Why access to fertility treatment should be fair

Fairness and justice are two important principles in health care.

NHS England, have a page on their website titled: ‘Personal, fair and diverse health and care system’. They state that “services are personal, designed to give people what they want and need; fairness is built in – so that everyone has equal opportunities and treatment”.¹ So why when it comes to fertility treatment does the NHS fall short?

Funding for fertility treatment in the UK is grossly unfair and discrimination exists on many levels. Here are just a few examples:

Post code lottery
Data from Fertility Network UK’s 2021 audit of England’s clinical commissioning groups (CCGs) shows that fertility treatment is a complete postcode lottery. The majority of NHS CCGs ration access to NHS-funded fertility treatment.

For example, the North East fund up to three cycles of IVF treatment where as Basildon and Brentwood CCG do not fund any cycles².

Previous children
If a woman has had a previous child, then fertility treatment isn’t usually funded by the NHS. Many people think this is fair. However, I would ask them to apply the same logic to China’s one child policy, or ask if they believe younger siblings provide less value. In Israel, the state funds IVF treatment for multiple children, why not the UK?

Unfairness increases when looking at women whose partners have previously had a child. Just because a woman happens to fall in love with a man who has fathered a child previously, they are discriminated against by losing NHS funding.

I’ve seen many cases where a woman has lost her fertility due to previous cancer treatment, but because she wants a child with a father who has a child from a previous relationship they are not eligible for NHS funded treatment. To me this seems incredibly unfair.

Another example is Alex Davies-Jones, Labour MP for Pontypridd.

Obesity
Pregnancy is risker for women who are obese. Nonetheless, the NHS does not advise obese women to use contraception. Furthermore, fertility treatments are not particularly less effective for women with a BMI over 30. The American Society for Reproductive Medicine (ASRM) conclude that obesity should not be the sole criteria for denying a patient or couple access to infertility treatment. ³

“Obesity should not be the sole criteria for denying a patient or couple access to infertility treatment.”

American Society for Reproductive Medicine (ASRM)

Unfortunately in the UK, obesity is a key factors for rationing NHS funded fertility treatment.

Age
The National Institute for Health and Care Excellence recommend that women under 40 should be offered up to three cycles of IVF treatment. Women 40 or over should be offered one full cycle if they have a normal ovarian reserve. This recommendation is based on cost effectiveness.

Looking at the data this does not quite add up. One can argue that women over 40 should be offered more cycles as success rates are lower at this age group.

One treatment to hedge against age related decline in fertility is fertility preservation with egg freezing. This is not offered on the NHS unless they are to have treatment which will affect fertility, such as chemotherapy for breast cancer.

Gender
Lesbian women do not get funding for fertility treatment unless one of them has a proven fertility problem or they have not conceived after insemination treatment. Nevertheless, gay men do not get NHS funded treatment full stop. Interestingly, a woman with a trans man are entitled to funded treatment.

Arguments for fertility fairness

Some would argue that the NHS should not fund fertility treatments at all and often use the following arguments.

1. The world is already overpopulated
2. Having children is a lifestyle choice
3. Why not adopt?

The first argument is often used to suggest that more children is a burden to the planet and society as a whole. Nevertheless, evidence points to the contrary. Children born from fertility treatment are very much wanted children. Cost-effectiveness studies show that these children go on to be a huge benefit to society providing more in terms of taxes as they grow older. This makes this argument defunct.

Secondly the lifestyle choice argument. The United Nations (UN) recognise the right to reproductive choice which means that women has a right to choose whether or not to reproduce. Even if we take this argument at face value, many health care treatments are for essentially lifestyle choices. For example, fixing broken bones from recreational activities or the treatment of alcohol related illness.

Finally, why not adopt? This infers that on top of the fertility diagnosis, it becomes the responsibility of infertile couples to look after unwanted children. Using this reasoning all couples should have to adopt before they are allowed to have a child themselves.

NHS funding of fertility treatment is incredibly unfair on a number of levels and even goes against NHS England’s aim of a fair and diverse health care system.

We continue to support Fertility Fairness which campaigns for people to have comprehensive and equal access to a full range of appropriate NHS investigations and treatments.⁴

Sources

Authors

Dr Matt Prior

Matt is an NHS Consultant in Newcastle with over ten years of experience. His PhD research into subfertility and miscarriage involved developing a clinical trial and patient engagement.