The Policy on Fertility Services - Cheshire, Merseyside
& West Lancashire PCTs
BCP Policy Number: 2009007
Version No : 3 Number of pages : 14
Date of Issue : 2006 - 2009
Date of Next Review: April 2013
Date of Authorisation : 17th June
Equality Impact Assessment under
process
Post Responsible for Review:
Author: Cheshire & Merseyside and
West Lancashire PCT
Bespoke Care Manager
Authorised by : PEC
Distribution : CECPCT Intranet Site
Target Audience: Bespoke Care, NHS Trust, Patients
Description: The Policy on Fertility Service
PLEASE NOTE: Check that this document is the most current version of this
policy – you will find it on the PCT Intranet
2009007 - The Policy on Fertility Services Rev 3
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Version Control Sheet
Version
Date
Author
Status
Comment
2006-
C & M and W.
For approval PEC Board
1
For Approval
2009
Lancashire PCT
17.06.09
C & M and W.
Approved 17th June 09 PEC
2
17.06.09
Approved
Lancashire PCT
Board Meeting
3
04.11.11 C & M and W.
Continuance –
BCIG recommended
Lancashire PCT awaiting
continuance during transition. To
ratification by
be ratified by Commissioning
Commissioning
Executive
Executive
2009007 - The Policy on Fertility Services Rev 3
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2006 - 2009
The Policy on Fertility Services
Cheshire, Merseyside
and West Lancashire
Primary Care Trusts
2009007 - The Policy on Fertility Services Rev 3
3 of 14 06/03/2012
Contents
Page
1
Introduction ............................................................................................................. 3
2
General principles ................................................................................................. 4
3
Routine access to services
3.1 Investigations ......................................................................................................... 4
3.2 Fertility treatments ................................................................................................ 5
3.3 Reversal of sterilisation and treatment
following reversal of sterilisation ............................................................................... 6
4
Fertility treatments in detail .............................................................................. 7
5
Access to services for single people
and those in same sex partnerships ................................................................ 9
6
Practice in hospitals and clinics delivering fertility services ................ 10
7
Further copies ........................................................................................................ 11
Document Purpose
Action
Title
The Policy on Fertility Services
Cheshire and Merseyside Specialised Services
Author
Commissioning Team
Tel: 01244 650307
Email: www.cmssct.nhs.uk
Publication Date
5 April 2006
PCT CEs, PCT PEC Chairs, Hospital Fertility Clinicians,
Target Audience
Directors of Commissioning, Directors of Public Health,
NHS and Foundation Trust CEs, Medical Directors,
General Practitioners, Service Users.
This document sets out the policy on access to fertility
services for the residents of the Cheshire, Merseyside
Description
and West Lancashire PCTs wherever they receive
treatment. It also covers the types of assessments,
investigations and treatments that will be
commissioned for the residents of the above PCTs.
Cross Ref
N/A
Superseded Documents
All individual PCT policies on fertility treatments prior
to 1 April 2006.
Action Required
Adherence to this policy except in exceptional
circumstances in which instant referral should be made
to the Exceptional Case Provision of the respective PCT.
Timing
With effect from 1 April 2006.
For Further Copies
These can be obtained from your Commissioning Lead
at your local Primary Care Trust or direct from
Dimension Creative Limited.
For Recipient Use
2
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Introduction
1
This Policy describes in detail how NHS Fertility Services should operate for the people
who live in Cheshire, Merseyside and West Lancashire regardless of where they have
treatment. It includes the latest guidance on good practice 1 to make sure people receive
the most effective forms of treatment. Following this Policy is the way we prioritise
patients for treatment.
Family doctors, hospital specialists who provide fertility services, and those who plan
fertility services in the Primary Care Trusts (PCTs) use this document. Because of this,
it contains some very technical details.
However, because it is just as important that people who have fertility problems are able
to use the document too, we have added a short explanation beside each section. This
has been written for the general reader without specialist knowledge.
The Policy describes the circumstances in which Cheshire, Merseyside and West
Lancashire PCTs will fund fertility treatment and the type of treatments that will be
available. It takes the form of conditions under which the NHS will fund treatment
routinely.
The PCTs are committed to improving fertility services over the coming years. However,
currently, local services vary and so it will take time for some changes to come into effect.
In general these differences relate to the most complex fertility treatments. As individual
PCT positions will change over time, details of the current situation for residents of a PCT
can be found by contacting the Commissioning Department of that PCT.
1 National Institute for Health and Clinical Excellence:
Fertility, assessment and treatment for people with
fertility problems Feb.2004. www.nice.org.uk
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General Principles
2
We will fund investigations and treatment for sub-fertility
that follow Clinical Guideline 11 from the National Institute
IN PLAIN ENGLISH WE MEAN
for Health and Clinical Excellence (NICE). We expect that
We want our residents to be treated according to the
management of those with fertility problems in primary,
good practice guidance produced by the National
secondary and tertiary care will be in line with the clinical
Institute for Health and Clinical Excellence (NICE). This
practice algorithm contained in this guidance.
will make sure the advice, investigations and treatments
We realise that clinical guidance does not override the
people receive will give them their best chance of having
responsibilities of professionals involved in managing
a child. However, occasionally a doctor may feel that it is
people with fertility problems. There may be instances in
in the best interest of a patient to have treatment that is
which the circumstances of any individual patient may
different to the guidelines. If this is the case, the doctor
suggest to the clinician that to manage the case
can contact us to discuss the matter and agree on a
appropriately, they need to make an exception to this
course of action that is best for the patient.
advice. In this case, it is the responsibility of the clinician to
discuss the situation with the commissioning body prior to
taking any action.
3
Routine Access to Services
3.1 Investigations
IN PLAIN ENGLISH WE MEAN
There is no restriction on access to investigations for fertility
problems. However, fertility treatments, which are subject
Anyone who has fertility problems can be referred to a
to access criteria, are described in the next section.
hospital specialist for investigations of their problems.
However, there are restrictions on who can routinely
The access criteria do not apply to:
receive NHS funding for treatment. These restrictions are
in the next section.
The primary treatment of conditions found during
investigation (e.g. ablation of endometrial tissue found
These restrictions will not
at laparoscopy).
Apply to people who have any investigations for fertility
Changes to treatment regimes of pre-existing
problems (these will still be available to everyone).
pathological conditions that reduce fertility, in order to
Prevent doctors who treat people who have other
maximise existing fertility.
medical problems that make it more difficult for them
The use of assisted conception techniques for reasons
to conceive from changing their treatment, or the
other than to treat sub-fertility (for example, as part of
medicines they take, if there is a possibility that those
a screening process to exclude inherited abnormalities,
changes might improve the chances of natural conception.
as in pre-implantation genetic diagnosis).
Apply to people who are using the fertility medicines or
treatments for another reason. For example, in some
families with very serious inherited diseases, IVF
techniques are used to screen embryos to try to avoid
the family having a child affected by that serious disease.
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Routine Access to Services
3
3.2 Fertility Treatments
IN PLAIN ENGLISH WE MEAN
Funding for sub-fertility treatment will be available if a couple
does not have a living child from their relationship nor any
The aim of NHS-funded fertility treatment is to help
those who want to have a family life that includes a child
previous relationship. A child adopted by the couple, or
to do so if possible. Given the limited resources available
adopted in a previous relationship, is considered to have the
within the NHS, in common with other areas of the
same status as a biological child.
country, we consider that it would not be appropriate
Very rarely, those who would not be eligible for treatment
for the treatments to be routinely available to all
because they do not meet this criterion may, because of their
couples. Following the results of a public consultation on
personal circumstances, receive NHS-funded treatment. This
this, priority will be given to people who are childless.
would take place after consideration of those circumstances
In the case of couples, this means that both partners
within the procedure the PCT has for funding exceptional
would have no living children.
cases. If such circumstances are thought to exist, the patient
or their general practitioner should contact the relevant PCT
Health policies like this one are written to describe how
services will work for most people who use them.
to discuss how an application might be made. There is
Occasionally, people who want fertility treatment may
separate guidance on this, please refer to Applying for
have such unusual personal circumstances that their PCT
Consideration for Exceptional Case Status.
would be willing to fund their fertility treatment even
though they would not normally be eligible for NHS
treatment. If you think that this might be the case for
you, although you can apply to the PCT directly yourself,
it is always helpful to discuss this with your hospital
specialist or GP. They will be able to discuss the situation
and advise you whether NHS treatment might be
available. Most commonly, your GP or specialist will
contact the local PCT on your behalf.
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Routine Access to Services
3
3.3 Reversal of sterilisation
and treatment following
IN PLAIN ENGLISH WE MEAN
reversal of sterilisation
Sterilisation is offered within the NHS as an irreversible
Fertility treatment will be available as long as the sub-
method of contraception. At the time someone is
fertility is not the result of a sterilisation procedure in either
considering sterilisation they are asked to confirm that
partner. The surgical reversal of either male or female
they do not want to have any more children under any
sterilisation will only be funded in exceptional
circumstances. Most requests to reverse sterilisation
circumstances.
are because someone has a new partner 2, 3, 4, 5.
In cases in which sub-fertility remains after a reversal of
We consider that it is not appropriate to use NHS funds
sterilisation, funding will only be available in exceptional
to reverse sterilisation unless there are exceptional
circumstances. If the individual's situation is thought to
circumstances.
justify consideration, the patient's GP should contact the
The chances of conception after reversing sterilisation
relevant PCT to discuss how an application may be made.
depend on a number of factors. We believe that the NHS
There is separate guidance on Applying Consideration for
should not routinely fund these procedures, so we also
Exceptional Case Status.
believe that if a person has had a sterilisation reversed
and there are still problems conceiving, we should only
fund further fertility treatment if there are exceptional
circumstances.
As before, this part of the policy describes how services
will run for most people who use them. If you feel you
have such unusual personal circumstances that your PCT
might be willing to fund your treatment, you can discuss
the matter with your GP or hospital specialist or you can
contact the PCT directly yourself.
2 Cahill DJ Wardle PG Coulson C Harris S Ford WCL Hull MGR Reversing vasectomy (letter) BMJ 1992 305 52
3 Wright GM Cato A Webb DR Microsurgical vasovasotomy in military personnel Aust. N.Z. Surg 1995 Jan; 65 (1): 20-6
4 Calvert J.P. Reversal of female sterilisation Br. J. Hosp. Med 1995 53 (6) 267-270
5 Wilcox LS, Chu SY, Eaker ED, Zeger SL, Peterson HB. Risk factors for regret after tubal sterilisation: 5 years of follow up in a prospective study. Fertil Steril 1991; 55 927-33
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Fertility Treatments in Detail
4
Treatment for sub-fertility will be funded for those that
have been attempting to conceive for at least 24 months 6.
IN PLAIN ENGLISH WE MEAN
This criterion should not be applied in circumstances in
which there is a diagnosed condition or congenital
The likelihood of people becoming pregnant increases with
the length of time they have been trying to conceive. In
abnormality that would make natural conception
people trying to have a child:
impossible or extremely unlikely, or if there is other relevant
clinical information.
After trying for one year it is likely that 16% of couples
will not have conceived
After two years of trying, only 4% are likely to still not
have conceived
After three years, only 1% will not have conceived 7 , 8
Because it is not a sensible use of NHS resources to
treat
people who are likely to conceive naturally, we ask people to
try to conceive for at least two years before starting
treatment.
Obviously there are some people who will not be able to
conceive naturally because of a medical problem or because
of a condition they have had since birth. These people will
not have to wait for two years.
There may be times when other clinical information will
mean that people may receive treatment after trying to
conceive for less than two years.
Pharmacological ovulation induction will be funded if the
Drugs can be used to stimulate a woman's ovaries to
menstrual follicle stimulating hormone (day 3 FSH) level is
less than 13iu/L 9. The number of cycles that may be given
produce eggs. Measuring the level of a hormone (FSH) at a
should keep to current clinical guidance for the agent to be
specific point in the woman's cycle shows how well her
used. The requirement for follicular tracking during
ovaries are likely to respond to this treatment. High levels of
ovulation stimulation means that this treatment should not
this hormone are associated with a strong probability that
be undertaken in primary care settings unless there are
she will not respond well to treatment.
formal shared care arrangements in place.
We will provide funding for cycles of IVF, ICSI or IUI
The likelihood of having a child following the more
(including DI) if the cycle will begin before the female
complicated fertility treatments (IUI, IVF and ICSI) depends
partner has reached the age of 40.
on how old the woman is when she has treatment. As part
of the natural ageing process, women become less fertile as
they get older and if they do become pregnant, they are
more likely than younger women to have a miscarriage.
The Human Fertilisation and Embryology Authority (HFEA)
publish information on the number of children born as a
result of the most complicated treatments. Their most recent
figures suggest that in women aged over 40 having a cycle
of IVF treatment, between 6% and 7% would have a child
as a result of the treatment. The situation is very different for
younger women. For example, in women aged between 31
6 Defined as unprotected intercourse at least three times a month.
and 36, it is likely that between 20% and 21% would have
7 National Institute for Clinical Excellence Fertility; assessment and treatment
a child following a cycle of treatment. We will follow the
for people with fertility problems page 7 February 2004.
www.nice.org.uk
NICE guidance and make sure we spend NHS resources on
8 Effective Health Care. The management of subfertility. Effective Health Care
Bulletin 1992 3 13 University of York.
those most likely to have successful treatment.
9 Gurgan T, Urman B, Yarali H, Duran H.E. Follicle stimulating hormone levels on
cycle day three to predict ovarian response in women undergoing controlled
ovarian stimulation for in vitro fertilisation using a flare-up protocol.
Fert.- Steril.1997 68 483 - 487.
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Fertility Treatments in Detail
4
We plan to phase in the guidance given by NICE on the
number of cycles of IVF or ICSI funded by the NHS.
IN PLAIN ENGLISH WE MEAN
Consequently, currently two cycles of IVF or ICSI10 10 are
Most people who have a child after IVF or ICSI treatment
funded for women aged under 40 years at the time of
need one or two cycles of treatment. The NICE guidance
treatment.
suggests that over the first three cycles of treatment, the
likelihood of having a child is the same. The success rate
We will take account of any treatments received previously,
of further cycles of treatment is uncertain. They have
whether these treatments were funded by the NHS or
suggested that the NHS should offer up to three cycles.
privately, when deciding the number of cycles a couple may
In Cheshire and Merseyside we offer two cycles of
receive. This will mean the woman will not receive more
IVF/ICSI treatment. We need to change many aspect
than a total of three IVF/ICSI cycles. If a cycle of treatment
of our fertility services and because we already offer
results in a live birth, the only further treatment funded by
more cycles of IVF/ICSI than many other areas of the
the NHS will be embryo replacement.
country, we have decided not to increase the number
of cycles available straight away. However, we are
committed to offering an extra cycle as soon as possible.
The NICE guidance says that the success rate is the same
for the first three cycles of IVF. For further cycles, the
success is less certain. Because of this, we will fund
IVF treatment even if a patient has had some treatment
in another area or paid for it themselves, as long as
the total number of treatments is not more than three.
In practice this means that someone can have had one
cycle of treatment elsewhere and still have two cycles of
NHS treatment or two cycles elsewhere and one cycle
of NHS treatment.
Women who are not at their ideal body weight, either
underweight or overweight, are less likely to benefit
from fertility treatment 11, 12 . There is a weight range in
which the chance of success from treatment is highest.
We will provide funding for fertility treatment in women
whose body mass index is within the range 19 to 29.
We will fund fertility treatment for women within this
Women should be within this range at the point at which
range and encourage doctors and nurses to help and
they join any waiting list for treatment
advise women on how to lose or gain weight.
10 A cycle of treatment is defined beginning drug therapy to induce follicular development. If a cycle is abandoned for a cause unrelated to the fertility problem being treated,
we will ignore it for the purpose of fertility treatment.
11 Wittemer C, Ohl J, BaillyM, Bettahar-LebugleK. NisandI. Does body mass index of infertile women have an impact on IVF procedure and outcomes? J. Assist. Reprod. Genet
2000 17 547-552
12 Nichols JE, Crane MM, higdon HL, Miller, PB Boone WR Extremes of body mass index reduce in vitro fertilisation pregnancy rates. Fertil Steril 2003 79 645-647
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Access to Services for People not in
5
Parnerships and for Same Sex Couples
Funding will be available for sub-fertility treatment for
individuals not in a partnership or same-sex couples as long
IN PLAIN ENGLISH WE MEAN
as there is proven sub-fertility. In these people
In the case of a single individual or those in a same-sex
sub-fertility can be defined as no live birth following
relationship, deciding that someone has a fertility
insemination at or just before the known time of ovulation
problem can be more difficult than in a heterosexual
on at least 10 non-stimulated cycles or six cycles of clinically
couple. However, because we believe that NHS resources
delivered insemination or a fertility problem proven during
should be available to treat childless people with fertility
investigation.
problems, we have worked with fertility experts and
In the case of same-sex couples in which only one partner
members of the gay and lesbian community to create a
is sub-fertile, clinicians should discuss the possibility of the
definition that we can use in deciding on whether
other partner becoming the biological parent before
fertility problems are present.
carrying out interventions involving the sub-fertile partner.
NHS funding will not be available for access to insemination
facilities for fertile women who are not in a partnership or
are part of a same-sex partnership.
In circumstances in which individuals or those in a same-sex
partnership are eligible for sub-fertility treatments, the
other conditions for eligibility for sub-fertility treatments
will apply as well.
Individuals and same-sex couples should have access to
experts in reproductive medicine for advice on the options
available to them to allow them to make an informed
choice on those options.
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Practice in Hospitals and Clinics
6
Delivering Fertility Services
The Human Fertilisation and Embryology Authority (HFEA)
regulates, using a licensing system, any treatment that
IN PLAIN ENGLISH WE MEAN
involves creating, keeping and using human embryos
There is a code of practice that people working in
outside the body. Within the code of practice of the HFEA
fertility services must follow to keep within the law
are requirements for clinics to take account of the welfare
covering these services. All hospitals and clinics with
of individuals who want treatment and that of any child
which we have an agreement must provide fertility
who may be born or affected as a result of the treatment.
services that meet these requirements. Also, all those
All our hospitals and clinics providing fertility treatments
who provide fertility services must offer those services
must meet this requirement regardless of any eligibility
in keeping with the NICE guidance on how clinics should
criteria set by any PCT.
be set up and run.
We also ask that hospitals and clinics providing fertility
treatments keep to the National Institute for Clinical
Excellence clinical guidance on assessing and treating
people with fertility problems in terms of the principles of
care, presence of multidisciplinary teams and treatment
protocols of units.
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Further Copies
7
Further copies of this Policy can be obtained by contacting
the Commissioning Lead at your local Primary Care Trust.
Print supplier:
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Published by:
Cheshire & Merseyside Specialised Services Commissioning Team.
Should you require any additional copies of this or any other Fertility documents,
Cheshire, Merseyside
please contact the Commissioning Lead at your local Primary Care Trust.
Large print and alternative language versions are also available.
and West Lancashire
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