Fertility Treatment for Single People: Who Should Pay?

There was an air of excitement about the first face-to-face PET (Progress Educational Trust) event since the pandemic, enhanced by the wonderful surroundings of the Royal College of Physicians in Edinburgh.

Sarah Norcross, director of PET, acted as chair and introduced the topic of discussion – the potential for UK fertility funding for single people, including single men.

Dr Sarah Martins da Silva (clinical lead for fertility services at NHS Tayside) opened the discussion from a clinician's perspective, specifically from within an NHS service. She reminded us that the NHS promises medical treatment free at the point of care, and that in principle the NHS provides impartial, non-judgmental, evidence-based investigation and management. However, she acknowledged that even medical practitioners on the ground probably don't fully recognise the true cost of delivering health care to the UK population.

The National Institute for Health and Care Excellence (NICE) is commissioned to look at the best treatments and, taking into account cost-effectiveness, has provided access criteria for fertility treatment based primarily on outcomes including success rates (for example, age criteria) but also health of mother and child (for example, BMI recommendations). However, these are not followed uniformly across the UK.

NICE and the NHS also retain a couple bias in terms of an infertility diagnosis, but Dr Martins da Silva noted that the American Society for Reproductive Medicine and other organisations are beginning to take a broader approach. She went on to explain the wide impact of fertility issues, in particular the huge psychological burden. There is a huge potential for (often underappreciated) collateral damage in not managing infertility.

Dr Martins da Silva raised several important questions. Why is treating single people different from treating couples? Is being a childless and single a medical issue? The basic components required to treat single people – reciprocal gametes, and the possible need for a surrogate – are scarce, and it would be costly to expand to meet possible extra demand.

The main message was that while the idea of enabling fertility treatment for single people of either sex might be supported, without infrastructure investment and equity across all aspects of fertility management, it is unlikely to happen. Dr Martins da Silva concluded pragmatically that it may be short-sighted to deny treatment to single people when young, single people may have some of the best outcomes as good prognosis patients.

The role of Dr Alan Brown (senior lecturer in private law at the University of Glasgow) was to consider the potential impact of the law upon the discussion. He began by stating that the law is unlikely to provide solutions. The Human Fertilisation and Embryology Act 1990 and its 2008 update govern fertility treatment UK-wide. However, all aspects of healthcare delivery are devolved to the four nations, and – in England – are further devolved to regional commissioners.

Dr Brown pointed out that the legislation itself is not a barrier to treating single people, particularly since the 'need for a father' provision was removed in 2008 (see BioNews 459). There is indeed no distinction in the act between patients receiving NHS-funded care, and self-funded patients. Moreover, the Human Fertilisation and Embryology Authority (HFEA) has no powers over funding or access to treatment.

Dr Brown explained that funding decisions made by health boards can be legally challenged via judicial review, but any such challenge has to show that the decision was irrational, illegal or contrary to human rights. It would be unlikely for such decisions to be considered irrational, and since it is the responsibility of the commissioners to make such decisions, the legality of the decisions is unlikely to be challenged. What of human rights?

Although Articles 8, 12 and 14 of the European Convention on Human Rights are relevant in vouchsafing reproductive autonomy, they do not include a positive obligation to provide treatment and it is not clear therefore that lack of NHS access – involving lack of funding or otherwise – is an infringement of those rights. Dr Brown noted that the European Court of Human Rights in Strasbourg has been reluctant to engage in challenges relating to distribution of resources, as this is seen to be largely a political matter. It only comes to the Court's notice if there is evidence of egregious discrimination.

It has often been suggested that non-traditional family configurations might put children at a disadvantage. Dr Catherine Jones (lecturer in developmental psychopathology at King's College London) was asked to provide some insight into the outcomes of single parents and their children, to see whether such concerns are well-founded. She described research led by Professor Susan Golombok, who is well known for generating evidence in this field, concerning parent/child adjustment and single parent experience.

First, Dr Jones discussed a longitudinal study of heterosexual single mothers and heterosexual coupled mothers with children aged 4+ years. Both family types had used sperm donation. There were 51 women who were single, and 52 who were partnered. The majority had used a known donor. The first phase of the study involved interviews with the mothers, questionnaires, observation of mother and child joint tasks, and an assessment of the child's development. Overall, it was considered that for the mothers there were no differences between the single and partnered women in terms of mental health, parenting quality or child adjustment.

Eighty-one of these women also took part in the second phase of the study, when the children were at least eight years old. These children were found to understand the process of their conception more and while the majority (58 percent) gave positive descriptions a small number (16 percent) were more negative – this was found to relate to the mother-child interactions. It was discovered that family functioning affected the child's view of the donor and donor conception process.

Next, Dr Jones discussed a study to which she had contributed, in which 21 single men – most of whom were gay and recruited internationally – underwent similar assessment. Their children were younger, and therefore not separately assessed. When compared with the women from the first study, there were no apparent differences in mental health or parenting quality. Moreover, they described established supportive networks, said that there were positive public reactions to their families, and said it was important to them that they were given that choice to build their families. In this situation, they often maintained a special relationship with their surrogate.

Overall, these studies were suggestive of good outcomes and experiences for single parents – whether male or female – and for their offspring. On this basis, Dr Jones argued that planning to be a single parent should not preclude access to funded treatment.

Finally, an ethical dimension was added by Professor Guido Pennings (director of the Bioethics Institute Ghent). He provided an international perspective, observing that one-third of donor gamete recipients in Belgium are single women, and the proportion is even higher in France (38 percent). In these countries, funding is supposed to be available (by way of reimbursement) irrespective of relationship status.

Professor Pennings argued that although each country should have the latitude to decide whether it is offers public funding for fertility treatment, if it chooses to do so, then treatment should be available all except where 'relevant' differences pertain. Otherwise, exclusion of a particular group constitutes discrimination. Professor Pennings then considered what a 'relevant' factor might be.

He observed that even where there are equitable funding provisions, clinics might still impose their own criteria, in which case they are effectively gatekeeping access by other means. He gave the example of a four-page questionnaire provided to single women in Belgium, that was clearly off-putting – 50 percent of women who made enquiries never completed the questionnaire and presented for treatment. In addition, requirements included not living with parents or having had prior long-term relationships. He argued that most of these considerations had no clear impact on one's capacity to parent, and that this therefore constituted discrimination.

Closer to home, Professor Pennings noted that according to HFEA data, in 2022 only eight percent of treatment cycles for single women in the UK were publicly funded. He questioned the ethics of this, since it drove determined women to more risky strategies such as seeking sperm donors online. Even when the actually treatment was funded, he noted that costly purchase of sperm was often the responsibility of the recipient. He questioned why this should be the case, when other donations – for example, blood and organs – are provided as needed. Thus, while in some jurisdictions there is theoretical access to funded treatment for single women, even here there remain unnecessary extra barriers. As for fertility treatment for single men, he noted that this remains almost entirely unaddressed.

The audience questions and panel discussion that followed were characterised by empathy for single would-be mothers, and indeed there were proposals to allow for unencumbered access to fertility treatment for single people in general. However, there was some caution around the greater cost and complication of surrogacy, and recognition of the fact that recruitment of donors and surrogates requires significant investment. There was also a sense that the NHS situation is unlikely to allow for this in the foreseeable future.

A question was asked about the the need for proof of infertility, before funded treatment can be accessed. Professor Pennings recommended that we think of treatment as addressing involuntary childlessness, rather than infertility per se. The discussion was broadened further to consider prioritisation of funding generally, and the role played by societal norms.

Overall, we were left overall with a sympathetic view of single people who wish to be parents, and an agreement that funding criteria should be non-discriminatory. However, there was a lingering question about how to put this into practice, in a context of diminishing resources.

PET is grateful to the Scottish Government for supporting this event.

The next free-to-attend PET events will be:

• Welfare of the Fertility Patient: Spotting Signs and Treatment after Trauma, taking place online on Wednesday 13 March 2024 – register here.
• Mary Warnock at 100: The Architect of Embryo Law?, taking place online on Wednesday 17 April 2024 – register here.