Access to fertility treatment must be improved and simplified

The last few years have been very challenging for us all. The financial crisis was followed by a steep economic recession and just when we thought we were getting over that, the COVID-19 pandemic arrived and turned our lives upside down, putting many healthcare workers very much on the front line. Ongoing financial, political and industrial problems have had a major impact on all aspects of life, including on healthcare and it sometimes seems that the old certainties no longer exist.

Fertility treatment has always been seen as a 'special case' and has been treated very differently to other health problems. In the early days, IVF treatment was deemed by many in society to be controversial and experimental, therefore it required specific legislation and regulation to ensure that oversight was maintained over what was happening in fertility clinics and research centres across the UK. Fertility treatments were and still are, rationed. Historically, family building was not seen as a health concern and this view still persists in some circles. It is clear though from contemporary surveys that attitudes have changed markedly over time and the majority of the UK population no longer see it this way, with IVF now being viewed as a standard medical treatment, much like any other.

However, important differences remain between fertility and other healthcare. When I first started working in fertility as a urologist, I was struck by the large number of people that were not eligible to receive NHS-funded care due to their personal circumstances. Typically in my own male fertility practice, this was due to the female partner having had a child in a previous relationship, often at a much younger age. This meant that even though the male patient did not have any children of his own and was experiencing a defined health problem, the couple's only option of becoming biological parents together, would be through private fertility treatment.

I have lost count of the number of cases where couples were unable to try to become parents due to the cost involved and this situation seems to have worsened with the cost-of-living crisis. To me this restriction seems like a moral judgement rather than a clinical policy developed through scientific understanding. Like many, I do not feel very comfortable with a situation that limits attempts at achieving biological parenthood only to those who have the means to pay for what is a very expensive treatment. I feel also that it implies that wealthier people are more deserving of parenthood than those on low incomes (do we really feel that more affluent people make better parents?). This situation is in stark contrast to what I experienced in the world of NHS urology, where social factors alone did not determine access to specific treatments.

Restrictions on access to treatment are compounded by inequalities across the UK in terms of the number of funded cycles that NHS patients are entitled to. Patients in some parts of England have more or less access to NHS-funded IVF treatment than other patients with similar health fertility problems who might only live a few miles away from them. This 'postcode lottery' is something that the British Fertility Society, along with other professional bodies, PET (the Progress Educational Trust) and patient organisations have been campaigning against for many years and we will continue to do so. It is somewhat ironic that at a time when birth rates worldwide are declining and there are concerns about the impact of a rapidly ageing population on our society, that IVF remains so restricted when there is evidence to suggest that it is one of the most effective ways of moderating the economic impact of this important social change.

Nevertheless, fertility treatment remains safe and increasingly effective. Strategies like single embryo transfer have – by reducing the number of multiple births – had a major impact on reducing IVF-related perinatal morbidity. The strict quality management systems that we employ insure that problems with efficacy are quickly identified and addressed, ensuring consistency of treatment and the best possible outcomes for our patients.

Followers of PET will be no strangers to the astonishing pace of development in this dynamic and exciting environment, where professionals from a broad range of backgrounds – doctors, clinical scientists, nurses and counsellors work together to treat and support patients who seek to form families. In recent years, there has been a welcome interest in male fertility problems, which can be a factor in up to half of all cases, with new light being shone on the causes of male-factor infertility and a better understanding being achieved of the experiences of men undergoing fertility treatment.

It is very difficult to predict what will come next. In vitro gametogenesis, genetic technology and artificial intelligence have the potential to revolutionise the way that we practice medicine, but pose questions in terms of safety and acceptability.  However, it is likely that the next generation of fertility practitioners will work with different tools and in different settings than those currently used.

But it is not just scientific developments that we need to consider. In the not-too-distant future, we hope that the opportunity will arise for reform of the Human Fertilisation and Embryology Act, under which we practise. Reproductive medicine and science is clearly not in the same place as it was when the act was originally written and there are calls from those across the sector, including the regulator, for reform.

Those working in patient-facing disciplines are aware of the burden placed on patients to complete the mandated forms. Now that IVF is a standard healthcare treatment, could there be an opportunity for these forms to be modified, to make it easier and simpler for everyone? Might there be a way of future-proofing legislation, to enable it to accommodate new scientific and technical developments without the need to change the primary legislation? Might there be a way to improve and simplify legal parenthood?

Sometimes it seemed to me that the learned societies would respond to policy announcements, often given at short notice in a reactive rather than pro-active way. This made it difficult sometimes to get a balanced view that reflected thought and experience of the membership. In order to get ahead of the curve and try to establish policy suggestions that we felt would improve the experience and treatment of fertility patients and those that treat them, as well as to address some the matters discussed above, the British Fertility Society set up a Law Policy and Ethics Special Interest Group. This new group, currently chaired by PET director Sarah Norcross, is comprised of doctors, nurses, clinical scientists and other from within the British Fertility Society, as well as experts in fertility law. This broad range of experts has enabled us to produce documents on a number of matters and most particularly, what we think should go into a reformed HFE act. We have now submitted a detailed and comprehensive document that reflects the views of the Society to both the Department of Health and Social Care as well as the Human Fertilisation and Embryology Authority. Hopefully the opportunity will arise for some of these ideas to be implemented in the future and in that way, benefit our services and the patients that we treat.

The next 50 years in the fertility sector are likely to be as fast-moving and dramatic as the last 50 years and hopefully, we will have a legislative framework that will enable innovation to flourish, while maintaining the excellent work that we do. In the meantime, we will continue to work towards an environment where patients receive funded fertility treatment according to requirements, rather than to any other parameters.