If a straight couple goes to the doctor, you don't make them pay for six rounds of IVF first! It's a gay tax!" (Testing the doctor's empathy and ability to de-escalate without getting defensive).
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If the Doctor tells you the at-home attempts "don't count":
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Reaction: "Why doesn't it count? We've been putting sperm in exactly when I ovulate. That proves we are trying. Why does it have to be in an expensive private clinic?"
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If the Doctor explains the risks of an unregulated known donor (Infections/Legal):
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Reaction: Surprised, sobering up. "I didn't realize that. You're saying if we do it at home, he could legally be considered the father and claim custody? And the sperm isn't washed? Okay, that's actually quite scary."
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If the Doctor completely ignores the at-home method and just sends a referral:
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Reaction: "Great, so how long will the waiting list be for the NHS clinic?" (Note: Candidate fails for making an inappropriate referral that will be rejected, and for failing to counsel on donor risks).
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Safety Netting / Follow-up
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If the Doctor offers baseline blood tests while they think about their options:
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Reaction: "Yes, please. I'd like to at least know my hormones are working normally while Sarah and I figure out how we are going to afford this private clinic."
If Asked — Medical History and Medications
(Actor guidance: Emily will confirm the following if the candidate asks directly. She considers herself very healthy and may be slightly dismissive — "I'm fit as a fiddle, honestly.")
- ●If asked about past medical history: "Nothing, really. I've never had any operations or been in hospital. I don't have any conditions."
- ●If asked about medications: "I don't take anything — no regular tablets, no contraception, nothing. I used to be on the pill years ago in my early twenties, but I stopped that a long time ago."
- ●If asked about allergies: "No, no allergies to anything."
- ●If asked about her cervical smear: "Yes, I had that done last year — it was all normal, they sent me a letter saying everything was fine."
- ●If asked about immunisations / rubella status: "I think I'm up to date with everything — I had all my jabs at school and uni. I'm not sure about rubella specifically, but I assume I've had the MMR."
Social History and Lifestyle Impact
(Actor guidance: Emily will share these details naturally in conversation if the topic comes up, or if the candidate asks about her work and daily life.)
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Occupation / daily life context: Emily works as a junior solicitor at a mid-sized law firm in the city. It's a demanding job with long hours, but she enjoys it. Sarah works as a primary school teaching assistant. They rent a two-bedroom flat together. "I work in law — it's busy, long hours, but I love it. Sarah works at a primary school, so she'd be brilliant with kids. We've got a spare room ready and everything."
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Lifestyle impact of the condition: The monthly cycle of trying and failing at home is starting to take an emotional toll. Emily has been tracking her ovulation obsessively, and the coordination with their donor friend has become awkward and stressful. The disappointment each month is wearing on both of them. "Every month it's the same — I track everything on my app, we arrange for our friend to come over, and then two weeks later it's another negative test. It's starting to feel really clinical already, and it's affecting our weekends because we have to plan everything around my cycle. I just want it to be in proper hands so we can stop doing it all ourselves."
If Asked — Associated Symptoms
(Actor guidance: Emily responds to these questions straightforwardly. She is healthy and has no concerning symptoms — these are all pertinent negatives that help the candidate complete a thorough pre-conception and fertility assessment.)
- ●If asked about her periods / menstrual cycle: "My periods are regular — every 28 to 30 days, they last about 5 days. They're not particularly heavy or painful. I use an app to track them, so I know exactly when I'm ovulating."
- ●If asked about any pain during sex or pelvic pain: "No, nothing like that. I don't get any pain down there at all — no cramps between periods or anything unusual."
- ●If asked about any unusual vaginal discharge: "No, nothing abnormal. Just normal discharge — nothing smelly or a different colour."
- ●If asked about any nipple discharge or breast changes: "No, nothing like that at all."
- ●If asked about weight changes or appetite: "No, my weight has been stable. I eat well and exercise regularly."
- ●If asked about fatigue, hair changes, or feeling unusually hot or cold: "No, I feel fine — I've got plenty of energy. No hair loss or anything like that."
- ●If asked about mood changes, stress, or mental health: "I mean, the whole trying-to-conceive thing is a bit stressful, but I wouldn't say I'm depressed or anxious in general. I'm coping okay."
- ●If asked about any previous pregnancies: "No, I've never been pregnant before."
- ●If asked about any history of sexually transmitted infections: "No, never had any STIs. I was tested years ago when I was younger and everything was clear."
- ●If asked about family history of fertility problems or early menopause: "Not that I know of. My mum had me and my brother without any problems. No one in the family has had trouble getting pregnant as far as I'm aware."
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Pre-conceptual Care
Regardless of the route to conception, every GP consultation with someone planning a pregnancy is an opportunity to optimise pre-conception health. For Emily, this should be initiated now — not deferred until a clinical pathway is confirmed.
- ●Folic acid: 400 micrograms daily, started as soon as pregnancy is being planned and continued until at least 12 weeks gestation. The higher dose of 5 mg daily is indicated where BMI > 30, there is a personal or family history of neural tube defects, the patient is on antiepileptics, or has coeliac disease, sickle cell disease, or diabetes. Emily has none of these risk factors.
- ●Rubella immunity: Check IgG status. If non-immune, offer MMR vaccination and advise avoiding pregnancy for at least one month post-vaccination. Rubella in early pregnancy carries a high risk of congenital rubella syndrome.
- ●Vitamin D: Advise 10 micrograms (400 IU) daily for all adults, and specifically in pregnancy planning — consistent with PHE and NICE guidance. This is particularly relevant in the UK climate.
- ●Lifestyle: Reinforce no alcohol in pregnancy (no safe threshold established), smoking cessation if applicable, and maintaining a healthy BMI. Emily's current lifestyle is already favourable — acknowledge this and avoid unnecessary counselling.
- ●Chlamydia screening: Offer a chlamydia screen as part of the pre-conception workup. Undetected chlamydia is a preventable cause of tubal damage and subfertility. This is especially relevant before initiating any formal fertility pathway.
- ●Cervical screening: Confirm up to date — Emily's smear was normal last year. No action required.
NHS Funding Criteria for Same-Sex Female Couples
NHS fertility funding criteria are set by local Integrated Care Boards (ICBs) and vary by region, but are broadly informed by NICE Guideline CG156 (Fertility: assessment and treatment). GP trainees must understand the pathway accurately to counsel patients without giving false hope or incorrect information.
- ●NICE CG156 recommends that same-sex female couples should be offered NHS-funded IUI after 6 cycles of donor insemination at a licensed clinic in which conception has not occurred.
- ●In practice, these first 6 cycles are almost universally self-funded (private), as ICBs treat them as the equivalent of the two-year natural conception period required of heterosexual couples. This is the mechanism by which 'unexplained infertility' is formally established in the absence of male-female intercourse.
- ●At-home inseminations do not count toward this quota. They are unmonitored, use unprocessed sperm, and generate no clinical record that funding panels will accept.
- ●The policy is widely acknowledged — including by NICE itself — to place a significant financial burden on same-sex couples and is the subject of ongoing advocacy. Clinicians should acknowledge this inequity openly when explaining the criteria, rather than presenting the policy as straightforwardly fair.
- ●ICB policies differ: some areas offer fewer than 6 funded cycles, and some have additional eligibility criteria (e.g. age thresholds, BMI requirements, smoking status). Always direct the patient to their local ICB or the HFEA website (hfea.gov.uk) for region-specific information.
Risks of At-Home Insemination with a Known Donor
This is one of the most clinically and legally significant aspects of the consultation. Both risks must be explained clearly, without making the patient feel judged.
Infection Risk
Licensed HFEA clinics are legally required to screen sperm donors comprehensively before any treatment. This includes:
- ●Virology: HIV, Hepatitis B, Hepatitis C, syphilis, CMV
- ●Donor sperm is then quarantined for a minimum of 6 months and the donor re-tested before release — this accounts for the window period of HIV and other infections
- ●Fresh sperm used at home bypasses all of this. There is a real risk of transmitting serious infections to the recipient and, if conception occurs, to the fetus. CMV in particular is an important cause of congenital infection and neurodevelopmental impairment.
Legal Parenthood Risk — Human Fertilisation and Embryology Act 2008
- ●Where a woman conceives via home insemination using a known donor, that donor is legally treated as the father of the child under UK law — regardless of any informal agreement to the contrary. This confers potential parental rights, financial responsibilities, and the ability to apply for custody or contact.
- ●Conversely, where donor sperm is used via a licensed HFEA clinic, the donor has no legal rights or responsibilities. The woman's partner (of any sex) can be registered as the child's second legal parent, provided both partners consent to treatment together at the clinic.
- ●Informal written or verbal agreements between friends are not legally binding in UK law when conception occurs outside a licensed clinic. They offer no legal protection.
Baseline Investigations in Primary Care
Even where NHS-funded treatment is not yet accessible, the GP can initiate a valuable package of primary care investigations. These save the couple significant expense in the private sector and provide useful clinical information regardless of the eventual pathway.
Recommended baseline investigations for the intended gestational parent:
- ●Day 2–5 serum FSH and LH — ovarian reserve screen; elevated FSH or low LH:FSH ratio may indicate diminished ovarian reserve
- ●Day 21 serum progesterone — confirms ovulation (a level > 30 nmol/L in a 28-day cycle is consistent with ovulation; adjust timing for longer cycles)
- ●Anti-Müllerian hormone (AMH) — marker of ovarian reserve; increasingly available in primary care and useful for counselling and pathway planning
- ●Thyroid function (TSH) — thyroid dysfunction is a reversible cause of subfertility and early pregnancy loss
- ●Rubella IgG — as above
- ●Chlamydia screen — as above
- ●A pelvic ultrasound can be requested in primary care to assess uterine anatomy and exclude obvious pathology such as fibroids or ovarian cysts; this is not always immediately necessary but is reasonable where there is any clinical concern
Referral and Next Steps
The GP cannot refer Emily for NHS-funded IUI at this stage, but they are not without options — and presenting actionable next steps is a core component of a passing consultation.
- ●Signpost to the HFEA website (hfea.gov.uk): the definitive resource for finding licensed clinics, understanding legal parenthood, and checking donor conception rights. The HFEA's 'choose a fertility clinic' tool allows patients to compare clinics by success rates.
- ●Private IUI with anonymous donor sperm at a licensed clinic typically costs £800–1,500 per cycle including sperm, monitoring, and the procedure. Prices vary between clinics.
- ●Recommend the Donor Conception Network (dcnetwork.org) — a peer support charity for families created through donor conception, with specific resources for same-sex couples.
- ●Stonewall and LGBT Foundation offer signposting to LGBTQ+-inclusive fertility services and support.
- ●Advise Emily and Sarah to attend the licensed clinic together and to formally consent as a couple — this is what establishes Sarah's legal parenthood from the outset.
Safety Netting and Follow-up
- ●Emily should return for results of baseline blood tests — agree a specific timeframe (typically 2–3 weeks, or after Day 21 progesterone is taken).
- ●Advise her to return promptly if she develops: new or worsening pelvic pain, irregular bleeding, abnormal vaginal discharge, or any systemic symptoms — these may suggest a new gynaecological condition requiring assessment before she proceeds with fertility treatment.
- ●Make clear that the practice remains her ongoing point of support. She should feel able to return at any point as she navigates the private pathway — whether for further investigations, prescriptions (folic acid), results discussion, or emotional support.
- ●If she continues at-home insemination despite counselling, safety-net around infection risk: she should seek urgent review if she develops any features consistent with STI transmission.
Common Candidate Mistakes in This Case
- ●Promising an NHS referral: The most common error. Candidates who send an immediate referral without understanding the funding criteria will have their referral rejected. This leaves the patient worse off and demonstrates a significant knowledge gap.
- ●Missing the at-home insemination: Candidates who ask only 'have you been trying?' without establishing how will miss the infection and legal risks entirely — the single most important clinical issue in this case beyond the funding discussion.
- ●Dismissing at-home attempts without explanation: Saying 'that doesn't count' without explaining why (unscreened sperm, no clinical monitoring, no funding panel record) leaves the patient feeling invalidated and fails to impart the safety information she needs.
- ●Underdosing or omitting folic acid advice: Forgetting to recommend folic acid, or recommending it vaguely without specifying 400 micrograms daily and the duration, is a straightforward mark lost.
- ●Failing to initiate any primary care investigation: Leaving Emily with nothing actionable — no bloods, no folic acid, no signposting — when several free and useful steps are available represents a missed opportunity and a weaker consultation overall.
- ●Reassuring without nuance: Telling Emily 'everything will be fine' or 'you're young and healthy so it will work' is not accurate or appropriate. At 31 with no concerning history, her outlook is broadly positive — but baseline bloods are needed to confirm this, and the funded pathway involves significant time and financial commitment.
Mapped to the RCGP curriculum topic: Maternity and Reproductive Health.
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