Infertility treatment in the UK: Implementing the NICE guidelines

Many years ago the then Minister of Health, Frank Dobson, drew attention to the unfairness of the 'postcode lottery' of provision of infertility treatments in the UK. Following his initiative, a subsequent Minister, Alan Milburn, later commissioned the National Institute for Health and Clinical Excellence (NICE) to look into this topic, and NICE published its conclusions in guidelines entitled 'Fertility, assessment and treatment for people with fertility problems', in late 2003. A third incumbent in the Ministerial post, John Reid, responded to this in February 2004 with a public statement: 'As a first step, I want all PCTs, including those who at present provide no IVF, to fund one full cycle for all those eligible. In the longer term I would expect the NHS to make progress towards full implementation of the NICE guidance'.

Implementation of the guidelines was planned to put an end to the lottery, with fair and equal provision in all corners of the country. It is a sad fact that the lottery remains alive and well some 18 months after John Reid's promise. Whilst funding for IVF has increased in some areas, it has remained static or even declined in others. There is also a lack of national consensus on eligibility criteria. A recent survey coordinated by Infertility UK and the National Infertility Awareness Campaign has clearly shown the major differences in amount of funding, and in eligibility criteria for NHS treatment, that exist between adjacent PCTs in England and Wales. These include provision ranging from no treatment to two cycles, including frozen embryo transfer. With regard to differences in eligibility, there are significant variations in provision to couples with children from a previous relationship, or to couples in which the woman is older, or overweight. In addition, some PCTs persist in only funding IVF treatment when the woman reaches a 'cutoff' age, often at a point beyond the optimum age for a chance of IVF success. The continued paucity of help from the NHS for infertile couples in UK contrasts poorly with the more generous State provision in most of Western Europe (see table below).

COUNTRY / NUMBER OF STATE-FUNDED ART CYCLES / AGE LIMIT

Spain / 3 / Up to 37

Belgium / No limit / Up to 43

Slovenia / 4 / Up to 42

Portugal / No limit / Up to 42

France / 4 / Up to 43

Israel / No limit / Up to 45

Italy / No limit / No limit

Sweden / 2 / Up to 38

UK / None to 1, rarely 2 / Up to 40

SOURCE: European Society for Human Reproduction and Embryology Advisory Committee, September 2005.

New drivers for increased State provision include a move to single embryo transfer for NHS funded IVF patients. We have shown that this policy would produce substantial cost savings, since the costs associated with long term care for twin or triplet pregnancies and offspring are substantial. We have suggested that this saving could be used as a 'cost-neutral' means of improving NHS funding for IVF, although it would obviously require a Government initiative to do so. At the time of writing, the three full cycles of NHS funded IVF recommended two years ago by NICE remain a distant dream. If NHS funding is not improved than I feel it is unlikely that patients will be willing to adopt a 'single embryo transfer' philosophy, since most wish to optimise the chances of pregnancy from one cycle if they are investing in treatment from their own resources.