STUDY QUESTION How did general practitioners (GPs) (family physicians) manage infertility in females and males in primary care between 2000 and 2016? SUMMARY ANSWER The number of GP infertility consultations for females increased 1.6 folds during the study period, with 42.9% of consultations resulting in a referral to a fertility clinic or specialist, compared to a 3-fold increase in the number of consultations for men, with 21.5% of consultations resulting in a referral. WHAT IS KNOWN ALREADY Infertility affects one in six couples and is expected to increase with the trend to later childbearing and reports of declining sperm counts. Despite GPs often being the first contact for infertile people, very limited information is available on the management of infertility in primary care. STUDY DESIGN, SIZE, DURATION Data from the Bettering the Evaluation and Care of Health programme were used, which is a national study of Australian primary care (general practice) clinical activity based on 1000 ever-changing, randomly selected GPs involved in 100 000 GP–patient consultations per year between 2000 and 2016. PARTICIPANTS/MATERIALS, SETTING, METHODS Females and males aged 18–49 years attending GPs for the management of infertility were included in the study. Details recorded by GPs included patient characteristics, problems managed and management actions (including counselling/education, imaging, pathology, medications and referrals to specialists and fertility clinics). Analyses included trends in the rates of infertility consultations by sex of patient, descriptive and univariate analyses of patient characteristics and management actions and multivariate logistic regression to determine which patient and GP characteristics were independently associated with increased rates of infertility management and referrals. MAIN RESULTS AND THE ROLE OF CHANCE The rate of infertility consultations per capita increased 1.6 folds for women (17.7–28.3 per 1000 women aged 18–49 years) and 3 folds for men over the time period (3.4–10.2 per 1000 men aged 18–49 years). Referral to a fertility clinic or relevant specialist occurred in 42.9% of female infertility consultations and 21.5% of male infertility consultations. After controlling for age and other patient characteristics, being aged in their 30s, not having income assistance, attending primary care in later years of the study and coming from a non-English-speaking background, were associated with an increased likelihood of infertility being managed in primary care. In female patients, holding a Commonwealth concession card (indicating low income), living in a remote area and having a female GP all indicated a lower adjusted odds of referral to a fertility clinic or specialist. LIMITATIONS, REASONS FOR CAUTION Data are lacking for the period of infertility and infertility diagnosis, which would provide a more complete picture of the epidemiology of treatment-seeking behaviour for infertility. Australia’s universal insurance scheme provides residents with access to a GP, and therefore these findings may not be generalizable to other settings. WIDER IMPLICATIONS OF THE FINDINGS This study informs public policy on how infertility is managed in primary care in different patient groups. Whether the management actions taken and rates of secondary referral to a fertility clinic or specialist are appropriate warrants further investigation. The development of clinical practice guidelines for the management of infertility would provide a standardized approach to advice, investigations, treatment and referral pathways in primary care. STUDY FUNDING/COMPETING INTEREST(S) This paper is part of a study being funded by an Australian National Health and Medical Research Council project grant APP1104543. G.C. reports that she is an employee of The University of New South Wales (UNSW) and Director of the National Perinatal Epidemiology and Statistics Unit (NPESU), UNSW. The NPESU manages the Australian and New Zealand Assisted Reproductive Technology Database on behalf of the Fertility Society of Australia. W.L. reports being a part-time paid employee and minor shareholder of Virtus Health, a fertility company. R.N. reports being a small unitholder in a fertility company, receiving grants for research from Merck and Ferring and speaker travel grants from Merck. TRIAL REGISTRATION NUMBER NA
In this paper, we analyse how optimal forest management of even aged Norway spruce changes when economic values are placed on carbon fixation, release, and saved greenhouse gas emissions from using wood instead of more energy intensive materials or fossil fuels. The analyses are done for three different site qualities in Norway, assuming present climate and with a range of CO 2 prices and real rates of return. Compared to current recommended management, the optimal number of plants per ha and harvest age are considerably higher when carbon benefits are included, and increase with increasing price on CO 2. Furthermore, planting becomes more favourable compared to natural regeneration. At the medium site quality, assuming 2% p.a. real rate of return and € 20 per ton CO 2 , optimal planting density increases from 1500 per ha to 3000 per ha. Optimal harvest age increases from 90 to 140 years. Including saved greenhouse gas emissions when wood is used instead of more energy intensive materials or fossil fuels, i.e. substitution effects, does not affect optimal planting density much, but implies harvesting up to 20 years earlier. The value of the forest area increases with increasing price on CO 2 , and most of the income is from carbon. By using the current recommended management in calculations of carbon benefit, our results indicate that the forest's potential to provide this environmental good is underestimated. The study includes many uncertain factors. Highest uncertainty is related to the accuracy of the forest growth and mortality functions at high stand ages and densities, and that albedo effects and future climate changes are not considered. As such, the results should be viewed as exploratory and not normative.
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