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31 Jan 2007 : Column 106WH—continued
NICE published a set of national guidelines in February 2004, which recommended that the national health service should provide three free cycles of IVF treatment for suitable patients in England and Wales. The then Secretary of State responded positively to the guidelines and as an intermediate step stated that all patients meeting the eligibility criteria established by NICE should be offered one cycle of treatment funded by the NHS by April 2005.
The longer-term aim was full implementation of the NICE guidelines that recommended three cycles of treatment for each appropriate patient. In February 2004 the Prime Minister told the House:
“We hope that over the next couple of years we shall see at least very substantial progress towards implementation of the full NICE guidelines, and that they will allow us to end the current postcode lottery”. —[Official Report, 25 February 2004; Vol. 418, c. 278.]
Those were the Prime Minister’s words, not mine.
It is three years since those statements and so it is worth standing back and taking a look at where we are today. I have had a long-term interest in this subject and in 2005 I conducted my own survey by writing to primary care trusts and asking a few fairly simple questions. I had a good response, but unfortunately the results did not provide happy reading. The majority of primary care trusts were, at that time, unconfident about being able to offer more than one cycle of IVF by April 2006. Two thirds of trusts were taking no steps to offer more cycles, and eight out of 10 trusts offered only one cycle. Some 82 per cent. of trusts cited funding as the major barrier to providing more cycles, yet that was despite an increase in the IVF budget in 72 per cent. of primary care trusts. Some 60 per cent. of trusts had a waiting time of more than a year and one in 10 had a waiting time of more than two and a half years. One PCT stated that some couples had been waiting seven years for treatment. It was also clear that many trusts had added their own criteria that further diluted the NICE guidelines. One of the concerns often raised is that criteria are often social criteria, which almost suggests a degree of social engineering that varies around the country.
Anyone who has listened to “The Archers” recently will know that Hayley is being denied the opportunity to have a baby of her own because she has married Roy, who is the father of Kate’s child. I do not intend to go into the relationships of the characters in “The Archers” and who has slept with who over the years, but, basically, Hayley was denied treatment because she is in a relationship where there is a child. It is not her child; it is another woman’s child.
Mr. Andrew Lansley (South Cambridgeshire) (Con): I know the hon. Lady will recall the debate in Westminster Hall initiated by the right hon. Member for Rother Valley (Mr. Barron) in 2005. He asked a good question: why did the then Secretary of State in 2004 add the criterion that priority should be given to couples where there were no living children? That is a social criterion and was not in the NICE guidelines. The Secretary of State added it and many PCTs are now adopting that, including my own. We have never been able to find out why the Department of Health and the Secretary of State chose to put that criterion in.
Sandra Gidley: The hon. Gentleman makes an extremely good point. He is absolutely right; there has been no explanation as to why that was added when it was not in the initial guidelines. I suspect that that has sent the signal to PCTs that they can add further restrictive social criteria. I am sure that all hon. Members would be interested to hear from the Minister why that guideline exists.
I will not labour the point about “The Archers”, but it was interesting that Hayley’s doctor sounded like Lord Winston from the other place. I am glad to see that he is providing NHS services up and down the country. That is what soap operas are made of, but this is a real problem affecting real couples up and down the land.
There are other criterion to the one already mentioned. In Thames valley, doctors only offer treatment to patients who are between the ages of 36 and 40. By that time the fertility of an average woman will usually have declined by half compared with their fertility at the age of 30. Health officials have defended that by claiming that younger women have more options available, for example, they may be able to adopt or they have more time to overcome fertility problems naturally. However, others have said that such a selection process penalises women who may have had a greater chance of success with IVF if treated at a younger age.
For those who doubt the robustness of Lib Dem research, NICE conducted a survey in October 2005, which found that the vast majority of PCTs—94.5( )per cent.—had defined their own eligibility criteria . Some 80 per cent. of those responded that their criteria were stricter than those proposed by NICE. Just over 60 per cent. of trusts were offering one cycle. NICE had slightly better results in that it found that a further third were offering two cycles, but not one trust was, at that time, offering three cycles, and one county was not funding any cycles of IVF at all. Since that survey was conducted, some trusts have temporarily put IVF programmes on hold.
NICE also asked about the timetable for implementation of the guidelines. Fewer than 10 per cent. said that that would be within a year. Even more worrying, nearly a quarter of trusts said that there was simply no time line.
The British Fertility Society recently conducted a survey of IVF providers. There was an increase in the number of NHS-funded cycles, but in some areas there is still only a token gesture towards implementation. The society also discovered that there was no clarity over the definition of what constituted a funded cycle. NICE says that that should include ovarian stimulation and the replacement of fresh embryos and the subsequent replacement of frozen-thawed embryos generated by the ovarian stimulation episode. There is no consistency in the application of that definition by funding commissioners.
Although short-term financial pressures are clearly affecting decisions, I also suggest that this could be a time for joined-up government. Research by Professor William Ledger at the university of Sheffield shows that free fertility treatment could boost the economy. He says:
“The costs of IVF are in fact trivial and truly insignificant compared with the huge amount that the child gives back to society, including financially in terms of taxes paid.”
Research by the RAND institute suggests that a case can be made for including fertility treatment as part of a “population policy mix” aimed at increasing fertility rates.
I do not have the advantage of an in-depth cost-benefit analysis, but it would be useful if the Minister, in summing up the debate, informed us whether such work is being undertaken, because if the long-term financial benefits were proved, there would possibly be a case for a separate pot of money, ring-fenced for the prime purpose of boosting fertility. It would not necessarily have to come out of existing health budgets.
The National Infertility Awareness Campaign has been campaigning on these issues for some time. It has raised concerns about a recent recommendation, made by an independent expert group set up by the Human Fertilisation and Embryology Authority, that reducing the number of embryos transferred from two to one for some women could reduce the number of multiple births. That process is known as single embryo transfer. It is true that the increased incidence of multiple births has a long-term impact on the health service, as twins are often born prematurely and with a lower birth weight and are linked to a significant risk of post-natal death. Twins are also at a higher risk of long-term problems such as cerebral palsy. If triplets are put into the equation, the risk is even higher; it is 16 times greater.
The expert group concluded that
“the failure to implement the NICE guideline on fertility (3 cycles) is the major obstacle to the acceptance by NICE and clinicians of introducing Single embryo transfer policies in the UK.”
The National Infertility Awareness Campaign has pointed out that the cost savings that could be achieved in neonatal care as a result of such a move towards the NICE guidelines could be invested in funding more infertility treatment. In other words, single embryo transfer must be introduced at the same time as the number of cycles is increased. Otherwise, if women think that they have only one chance, they will want to maximise their chances.
There are wider issues relating to infertility. Some women are unable to conceive due to blocked fallopian tubes. In some cases, that is a direct result of an infection such as chlamydia. A report by the Select Committee on Health in 2002 highlighted the inadequacies of current sexual health education. More should be done to get some of these messages across to people at a younger age. At a time when women are concerned about preventing a baby, they may take oral contraceptives and not think too much about the possibility of contracting chlamydia or another infection. Chlamydia is often symptomless in women and, despite the availability of testing, is often undetected. When a woman decides that the time is right to start her family, the damage has often been done. I would like to ask the Minister whether she has any plans to ensure that young women are more aware of that potential problem.
Obesity and anorexia also have an impact on fertility. Women with anorexia often find that their menstrual cycles are completely disrupted and sometimes there is a long-term impact. A person with a body mass index outside the range of 19 to 30 is likely to have greater difficulty in conceiving, with or without some form of assisted technology. Again, if more is done to tackle the problem of obesity, there will be benefits in the long term.
The messages are slightly misplaced, although accurate. We often say, for example, “We must tackle the problem of childhood obesity because diabetes is on the increase.” I suggest that most young children who overeat do not really think of themselves as diabetic or not; that is simply not something on their horizon. However, if they thought that their long-term fertility might be affected, that might be a more powerful incentive to try to get their weight under control.
It is not appropriate to highlight individual cases, but as more and more couples are forced to access private care, there is a great need to ensure that the private provision of infertility services is properly regulated. A recent “Panorama” programme attracted attention. I do not want to dwell on that problem, because it centred on a specific clinic and I feel that there is a far bigger scandal than anything that one individual doctor may or may not have been doing.
The scandal is that although this subject was debated in Westminster Hall just over two years ago, there seems to have been little or no progress. It is a scandal that the Government have made no further progress in asking primary care trusts to implement NICE guidelines. It is a scandal that a blind eye is turned to the actions that PCTs take to avoid implementing the guidelines that exist. I hope that the Minister will commit today to ending that scandal here and now by acting to resolve the problems that blight the lives of many.
2.47 pm
Dr. Ian Gibson (Norwich, North) (Lab): It is a pleasure to speak under your tutelage again, Mr. Cook. I am delighted to follow the hon. Member for Romsey (Sandra Gidley), who is the major speaker here on this subject. I want to make one or two general comments and then talk about a conference that I went to before Christmas in London—it was the first of its kind—that opened a way up for improvements in IVF treatment and which gives us the chance to do much more to help people to have the children that they obviously desire to have.
I am supported in what I am about to say by Geeta Nargund, who is the head of the reproductive medicine unit at St. George’s hospital and the chief executive of the Health Education Research Trust, which is a women’s health foundation. It is an innovative charity that aims to change the lives of women across the world. It was founded specifically to focus on women’s reproductive health from puberty to menopause. It is empowering, proactive and holistic. I think that this country is leading the way forward in this regard, and I shall say more about that in a moment.
One in six couples in the United Kingdom has fertility problems, so for every 250,000 of population there is a need for about 250 assisted conception cycles per year.
There is a true rise in infertility in this country and across the world. That might be about the age of the woman: women are putting off having children until later in life. As an individual ages, the cells and so on change, and there is less propensity for having a child. We have heard about sexually transmitted conditions such as chlamydia and about obesity, but we have not heard about sperm counts, which are going down quite dramatically in parts of the world. We have to realise that environmental factors may be involved in that. All those issues play into difficulties in conceiving. There are other major factors, of course, such as tubal damage. In many instances, we cannot explain infertility. There is also male factor infertility and so on.
I want to make the point early on that the increased demand for IVF in this country is partly due to the fact that we now have more cancer survivors who would like to have children following their medical and surgical treatments for cancer. Cancer is becoming a chronic condition, so young people who are going through chemotherapy and radiotherapy are asking for technology to help them to look after their eggs—I am afraid that we are into the frozen gamete area here—so that later in life, as they recover and become healthy, they are able to have children. That has become quite a common practice in parts of the country, and it will certainly be a demand not only from patients groups but from individuals. The demand for egg donation will increase because ovarian function ceases after certain chemotherapies and radiotherapies for lymphomas and other tumours.
I do not want to say too much about the population decline in this country and the birth rate, but there is concern that the birth rate is a mere 1.66 per woman, which is below that of our European partners. The arguments about the need for future citizens in this country, and about having a young population and work force, loom large in political circles. I shall argue that national initiatives are urgently needed to prevent infertility in men and women, and for fertility protection.
Geeta Nargund and her team called a conference just before Christmas, on 15 and 16 December, at which I spoke. It was held at the Royal College of Obstetricians and Gynaecologists, and was called the First World Congress on Natural Cycle/Minimal Stimulation IVF. Without being too much of a clever dick, I shall keep technical words out of this and explain simply what the conference was all about and how we learned from other countries what they are doing.
The conference was hosted in London by Geeta and others, and some 55 countries were represented. During the two days of the conference, we examined the new research that is going on in IVF and discussed the best way forward for a new regime in the management of IVF. A new society—the International Society of Minimally Assisted Reproduction—was also set up, which will take forward, on a global level, IVF issues such as how to make IVF safer for women and children and affordable to all. IVF is expensive for many, but the new research shows that it is possible to do many more IVF cycles on the NHS than was previously possible.
There are simple treatments for infertility other than IVF. I shall not go into this in detail, but intra-uterine
insemination, for example, is still relevant in many cases. We need to ensure that IVF is simple, safer, affordable and successful. We have heard from the hon. Lady about ovarian suppression and stimulation, which were introduced 20 years ago. That process involves blocking ovulation so that more eggs are produced. There are then more embryos for transfer after they have been impregnated with sperm.
We have heard that single embryo transfer is on the agenda again to reduce multiple pregnancies. IVF babies are more likely to have a low birth weight and be premature even when they are singleton babies, so it does not help matters to have twins or triplets, which have an increased risk of having cerebral palsy. It is therefore important to reduce multiple births. The technology that I shall explain simply will enable that to happen. It stems from the interaction at the conference between different countries.
When women are given treatment to produce more eggs, they are often given hormones. The question is whether we are over-treating them with—let me use a few serious words—gonadotrophins and luteinising hormones. Those names will be familiar to some people in the Chamber. Are we overdosing people with those hormones either at that stage or when we fertilise in vitro? It was clear from the conference that experiments that have been conducted around the world show that we are overdoing it. What is the evidence? There is evidence that when there is hormonal stimulation, the early embryos—we can take samples and look at them—sustain chromosomal damage much more frequently than those produced without hormones. Some countries now say that we should minimise the use of hormones, or not use them at all.
In medicine, people get into habits because things have always been done in a certain way, so they think, “Why change it?” There is no doubt that there can be abnormal effects from overdosing with hormones. A lot of work is being done in that area.
Sandra Gidley: I have been in quite close contact with a number of women who have experienced hormone treatment. The effects on women’s lives are horrendous, but they go through the treatment because they are so desperate to have a baby. If, as the hon. Gentleman believes, those women could improve their fertility by some other means, I am sure that that news will be very welcome. For some of them, things have almost got to the stage of breaking up the marriage.
Dr. Gibson: It is true that women can be given minimal stimulation doses. I do not want to go into details about hormone dosages—just a little is needed, or none at all—but there are ways of carrying out the process without using the traditional technique that has been used for years. That knowledge is a result of the conference that was hosted in Britain.
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