- New research from the British Pregnancy Advisory Service, BPAS, has found that Clinical Commissioning Groups in England restrict access to NHS-funded fertility treatment using arbitrary limitations, such as relationship status, BMI, or the fact their partner has a child from a previous relationship. 3 CCGs do not offer any funded fertility treatment.
- Female same-sex couples and single women are disproportionately impacted by policies which require that they self-finance costly, and less effective, artificial insemination, in some cases for at least 2 years, before becoming eligible for funded IVF.
- The charity has said the restrictions are a consequence of a systemic problem with the way fertility services are funded in England.
- Infertility is recognised as a medical condition by the World Health Organisation, and it is known to cause psychological harm for many of the people affected.
- NICE guidance states that offering three full cycles to IVF is a cost-effective measure. However, 80% of CCGs have restrictions in place on the number of funded cycles, which reduces the cost-effectiveness of providing treatment. 3 CCGs do not fund any fertility treatment.
- The charity, BPAS, which is establishing a not-for-profit IVF service to address the inequalities in provision, is calling for NICE guidance to be implemented to ensure that all patients can access the same treatment regardless of where they live and their ability to pay for healthcare.
The charity the British Pregnancy Advisory, BPAS, has today released a report detailing the worrying extent to which NHS-funded fertility treatment is restricted on the basis of non-clinical limitations and in contravention of NICE guidance.
The most recent NICE clinical guideline for fertility treatment was issued in 2013 and determined that IVF is cost effective up to age 43. NICE recommends that women under 40 should be offered three full cycles of IVF, and those aged 40-42 should be offered one cycle. However, the vast majority of CCGs do not provide funded fertility treatment in line with these guidelines.
The key findings include:
- 14 CCGs do not offer fertility services to women aged over 35, and a further 6 CCGs have female age cut-off points between 37 and 39. Data suggests that the trend towards older motherhood is increasing and consequently CCG policies with low age limits are likely to be excluding a large cohort of patients who have not yet started their families and who therefore may need access to fertility services.
- The majority of CCGs (54%) do not routinely contribute any funding to patients who must undertake artificial insemination in order to verify their infertility, a policy which will disproportionately affects female same-sex couples and single women.
- 16 CCGs (12%) require a period of at least 3 years of unprotected sexual intercourse before a couple is eligible for referral for IVF, a delay to treatment which could hinder outcomes due to the impact of age on fertility.
- 88 CCGs (65%) state that a couple is ineligible for IVF if one person has a child from a previous relationship.
Reducing the number of cycles available to patients is likely to be intended as a cost-saving measure by CCGs, which have a wide range of services to provide out of limited budgets. Nonetheless such a measure will inevitably reduce patients’ chances of achieving a successful pregnancy. It is also likely to impact cost effectiveness: in its Quality Standard 73, NICE states that offering fewer than three cycles is unlikely to be cost effective based on a live birth rate per cycle of 28%.
The charity is also concerned that female same-sex couples and single women face significant financial obstacles to accessing treatment. CCG policies require single women or female same-sex couples to undergo 6-12 cycles of Artificial Insemination (AI) before their infertility can be determined and they can therefore qualify for funded treatment. Artificial insemination is a costly process, averaging between £350 - £1000 per cycle, with additional costs for purchasing donor sperm. The majority of CCGs (54%) do not routinely contribute any funding to patients who must undertake AI in order to verify their infertility. The requirement that patients should self-fund all cycles of AI conflicts with NICE guidance, which recommends that CCGs should fund at least 6 cycles, and is likely to present a significant additional barrier to IVF access, that disproportionately affects single women and female same-sex couples.
Almost all (96%) of CCGs restrict access to funded treatment on the basis of female BMI, and 24% restrict on the basis of male BMI. 4 CCG policies also require that BMI must be maintained for the previous 6 months before referral. NICE does not recommend that fertility treatment is withheld on the basis of BMI, but only that women should be informed that female BMI should ideally be in the range 19–30 before commencing assisted reproduction.
The scale of the divergence between CCG policies and the resulting IVF “postcode lottery” should be understood as the consequence of a systemic problem with the way fertility services are funded in England. In the context of intense funding pressures, CCG policymakers have the difficult job of allocating resources to address competing health needs, of which infertility is one. However, no other area of healthcare is restricted to the extent of fertility services, and the extent to which individuals are now expected to self-fund this one area of treatment, including by traveling abroad for care, is not seen in any other area of healthcare.
The withholding of fertility services has real consequences, both for patients and the health service. Infertility is recognised as a medical condition by the World Health Organisation, and it is known to cause psychological harm for many of the people affected. Many patients who are unable to access fertility care on the NHS travel abroad for care. This is associated with higher rates of multiple births, which are the single biggest risk of IVF to both mothers and babies and associated with higher rates of neonatal death. Others will access expensive private care in England, but this is only an option for those with the financial means to pay thousands of pounds per cycle.
Marta Jansa Perez, Director of Embryology at the British Pregnancy Advisory Service, BPAS, said:
“Access to any form of healthcare should be rooted in clinical evidence. Sadly, this report demonstrates that for most patients in need of fertility treatment, this is simply not the case.
“It is deeply unfair that systemic problems with funding have effectively created a fertility pot-luck, with devastating consequences for some patients. People living just a few streets apart are facing a gulf between them when it comes to the care they are entitled to – and that care could change the course of the rest of their lives. Same-sex couples are being told that they need to fund costly and less effective interventions before being entitled to funded treatment, which may price some couples out of receiving NHS care. The requirement of more than one in ten CCGs that couples must have tried at least 3 years of unprotected sexual intercourse before being eligible for treatment could lessen the chances of the couple eventually conceiving due to the impact of age on fertility.
“We know that the economic uncertainty caused by COVID-19 will mean that some couples delay starting their families, and the growing trend towards older motherhood means that more people are trying to conceive later in life. In this context, ensuring fair and comprehensive access to funded-IVF has never been more important.
“We believe that there needs to be a standardisation across CCGs to end harmful discrepancies, and fertility treatment should be commissioned in a way that reflects the importance – and cost-effectiveness – of patients receiving this care The Health Secretary Matt Hancock has previously called for national standards to guide provision, and we would welcome any such intervention.”
Emily Scott, founder of IVF Fairness, said:
"Not only does the report compiled by BPAS comprehensively evidence the shocking disparity in IVF provision available on the NHS across the country, it serves to raise fundamental questions about how seriously we adhere to and value the principles on which the NHS is founded. Under a truly National Health Service we would not expect to see such significant variety in treatment criteria across localities (e.g. maximum age, weight, already having children from a previous relationship). We would also reasonably not expect (or accept) non-clinical criteria such as postcode being used as an arbitrary proxy for a person-centred approach to treatment.
"Reform in this area is long overdue. IVF Fairness stands with BPAS in urging policy makers at a local and national level to finally take action, for the sake of fair and equal access to reproductive health services and in genuflection to the governing principles on which our National Health Service is founded."
The full report is online here.
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BPAS is a charity which sees almost 100,000 women a year for reproductive healthcare services including pregnancy counselling, abortion care, miscarriage management and contraception, at clinics across the UK. We support and advocate for reproductive choice.
BPAS intends to launch our own not-for-profit fertility service in Spring 2021, to provide ethical, evidence based, person-centred care that supports patients. We intend to only charge what it costs to provide a safe, high-quality, and accessible service to patients who may be unable to access NHS funded care.