29 Aug 2006

Unequal access to fertility treatment, poor planning to meet Government targets, and no clear criteria for who should receive NHS-funded fertility treatment; these are the findings of a survey by British fertility doctors to be published in the journal Human Fertility in September. In response, the British Fertility Society – the organisation representing professionals working with assisted conception – has issued a series of recommendations on social criteria for access to NHS-funded fertility treatment.

The BFS surveyed fertility clinics in England to establish how Primary Care Trusts are implementing the NICE guidance on fertility. Two years after publication of the NICE guidance, the survey results show a wide disparity of access to treatment, with little planning on how to implement the guidance in full.

They also show PCTs apply a wide variation of social criteria to determine who should qualify for fertility treatment, and the BFS is setting out a recommendations on criteria such as previous children, obesity, smoking, single-sex parenthood etc, to help PCTs decide who should receive NHS-funded fertility treatment.

The survey found that:

  • Number of cycles has increased, but there are still ‘black holes’. Despite the NICE recommendations, 16% of clinics report decreased support for fertility treatment.
  • Only one cycle is offered in vast majority of cases. Only 9% of respondents reported 2 cycles of treatment being provided.
  • There is little indication of PCTs making any long-term plans to implement the NICE guidance, and no reassurance that the full guidance will be implemented (in contrast to Scotland)
  • There is a wide disparity on the social criteria used for acceptance onto an NHS-funded programme, especially as regards existence of previous children, high BMI, smoking, etc. For example, half of the clinics said that their PCT wouldn’t fund treatment if either partner had had a child previously.

The British Fertility Society has written to every Primary Care Trust in England and Local Health Board in Wales asking them to meet government fertility targets, and setting out recommended criteria for NHS funding of fertility treatment.

The BFS makes eleven recommendations on social criteria for NHS treatment, including:

  • Waiting times for treatment should be the same as for any other medical condition
  • No woman should be commence NHS funded treatment after the age of 40
  • Women who are obese must initiate a weight reduction programme and those severely overweight (defined as having a BMI of 36 or more) should not receive treatment until their weight has reduced.
  • Single women and same sex couples should be treated the same way as heterosexual couples
  • If people have had children from a previous relationship, they should not be excluded from access to NHS treatment

The recommendations will be published in full in the September issue of the journal Human Fertility. A summary of the recommendations is attached. Infertility Network UK, the main fertility patient group, supports these recommendations.

Dr Mark Hamilton, Chair of the British Fertility Society, said:

Continued inequality of access to treatment is unacceptable in a state-funded health service and the source of considerable distress to a great number of people with fertility problems. We are presenting the recommendations to the PCT’s and Local Health Boards with the intention that they provide a basis for consistent application of social as well as medical criteria for access to State funded fertility treatment in England and Wales. They are similar to core recommendations currently before the health minister in Scotland. As Health Minister Caroline Flint pointed out in a recent letter to PCTs, “the persistent inequality of provision is hard to bear, and hard to understand for those affected”.

Lead author of the study, Mr Richard Kennedy (Coventry) said:

The results of this survey suggest that there is no sense of any long term planning for the provision of fertility services and provide no reassurance that full implementation of the NICE guidance will be achieved as was recommended by the Secretary of State for Health over 2 years ago. There is considerable disparity across England and Wales in the commissioning arrangements relating to a range of social criteria applied for acceptance into NHS fertility programmes. If we are to see an end to inequity of access across the United Kingdom there must be an explicit plan for the provision of three fresh cycles of IVF and consistency in the criteria used for NHS treatment. The criteria we propose, if adopted by all PCT’s in England and Wales, would standardise access to treatment. We must use the findings of this survey to pursue the goal of full implementation of the NICE Guideline.

Notes for Editors

  1. This press release is taken from, Implementation of the NICE Guideline – Recommendations from the British Fertility Society for National Criteria for NHS funding of Assisted Conception. Authors R Kennedy, C Kingsland, A Rutherford, M Hamilton, W Ledger, to be published in Human Fertility in September. A pdf. of the paper can be found at http://www.fertility.org.uk/news/documents/HumanFertilitypaper.pdf
  2. 64 licensed fertility clinics in England and Wales were surveyed in May and July 2005. 37 of the 64 units replied; these units were based in England.
  3. A summary of recommendations is attached.

The BFS has also issued a statement on fertility, obesity and social values as a follow up to this statement.

For more information: please contact the British Fertility Society press office


Summary of recommendations of the British Fertility Society for national criteria for NHS funding of assisted conception

Definition of infertility
In the absence of an obvious pathological cause infertility is defined as follows:

In the absence of any physical cause infertility is defined as the inability to conceive despite regular unprotected sexual intercourse over a period of at least 2 years.

Previous children
If the couple have no children they should qualify for funding. If either partner has a child/children from a previous relationship, but not the current relationship, they should qualify for NHS funding provided there has been consideration of the welfare of the child.

Where funds permit, couples, who already have a child from the current relationship and who have involuntary infertility, should receive funding, though childless couples should have priority. Treatment in these cases should be provided on the same basis as those with no children.

Age of female
No treatment cycle should be started after female’s 40 th birthday; no patient place on the waiting list within 6 months of the 40 th birthday but treatment funded up until the 40 th birthday of the female partner; no age limitation on the use of frozen embryos created during an NHS funded cycle carried out before the female partners’ 40 th birthday.

Unexplained infertility
Unexplained infertility should be treated by a phased approach according to the female partner’s age and duration of infertility.

Age of male partner
Paternal age should not be included in criteria for acceptance in NHS programmes.

Previous sterilisation
A history of sterilisation in either partner will normally exclude a couple from NHS funding of assisted conception or surgical reversal of male and female sterilisation although there may be exceptional cases where funding is agreed in these cases.

Weight
Women with a body mass index of < 19 and > 29 should be referred for advice from a dietician, warned of the potential risks in pregnancy, if appropriate, provided with access to exercise advice and offered psychosocial support. NHS funding of their treatment should be deferred until they demonstrate response to these interventions. Assisted conception may be provided if the BMI is < 36.

Smoking
Smoking should not be an exclusion criterion but patients who smoke should be given advice about its implications. In addition, all smokers should be given the opportunity to be referred to a smoking cessation programme.

Previous self funded treatment
NHS funding should not be provided to those who have already received the number of NHS funded cycles currently supported by their PCT. NHS funding should be provided to those patients who have had previously self- funded treatment irrespective of the number of cycles providing the clinical circumstances warrant further treatment.

Same sex couples and single women
Single women and same sex couples should be eligible for up to six cycles of NHS funded donor insemination treatment provided assessment of the Welfare of the Child has been undertaken in line with the Human Fertilisation and Embryology Authority Code of Practice, 2004. After failed donor insemination treatment or in the presence of an indication for IVF allocation of cycles should be on the same basis as for heterosexual couples.

Waiting times
Commissioners should ensure that waiting times for NHS referrals for infertility diagnosis and treatment are consistent with national targets for other medical conditions.

BFS Executive Committee

July 2006