Uptake of IVF and related technologies has increased exponentially throughout the developed world over the last two decades and births after assisted reproductive technology (ART) make a significant contribution to the total birth rate of many countries.
However, two major problems continue to impede progress in many settings, namely safety (mainly the impact of multiple births after multiple embryo transfer on the health of the children resulting from ART), and accessibility, with high costs of treatment preventing many couples from being able to pay to use this technology.
In this article, I will contrast possible solutions to these obstacles taken by two 'First World' countries.
The Office of National Statistics reports that, in 2018, there were 657,076 live births in England and Wales, a decrease of 3.2 percent since 2017 and a 9.9 percent decrease since the most recent peak live birth rate in 2012. This resulted in a fall in the Total Fertility Rate (TFR) to 1.7 children per woman, lower than all previous years on record except 1977 and 1999-2002.
More recent data showed that this trend is continuing, with fewer births in 2020 compared with 2019. The Human Fertilisation and Embryology Authority (HFEA) database shows that the number of live births resulting from IVF in the UK in 2018 was 19,728, suggesting that approximately three percent of live births resulted from IVF that year.
The comparison with practice in Australia is stark. There were 14,355 live births resulting from IVF in Australia in 2018, representing almost five percent of all live births. The population of Australia continues to grow, with an annual growth of 1.3 percent between 2019 and 2020, with a healthier total fertility rate of 1.83 in 2020.
My opportunity to explore the clinical, social and political forces that drive these variances in uptake of IVF in the two countries results from my having worked in reproductive medicine for the NHS for over 20 years before moving to work in a similar clinical academic practice in Sydney in 2011. This has given me insights into the provision and uptake of IVF services in the two countries.
The most obvious difference one perceives when moving from healthcare practice in the UK to Australia is the fundamental difference between the NHS and the Australian Medicare-funded public health system. Provision of Medicare services is universal in Australia to citizens and those with a permanent residency visa. The system is generous, reflecting the overall wealth of the nation, but requires all patients to pay a proportion of their healthcare costs in many situations. There is a liberal safety net which provides those of low income with access to quality healthcare across the country. From an IVF perspective, Medicare funds approximately 50 percent of the cost of an IVF cycle. At the present time, there are no limits on funding based on the number of cycles a woman or couple have had previously, nor on the woman's or man's age. Using some metrics, the Australian system is the second most generous to couples requiring IVF after Israel.
The position in the UK is not only vastly different from Australia but it is also different across the devolved nations. In England the NHS has never embraced IVF and has always placed it low on its list for funding priority. Although clinical commissioning groups (CCGs) are instructed by the NHS to provide three full cycles of IVF to eligible patients, this goal has never been achieved by more than a fraction of the 135 CCGs in England. Currently only 17 percent of CCGs offer three full cycles recommended by the UK Department of Health and Social Care. IVF is therefore usually funded from a couple's taxable earned income and although costs vary from centre to centre, many couples will spend more than £5000 per cycle of IVF treatment. The situation appears worst in London where less than 25 percent of IVF treatments are supported by the NHS .
The method of delivery of IVF also differs between the two nations. Australian IVF is almost entirely delivered in the private sector, mostly by large corporations that own networks of clinics within the main Eastern states. Corporatisation of IVF has not been without its problems – quality of research into human reproduction and its failings in Australia has dropped dramatically over the last two decades, and couples from less well-off sections of society find it difficult to cover the costs of their treatment even with Medicare reimbursement.
However, Australia continues to excel in one key area of IVF practice, namely single embryo transfer, which is almost universally practised across the country resulting in a multiple IVF birth rate of only four percent. Despite recent improvement, the equivalent figure for the UK is double, probably driven by a couple's desire to mitigate further financial burden by pushing for double embryo transfer. This problem may be exacerbated by the attitude of some prominent clinicians who continue to advocate for multiple embryo transfer despite overwhelming evidence of increased risk of harm to the children as a result of this outdated practice.
Conversely, one area in which the UK has considerably outstripped Australia is in the provision of clinical information to consumers, clinics and politicians. The HFEA has been in existence since 1991 and, despite many problems and setbacks, continues to provide high-quality clinic-specific data, which informs CCGs and patients.
Perhaps inevitably, due to the more corporate nature of ART provision in Australia, there has been a huge delay in providing clinic-specific data. As an outsider, I find this surprising, particularly since Medicare, ie, the Australian Government, covers approximately half the cost of IVF. However, after significant political pressure and negotiation of many roadblocks placed in its path by influential opponents, the 'yourivfsuccess.com.au' website developed by the National Perinatal Epidemiology and Statistics Unit with funding from the Australian Government has just gone live. This will no doubt attract significant press interest and its impact on the IVF sector will be fascinating to watch. Personally, I doubt much will change in the short term, but if the UK processes are replicated, performance of the lower quartile clinics will improve over time.
On a more basic level, Australians are used to paying for healthcare. The principle of co-payment for health such that the patient pays for some proportion of their treatment is universal, whilst the expectation in the UK continues to be that healthcare should be at no cost to the patient at the point of delivery. This laudable principle has underpinned the NHS since its foundation after the Second World War, but it may be time to reconsider its universality.
A partial subsidisation by the NHS of the majority of IVF cycles for those qualifying under well-established rules based on probability of IVF success would reduce costs to patients, improve access, improve quality of clinical care and increase the number of IVF births. This in turn may help reverse the fall in total fertility rate that the country is currently experiencing. The UK Government has now announced a reform of the governance of the NHS, reversing the internal market introduced as part of the Lansley review a decade ago, and abolishing GP led commissioning. A more 'top-down' approach may allow a measured introduction of a co-payment system for IVF patients, which would be to the benefit of many and the detriment of none.