On 20 February 2013, the National Institute for Health and Clinical Excellence (NICE) published its new guideline on the assessment and treatment of couples with fertility problems.
Updated and revised, the new guideline builds on recommendations within NICE's original guideline issued in 2004. Since then there have been significant advances in both treatments and in the understanding of different assisted conception techniques. The recommendations contained within the new guideline take into account these developments, as well as the latest statistical and clinical evidence.
Under the new guideline, people experiencing fertility problems will be able to seek NHS help sooner and get the medical treatment they might require earlier. For the first time, the guideline includes provisions for specific groups of people; including same sex couples, those who carry an infectious disease, such as Hepatitis B or HIV, and those who are physically unable to have intercourse due to a disability. It also includes updated recommendations for people who are preparing for cancer treatment who may wish to preserve their fertility.
Furthermore, women between the ages of 40 and 42 may be able to access one cycle of IVF on the NHS for the first time provided that they have not received treatment before.
These are exciting developments for people that have previously been denied treatment. However, these ambitions are unlikely to be realised if current levels of provision do not improve.
The most important recommendation within the new guideline is the need to provide three full cycles of IVF to those who require it. The fact that NICE has reiterated this recommendation in its latest version of the guideline is important, as it is the one that impacts access the most.
The provision of three cycles has proven to be cost-effective by NICE on two separate occasions, once in 2004 and now again in 2013. Yet almost a decade after the publication of the original guideline, IVF continues to be routinely rationed.
In 2011, the All Party Parliamentary Group on Infertility published a report detailing levels of provision throughout the country. It found that over 70 percent of NHS Primary Care Trusts (PCTs) were not providing the recommended three cycles of IVF to eligible couples. To make matters worse, a number of PCTs began implementing strict access criteria in order to limit the number of referrals to clinics.
These criteria dramatically decrease the chances of treating infertility successfully. Some couples produce more viable embryos than others, so those that produce a small number are immediately placed at a disadvantage if they are not allowed to have more than one or even two cycles of IVF treatment.
In little over a month, local GP-led Clinical Commissioning Groups will take over from PCTs, which shall be abolished. By handing over the purse strings to GPs and other health professionals, the Government hopes to reduce variation – the theory being that clinicians are more in touch with the needs of their local population - thus they will be able to budget accordingly.
Whilst at first glance this appears logical, there is a very real and imminent danger that fertility services could be subject to disinvestment. Lack of information in this area of commissioning has in the past contributed towards to a lack of interest at the level of PCT commissioners. If this knowledge gap is not addressed urgently, there is a danger that fertility services could become marginalised in the new system.
In 2011, the National Infertility Awareness Campaign (NIAC) conducted a survey of patients undergoing fertility treatment. Although more than half of GPs were perceived to hold the necessary information on infertility and the treatment options available, a significant number still lacked this vital knowledge.
As the 'gatekeepers' of NHS services, it is essential that GPs are well informed when it comes to the causes of, and treatments available for, infertility. GPs will play a leading role on CCG governing boards and will be expected to commission a number of services of which fertility will be just one. They will be directly responsible for managing around 60 percent of the total NHS budget, which they must ensure covers the health needs of their entire local population. Consequently, commissioners will be placed under enormous pressure to allocate funding appropriately.
If fertility services are to survive this prioritisation process and if NICE's new guideline is to be prevented from suffering the same fate as its predecessor - that is, to be an excellent guideline that is only partly recognised - then the benefits of providing fertility treatment need to be adequately represented by policy makers in Government and the NHS.
In the last two years we have heard brief statements of support from the current Prime Minister and the Deputy Chief Executive of the NHS, however these have been very much isolated incidents amidst a wider culture of complacency. The previous Labour Government endorsed the 2004 NICE guideline and its recommendation of three full cycles of IVF to eligible couples. For the sake of all those currently undergoing or wishing to undergo fertility treatment, this author sincerely hopes that the Coalition Government does the same with NICE's latest clinical guideline.