New NICE guidelines for NHS fertility treatment
New standards set out for treating fertility problems dominate the health news.
The coverage is based on updated infertility guidance from the National Institute for Health and Clinical Excellence (NICE). While these guidelines are wide-ranging, the media’s coverage focuses largely on recommendations that:
- NHS-funded IVF should now be offered up to the age of 42 (in certain circumstances) – the current IVF age limit is 39
- couples having difficulty conceiving should be offered treatment after two years of regular unprotected intercourse, instead of the current three
- same sex couples should be offered NHS fertility treatment
NICE says there is a need for new guidelines to reflect the medical advances which mean fertility problems (particularly in older women) can be treated more effectively.
Other recommendations say that women under the age of 37 should only have one embryo transferred in their first cycle of IVF. This is intended to reduce the number of multiple pregnancies arising from IVF, which can result in complications for both mother and child.
Most couples would no longer be offered intrauterine insemination, as NICE says the results are no better than those for sexual intercourse. An exception to this is if there are circumstances where vaginal intercourse would not be appropriate or possible.
NICE guidelines are considered best practice and are based on the best available evidence. Local NHS organisations should follow the recommendations.
What are the new NICE recommendations on infertility?
The updated NICE guidelines have been published following an extensive consultation on draft guidelines issued in May 2012. The new guidelines set out many recommendations, the most high profile of which are outlined below.
IVF
NICE now recommends that women aged under 40 who have been unable to conceive after two years of regular unprotected intercourse (or 12 cycles of artificial insemination (IUI), in which semen is introduced into the woman’s vagina), should be offered three full cycles of IVF. These IVF cycles can be either with or without intra-cytoplasmic sperm injection (ICSI), a technique in which a single sperm is injected into the egg. If the woman reaches the age of 40 during treatment, the current full cycle should be completed, but no further cycles offered. This is one year earlier than was previously recommended.
Women aged 40-42 years who have been unable to conceive after two years of regular unprotected intercourse (or 12 cycles of artificial insemination) should now be offered one full cycle of IVF, with or without ICSI. However, NICE recommends they must also:
- have never previously had IVF treatment
- show no evidence of low ovarian reserve (this is when eggs in the ovary are impaired or low in number)
- have been informed of the additional implications of IVF and pregnancy at this age
Previously, NICE did not recommend IVF for women over 39.
Ovarian stimulation
Women with unexplained infertility (where the cause of the problem is not known) should not be offered drugs which stimulate the ovaries (such as clomifene citrate, anastrozole or letrozole), as these drugs are now thought to be an ineffective treatment for the problem.
Intrauterine insemination
Couples with unexplained infertility, women with mild endometriosis, or men who have ‘mild male infertility’, should normally attempt to conceive through regular vaginal intercourse for two years rather than receive intrauterine insemination. NICE says this is because new evidence shows that it is no better at achieving a live birth than people attempting to conceive through regular vaginal intercourse.
However, intrauterine insemination may still be suitable in certain circumstances where vaginal intercourse would not be suitable or appropriate, for example:
- people who are unable to, or would find it very difficult to, have vaginal intercourse because of a clinically diagnosed physical disability or psychosexual problem, who are using partner or donor sperm
- people with conditions requiring specific consideration in relation to methods of conception (for example, where the man is HIV positive)
- people in same-sex relationships
Embryo transfers
The NICE guidelines also include new recommendations on the number of fresh or frozen embryos that should be transferred to a woman’s womb, these are designed to reduce the risk of multiple births following IVF. The recommendations state that:
- Women under 37 in their first IVF cycle should have only a single embryo transfer. In their second IVF cycle they should have a single embryo transfer if one or more top-quality embryos are available (embryo quality is assessed using a number of factors that point to the likelihood of an embryo leading to a successful pregnancy, such as the amount of cells in the embryo). Doctors should only consider using two embryos if no top-quality embryos are available. In the third IVF cycle, no more than two embryos should be transferred.
- Women aged 37–39 years in the first and second full IVF cycles should also have single embryo transfer if there are one or more top-quality embryos, and double embryo transfer should only be considered if there are no top-quality embryos. In the third cycle, no more than two embryos should be transferred.
- For women aged 40-42 years, double embryo transfer can be considered.
How have these fertility guidelines been received in the media?
The new guidelines were widely reported in the papers, although not always in a fair and balanced way. The Daily Mail’s headline inaccurately claims that, “lesbians will get IVF on the taxpayer”. The guidelines actually recommend that intrauterine insemination should be offered to women in same-sex relationships. Intrauterine insemination is an entirely different fertility treatment to IVF. After six unsuccessful cycles of IUI, the NICE guidance says that all women (regardless of sexual orientation and relationship status) should be eligible for IVF.
The Daily Mail also conflates its reporting of the new guidelines with a claim that “Five thousand fatherless children have been born to lesbian couples and single mothers following fertility treatment in the past decade”. This appears to be based on figures from the Human Fertilisation and Embryology Authority. The paper did not report on any other recommendations by NICE.
The BBC and The Guardian concentrate on the new recommendations that IVF be given sooner and to older women, while The Independent reports that women under 37 will not be permitted to try for twins at their first attempt at IVF. This is a slightly flippant response, as the main reason why double embryo transfer is sometimes used is to try to increase the chance of a having a single successful pregnancy (reducing risk to mother and unborn baby), not to ‘try for twins’.
However, as multiple pregnancy is also a possibility when more than one embryo is transferred – and multiple pregnancies carry higher health risks than single pregnancies – that is why single transfer is preferred when possible.
Independent experts have welcomed the new guidelines, but have argued that current provision of NHS-funded fertility treatments varies widely between areas, depending on budgetary pressures and the advice of medical experts in each local NHS organisation. There is the risk that local restrictions on NHS spending – in spite of NICE guidelines – may mean that they remain something of a ‘wish list’ for many.
