Professor Carlos Calhaz-Jorge, chair of the European Society of Human Reproduction and Embryology (ESHRE), was the session chair for the second session of the Progress Educational Trust (PET)'s 2022 annual conference.
The first presentation was 'Turkey: Restricted Access to Assisted Reproduction' by Dr Mete Işıkoğlu, gynaecologist at the Gelecek Centre for Human Reproduction in Turkey. Dr Işıkoğlu explained how the reproductive medicine sector in Turkey has expanded over the past thirty years since the first fertility clinic opened in 1988. Following the introduction of state funding for some forms of fertility treatment in 2005, the number of clinics has grown exponentially. However, this funding is restricted to married heterosexual couples.
Assisted reproduction as defined within Turkish legislation, includes any treatment in which a woman's egg is fertilised by her husband's sperm, and stipulates that any embryos created outside the body can only be transferred to the relevant woman's womb. All forms of third-party reproduction, such as gamete donation, embryo donation or surrogacy, are strictly prohibited. Further legislation introduced in 2010 states that anyone travelling outside of Turkey to access third-party reproductive treatment, and anyone who facilitates such cross-border treatment, will be 'reported to the state prosecutor'.
While this legislation restricts access to fertility treatment for many people within Turkey, Dr Işıkoğlu explained that it does not necessarily reflect the views of the general public within the country. One recent study suggests that only 15 percent of the population strongly objected to egg donation, for example.
Dr Işıkoğlu hoped that in the future, Turkish legislation would adapt to permit third-party reproduction, and also that the state would fund more forms of fertility treatment (such as egg freezing). He explained that funding needs to cover the full cost of treatment, because wages in Turkey are low compared to the cost of IVF and other treatments, making these treatments unaffordable for many.
In the second talk of the session Dr Diane De Neubourg, head of Antwerp University Hospital's Centre for Reproductive Medicine, shared her experience of working as a reproductive medicine specialist in her talk 'Belgium: Liberal Access to Assisted Reproduction'.
Perhaps the most impressive aspect of the Belgian fertility sector is the high level of government funding available to Belgian citizens who require treatment: they can access 90 percent funding for up to six IVF cycles, with patients paying the remaining cost – approximately €400 per cycle. This funding is available to women up to age 43.
Dr De Neubourg explained that this funding was introduced when the Belgian government recognised the medical and financial challenges that multiple pregnancies bring. Hoping that by providing a financial incentive for patients to have a single embryo transfer, it would be possible to reduce the number of multiple births and associated complications, the government agreed to cover 90 percent of the treatment costs on the condition that the fertility clinics would halve the rate of multiple births.
This deal seems to have been very successful, as the multiple birth rate from fertility treatment is now consistently less than ten percent in Belgium and the cumulative live birth rate from treatment is high. Interestingly, despite the offer of six funded cycles, Dr De Neubourg reported that there was a high dropout rate from treatment. Indeed, more than a quarter of patients do not return for a second IVF cycle if their first cycle is unsuccessful, which perhaps suggests that even if you remove a significant proportion of the financial burden of treatment from patients, the emotional and psychological burden should not be underestimated.
The third talk was entitled 'Germany: Restrictions on Egg Donation' and was presented by Dr Andreas Tandler-Schneider, gynaecologist at the Fertility Centre Berlin. Despite Germany and Belgium being neighbouring countries, the regulation and funding of fertility treatment in these two countries is vastly different. Fertility specialists in Germany are required to adhere to the 1990 Embryo Protection Act, which – as the name suggests – was designed to protect the status of the embryo, rather than to maximise safety for the patient or resulting child(ren).
The Embryo Protection Act creates a number of obstacles for fertility specialists. Any clinician who 'attempts to fertilise more egg cells from a woman than may be transferred to her womb within one treatment cycle' may face up to three years' imprisonment. German fertility specialists have had to find creative ways of performing treatment cycles to comply with the Act – or at least, work within a 'grey area of the law' – without significantly compromising success rates. Impacts on clinical practice include reluctance to grow many embryos to the blastocyst stage, and apprehension around freezing surplus blastocyst-stage embryos. As a result, there is a high multiple birth rate, as two embryos are transferred in more than half of the treatment cycles performed in Germany.
Interestingly, while sperm donation is permitted in Germany, egg donation is strictly prohibited and – again – is punishable by imprisonment. As a result, many patients travel abroad to access treatment with donor eggs. Dr Tandler-Schneider highlighted some of the risks involved, such as high travel costs, language barriers, the use of anonymous donors, and questionable practices such as transferring three or more embryos at a time.
The final talk was entitled 'Italy: Where Liberal Access Meets Practical Difficulties' and was presented by Dr Giulia Scaravelli, director of the Italian National Assisted Reproductive Technology Register. Despite the use of the word 'Liberal' in Dr Scaravelli's title, fertility treatment in Italy is limited to heterosexual couples. Treatment is not permitted for same-sex couples or single women, and surrogacy is strictly prohibited.
Both Dr Scaravelli and Dr Tandler-Schneider described funding and legislation issues that are very familiar to those that work in the UK fertility sector. Patients in Germany face a 'postcode lottery', just as English patients do when trying to access state funding for fertility treatment, while only 62 percent of Italian cycles qualify for reimbursement.
Discussions of UK law during other sessions of the conference were echoed here, by the panellists' frustrations at slow-moving governments when trying to initiate change at a legislative level. The laws that currently govern the use of fertility treatment in these European countries arguably no longer reflect the social, political and religious views of the public, but there does not seem to be a fast or efficient way of modernising the legislation to remedy this.
Overall, these four talks made me appreciate that fertility treatment in the UK is accessible to a diverse range of people regardless of their marital status, sexual orientation or gender identity. However, patients here could benefit from more generous state funding like that offered by Belgium, and from government policies that appreciate the long-term benefits of funding for fertility treatment.
PET would like to thank the sponsors of this session (ESHRE) and the other sponsors of its conference (the Anne McLaren Memorial Trust Fund, the Edwards and Steptoe Research Trust Fund, Vitrolife, Born Donor Bank, CooperSurgical, Ferring Pharmaceuticals, Merck, Theramex, TMRW Life Sciences and the Institute of Medical Ethics).
Register now for PET's free-to-attend online events in 2023:
- Your Guide to Genetics and Genomics in the Fertility Clinic (18 January 2023)
- 100 Years of Daedalus: The Birth of Assisted Reproductive Technology (1 February 2023)
- Understanding Miscarriage: Pregnancy Loss after Fertility Treatment (15 February 2023)
- When to Stop Storage: Improving Conversations About Unused Embryos (1 March 2023)
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