A service framework for the care of infertile couples in Scotland was published by the Expert Advisory Group on Infertility Services in Scotland (EAGISS) in February 2000. Since then, implementation has taken place to varying degrees, and five years on we still have some Health Boards who have yet to implement fully. Services in Scotland are far better than they are south of the border in terms of NHS provision. Nonetheless, there are still areas that need to be improved and where Scotland still has treatment by postcode, which, just as it is anywhere else, is totally unacceptable and must be eradicated.
In September 2005, the Scottish Executive announced a consultation reviewing infertility services, which closed on 8 December. It focused on two changes to the current eligibility criteria for assisted conception treatment, but it also gave us the opportunity to highlight other areas of fertility services that were in need of change and improvement.
One of the key questions laid out by the Executive in its consultation asked if the female upper age limit for assisted conception treatment funded by the NHS should be increased from 38 to 40. It also asked whether there should be a change to social criteria which would allow couple who already had children, or who had been previously sterilised, access to treatment, and how subsequent treatment cycles should be administered after a failed cycle. It makes sense to increase the female upper age limit, as this would bring Scotland into line with the NICE guidance in England and Wales, which is based on most recent data available.
The consultation speaks about a cycle of treatment - and one of the biggest problems existing in Scotland is the definition of a 'treatment cycle'. Some interpret this as including the replacement of any frozen embryos within that cycle whilst others do not. We have called on the Executive to give a very clear definition of a treatment cycle to end this confusion. It is our belief that a cycle should consist of ovarian stimulation and egg retrieval, followed by the transfer of fresh embryos as well as subsequent transfer of any frozen embryos derived from that single episode of ovarian stimulation.
Another major problem area in infertility services in Scotland is that waiting times for treatment vary dramatically throughout the country. A recent survey undertaken by Mary Scanlon MSP in conjunction with Infertility Network UK and The National Infertility Awareness Campaign, showed a huge variability, with waiting times from diagnosis to treatment ranging from two months in some areas, to 48 months in others. Recent advice from the Department of Health in England has made it clear that infertility, in common with other forms of medical need, should be addressed within 18 weeks of referral both for assessment and thereafter for ongoing treatment. We hope to see this advice being given in Scotland and have indicated this in our response to the consultation.
One really strange question appeared in the consultation, asking how subsequent treatments should be administered after a failed cycle. One of the options we were asked to consider was 'the first embryo transfer is the one most likely to succeed. Therefore based on effectiveness and equity couples should return to the end of the waiting list after their first cycle'. This would have a drastic effect on couples. The emotional and psychological distress which infertility brings should never be underestimated, and the practice of returning couples to the bottom of a waiting list after each cycle would considerably increase the stress they are already under and have a negative effect on their general wellbeing.
There would, of course, also be the question of how long the wait for subsequent treatment would be. If the current situation with waiting lists remain, couples could find themselves age-barred before they reached the top of the list again. This practice would also affect the chances of success on the grounds of the increasing age of the female while awaiting that next cycle. Only one Health Board in Scotland currently practices this unfair and inhuman system - as a patient representative, I would be extremely worried if this were to become commonplace across Scotland.
Some eligibility criteria for infertility treatment are in place not because they are based on sound medical evidence. Better known as 'social' criteria, they are simply a form of rationing. I receive many letters and calls from people who have fertility problems and who are denied NHS treatment simply because their partner has either brought a child with them into that relationship, or has been previously sterilised. It is discriminatory and wrong to deny someone treatment based on the status of their partner in respect to previous children or sterilisation and I believe it is a practice that must be ended.
This consultation has given everyone with an interest in provision of infertility services in Scotland the chance to give their views on those services. I only hope that the results will be made public within a reasonable timeframe and, more importantly, that Health Boards in Scotland are given very clear and specific instruction on the implementation of services. Hopefully, this will remove the unacceptable practice of treatment by postcode and give couples the fair and equitable service they deserve.