Access to IVF Help us decide Discussion paper South Central Specialised Commissioning Group 1 South Central Specialised Commissioning Group FINAL DRAFT Access to IVF treatment Contents 1. Background……………………………………………………………………………………3 2. Developing a single policy for NHS South Central………………………………………..4 3. What local people have told us so far……………………………………………..............5 4. What changes are being proposed?...............................................................................6 The woman’s age How long has the couple been infertile? Storage of frozen embryos Previous infertility treatment Storing eggs and sperm 5. What are the other changes to the policy?....................................................................8 Donated eggs IVF using frozen embryos Intra-uterine insemination HIV infection and sperm washing Surgical sperm retrieval 6. How do I have my say?.................................................................................................9 7. How will the decision be taken?……………………………………………………………9 APPENDIX A: Feedback form………………………………………………………………10 APPENDIX B: Areas where the policy does not change………………………………….13 2 South Central Specialised Commissioning Group FINAL DRAFT Access to IVF treatment: help us decide 1. Background Trying for a baby Although most women fall pregnant within two years of trying for a baby, around 8% of couples are unsuccessful. This is called infertility. There are numerous reasons why couples don’t conceive within two years including a whole range of medical conditions in either the man or woman, the women’s age, obesity and/or lifestyle factors such as excessive smoking or drinking. There are a number of potential treatments for infertility including a range of drug treatments or surgery. However, some couples can only conceive via in-vitro fertilisation (IVF). IVF treatment IVF involves drug treatments, ultrasound-guided egg collection from the woman, mixing of eggs and sperm in the laboratory and implantation of a fertilised egg(s) into the woman’s womb. Any surplus embryo(s) can also be frozen for future use. NHS funding for IVF The South Central Specialised Commissioning Group (SCSCG) commissions IVF services on behalf of Hampshire PCT, Isle of Wight PCT, Southampton City PCT, Portsmouth City Teaching PCT, Berkshire East PCT, Berkshire West PCT, Milton Keynes PCT, Buckinghamshire PCT and Oxfordshire PCT. Each of these PCTs has finite resources to fund a whole range of health services and treatments. IVF is an expensive treatment which can often be unsuccessful. We need to balance funding for this treatment with the many other pressures on NHS funding by making sure that we offer IVF in the most effective way for people trying to have a baby. This is not straightforward – trying for a baby is an emotional time and there are a number of issues which influence the clinical and cost effectiveness of IVF. At the moment the policies for Hampshire and the Isle of Wight and Thames Valley (Berkshire, Buckinghamshire and Oxfordshire) are slightly different, so local people do not currently get the same access to IVF on the NHS. The cost of IVF One cycle of IVF costs on average £3,871. In 2007/2008, Hampshire and the Isle of Wight (including Portsmouth and Southampton) spent £503,000 on IVF and Thames Valley (Berkshire, Buckinghamshire, Milton Keynes and Oxfordshire) spent £688,000. Number of people in South Central receiving IVF treatment on the NHS The following table shows how many people received IVF funding on the NHS in the last two years. PCT 2007/8 2008/9 (estimate)* Hampshire 110 110 Isle of Wight 2 2 Portsmouth 7 8 Southampton 11 11 Berks East 56 42 Berkshire West 68 66 Buckingamshire 69 70 3 South Central Specialised Commissioning Group FINAL DRAFT Milton Keynes 12 28 Oxfordshire 84 96 *based on figure to end December 2008 NICE guidance In 2004 the National Institute for Clinical Excellence (NICE) produced guidance which said that: 1. Couples in which the woman is aged 23–39 years at the time of treatment and who have an identified cause for their fertility problems or who have infertility of at least three years’ duration should be offered up to three stimulated cycles of IVF treatment. 2. To balance the chance of a live birth and the risk of multiple pregnancy and its consequences, no more than two embryos should be transferred during any one cycle of in-vitro fertilisation treatment. If this guidance were to be funded across Oxfordshire, Berkshire, Buckinghamshire (including Milton Keynes) and Hampshire and the Isle of Wight (including Portsmouth and Southampton) it would cost the local NHS approximately £16million per year. 2. Developing a single policy for NHS South Central The South Central Specialised Commissioning Group has received many queries, comments, challenges, and appeals from patients, GPs, referring consultants and IVF providers concerning the polices currently in operation. We recognise that we need a single policy to make sure that everyone gets the same treatment across Hampshire, Isle of Wight, Berkshire, Buckinghamshire and Oxfordshire. Last year the Public Health Resource Unit Priorities Team was asked to review the existing policies and make recommendations to four Priority Committees in Oxfordshire, Berkshire, Buckinghamshire (including Milton Keynes) and Hampshire and the Isle of Wight (including Portsmouth and Southampton). Priorities Committees are groups of doctors, nurses, pharmacists, NHS commissioning staff and lay representatives who consider all the evidence on the clinical effectiveness of treatments and drugs and make recommendations about whether funding them is the best use of finite NHS resources. The four Priority Committees were asked to discuss and review the various options for IVF and assisted conception and develop recommendations for the whole of the area. The review has been focussed specifically upon the issues which have caused confusion or contention. The aim was to: • take into account the views of local people • maximise the effectiveness of the treatment • take account of national policy and guidance • maintain affordability for the local NHS • develop a consistent policy across NHS South Central 3. What have local people have told us so far? The issues which have caused confusion or contention are set out below together with how the proposed changes address these. What you told us How we’ve listened Patients in the Thames Valley who have This is why we are proposing in the new 4 South Central Specialised Commissioning Group FINAL DRAFT previously funded their own IVF have told us policy that every couple will be entitled to one that we are unfairly excluding them from NHS cycle of NHS-funded IVF as long as they funding. Local GPs, gynaecologists and have not had more than two previous fresh infertility specialists have also said this is cycles, and meet the other eligibility criteria. unfair. A very large number of patients and The Committees considered clinical evidence clinicians have told us that the present which shows that IVF is more effective in eligible age range (currently 36-39 years in women under 35 years old and much less Hampshire and IOW and 35-38 years in effective in women over 40. They also took Thames Valley) is unfair and illogical. The into account the views of couples and the effectiveness, and consequently cost- recommendation is that IVF be available from effectiveness, of IVF falls rapidly from age 30-34 years inclusive. 35, as female fertility declines. Patients have There will be phased arrangements for told us that it is unreasonable for women to women born between April 1, 1972 and have to wait until they reach the age when March 31, 1976 provided treatment IVF is less likely to be successful before they commences by March 31, 2010 to ensure become eligible to start IVF. that those who were waiting until they were 35/36 years old to receive funding under the current policies are not excluded from treatment. Many couples where the woman is unable to We are proposing to that egg donation produce eggs have asked us to fund IVF should be funded under the new policy. using donor eggs. In most cases this has been agreed, but the existing assisted conception policies do not address the issue of egg donation. Many patients about to undergo clinical In the light of the evidence we are proposing treatments likely to make them infertile that we should fund sperm storage where the (particularly cancer treatments) have told us circumstances make this appropriate, but that they want sperm storage or egg storage. that egg and ovarian tissue storage are still Because of this we have looked very experimental treatments with low success carefully at the research evidence. rates and should not be funded until there is more evidence to support them. We are proposing that we continue to consider requests for IVF and embryo storage on an individual basis, taking full account of the circumstances in each case. We have received many queries and We have considered these comments very comments concerning whether frozen cycles carefully. In the end, we have proposed that will be funded, and whether previous frozen in the interests of fairness the first priority cycles will affect couples’ eligibility for NHS- should be to extend the eligible age range, funded IVF. Patients have told us that using before funding second, frozen cycles for any frozen embryos before starting a further women aged 30-34. However, we are fresh cycle of IVF should not be allowed to proposing to offer to fund freezing and affect their eligibility for an NHS-funded cycle storage of surplus embryos for up to three of IVF. Patients have also told us that the years, so that couples have the option to self- NHS should fund the transfer of any stored fund future, frozen cycles if they wish to do frozen embryos as a result of their NHS- so. funded fresh cycle of IVF. Some couples have asked us to fund sperm We looked at the research evidence for this, 5 South Central Specialised Commissioning Group FINAL DRAFT washing and IVF to reduce the risk of and concluded that there was insufficient transmission of viruses such as HIV and evidence to support it.