Key facts on infertility, IVF
and NHS provision
Julian Jenkins, Clinical Director, Centre for
Reproductive Medicine, University of Bristol.
Richard
Fleming, Chair of the Policy and Practice Sub-Committee
of the British Fertility Society
Clare Brown,
Chief Executive Infertility Network UK (I N UK)
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as a PDF (160kb)
Feb 05
How common is infertility?
It has been estimated that at some time in their reproductive
lives at least a quarter of couples experience a period of infertility
(inability to conceive) lasting over 1 year1.
Some of these couples continue to be unable to conceive, leading
to at least 1 in 6 couples seeing an infertility specialist at
a hospital2. After assessment
by the specialist, many couples can be reassured that they do not
need treatment, just more time with regular sex. Others may require
some form of treatment to assist with conception. The most well
known treatment is In Vitro Fertilisation (IVF), but there
are a number of other options, including life style modification,
certain
drugs, surgery and a range of Assisted Reproduction Technologies
(ART).
For more information on different forms of ART go to: http://www.hfea.gov.uk/en/1449.html
How do we compare with Europe?
In 1999 there were 595,000 babies born in the UK, 8,337 (1.4%)
of these were born as a result of assisted reproduction treatment3.
In 2004 it was shown that the UK is falling behind our Northern
European counterparts with the amount of fertility treatment we
provide, and consequently, the proportion of babies born as a result
of ART4. The survey showed that
during the year 2000 in the UK there were 580 cycles of fertility
treatment per million people, compared to an average of 1057 per
million in other Northern European countries. In Denmark, the proportion
of babies born following ART was 3.7% of the national total births.
In the UK, over the same period, this figure was 1.0%.
Number of IVF cycles per million people
National Institute for Clinical Excellence (2004). Fertility: assessment
and treatment for people with fertility problems. NICE Clinical Guideline
No.11. London: National Institute for Clinical Excellence. Available
from: www.nice.org.uk. Reproduced with permission.
The postcode lottery of treatment
The highly publicised ‘postcode lottery’ refers to
the extreme variables in amount and type of fertility treatment
offered by different NHS trusts. This could literally mean that
an infertile couple living on one side of a street, under the control
of one NHS trust, could have access to three free cycles of IVF
(widely considered to be an acceptable amount of IVF treatment,
giving a good chance of pregnancy) whilst an infertile couple on
the other side, under the control of a different trust, could be
offered no NHS-funded IVF cycles at all.
This situation was highlighted in 1998 when a study revealed
a postcode variation in NHS service provision (measured as IVF
treatments per 100,000 people) from a high of 21.5 in Scotland
to a low of 0.3 in the South West of England5.
Since this survey the situation has worsened.
NHS IVF per 100,000 people in 1998
Calls for changes to the service
In 2002 a survey of over 800 members of the public revealed overwhelming
support for NHS funded infertility services and an end to the postcode
lottery of provision6 . In 2002
the Health Secretary Alan Milburn acknowledged that infertility
caused distress to thousands of couples and NHS fertility services
varied massively around the country. Milburn said it was time to
tackle infertility using some of the new funds being pumped into
the NHS. Accordingly, Milburn referred "infertility" to
the National Institute for Clinical Excellence (NICE) to develop
national guidelines to end the postcode lottery.
NICE guidelines
National guidelines called ‘Fertility: assessment and treatment
for people with fertility problems’ were published by NICE
in February 2004. The full guideline can be found at: http://www.nice.org.uk/page.aspx?o=104435.
Included in these guidelines was the recommendation that the
NHS should provide 3 cycles of IVF treatment for suitable patients
in England and Wales. The current Health Secretary, John Reid,
and the Welsh Assembly Government Minister for Health and Social
Services, Jane Hutt, responded positively to the guidelines. They
both called for all patients meeting the eligibility criteria established
by NICE to be offered one cycle of IVF treatment on the NHS by
April 2005, with the longer term aim of full implementation including
three cycles of IVF per appropriate patient. However, they added
an additional initial priority criterion above those recommended
by NICE that couples with a child/children from the current or
previous relationship should not have access to NHS treatment.
Initial Steps towards implementation of NICE guidelines
The publication of the NICE guidelines and subsequent political
support should be seen as a major step forward towards equality
of access of NHS-funded assisted conception treatment.
However, to date, there has been no central guidance from the
Department of Health to Strategic Health Authorities (SHAs) or
Primary Care Trusts (PCTs) on implementation of the NICE guidelines.
Nor has there been any central guidance for SHAs or PCTs on how
to prioritise treatment for patients with varying social criteria.
This lack of a national work plan has led to concerns that some
areas of England and Wales are further advanced in implementation
than others. A national survey of PCTs, presented in June 20047,
seemed to justify these concerns. Further, it is possible that
some SHAs/PCTs who previously funded more than one cycle of IVF
per patient, will in fact reduce the number of cycles they currently
fund.
These concerns need to be addressed to ensure that the potential
improvements in treatment provision promised by the NICE guidelines
are to be met.
References
1 Gunnell D.J. and Ewings P. Infertility prevalence, needs
assessment and purchasing. Journal of Public Health Medicine 1994;
16: 29-36
2 Hull M.G.R., Glazener C.M.A., Kelly N.J. et. al .
Population study of causes, treatment and outcome of infertility. BMJ 1985;
291: 1693-1697
3 HFEA, 2000 Ninth Annual Report & Accounts, p10
4 ESHRE. Assisted reproduction technology in Europe, 2000.
Results generated from European registers by ESHRE. Human
Reproduction, 2004: 19: 490 – 503
5 Lord J, Shaw L, Dobbs F and Acharya U Provision of fertility
services A time for change and a time for equality - infertility
services and the NHS Human Fertility 2001; 4: 256-260
6 Jenkins 2003 Public
awareness of infertility and views on provision of NHS treatment
7 Infertility Network UK 2004 Impact of NICE Clinical Guideline
on Fertility Services in Primary Care Trusts