As a first-year medical student at Newcastle, I was tasked with presenting an ethical issue in Medicine.
The politics of IVF funding has impacted friends and family of mine but is also a debate about the equity and equality of state-funded treatment. And a debate on the almost incommensurably sensitive subject of creating life itself.
In Newcastle, we are fortunate to have a local specialist fertility centre based at the Centre for Life. As part of my research, I reached out to fertility consultant Dr Matt Prior who kindly agreed to be interviewed.
IVF, as Dr Prior pointed out, is not just for heterosexual couples trying to get pregnant; patients vary from lesbian couples using donated sperm and gay couples with a surrogate, to solo parents and those wanting to preserve their fertility (such as patients going through gender transition or those undergoing chemotherapy). IVF reflects our changing society — a move away from the heterosexual nuclear family as the sole site of child rearing.
This essay discusses two main themes: the disparity of funding availability across the country (the so-called ‘post-code lottery’) and the sometimes bizarre restrictions on what funding is available.
The ‘Post-Code Lottery’
Before I started researching, I was aware that the funding for IVF is varied across the country, but I had no idea of the true extent of the disparity. For instance, in Manchester (where the first IVF baby was born in 1978) patients under 40 can receive the NICE recommended three rounds of treatment on the NHS, giving patients a 45-53% success rate overall. In places like Essex, however, patients will receive nothing. And Essex is not an exceptional case: only 1.9% of Clinical Commissioning Groups (the regional bodies that commission services in their area, known as ‘CCGs’) follow NICE guidelines.
These vast differences in funding across the country are termed the ‘post-code lottery’ — a lottery which leaves some patients having to fork out £5,000 for a single cycle of IVF while others can access it for free through the NHS in CCGs that follow NICE guidelines.
But as a friend put to me recently: can we really call this a ‘lottery’? After all, the whole point of a lottery is that we don’t know who the winners and losers are prior to the numbers’ being announced. This isn’t the case with NHS funding; we know who the winners and losers are already. It’s not so much a lottery as a stich-up.
I asked Dr Prior what has led to such regional variation. The answer is a mixed picture that goes back to (at least) 2010 and changes related to the Conservatives’ Social Care Act which introduced more market mechanisms to the NHS and less central regulation.
But there’s another important possible explanation for the variation: IVF isn’t considered enough of a priority and is more easily cast aside compared to other treatments. After all, the IVF patient isn’t critically unwell, and infertility is not going to shorten your life. And there also aren’t unborn IVF babies out there asking to be created. Despite infertility being a recognised disease, one may be able to see why IVF may be easily dismissed by commissioners.
Further Funding Restrictions
The postcode is not the only source of unfairness IVF patients must overcome; I was also shocked by some of the other funding criteria.
Otherwise eligible patients are often excluded if they or their partner has children from previous relationships. This is a cruel twist for patients who, already burdened by fertility issues, discover they are barred from funding because the person they fell in love with happens to already have children.
A patient’s BMI is a further criterion of restriction that may seem intuitive on the surface and yet is possibly a further source of unfairness. For instance, no CCG is willing to offer IVF to those with a BMI over 30 due to the increased risks of developing complications during pregnancy and birth.
But how risky is pregnancy at this BMI? As Dr Prior pointed out, NICE don’t recommend that those without fertility problems who also have a BMI over 30 permanently use contraception. And it is not just the case that patients can easily lose weight to receive IVF; for those with polycystic ovarian syndrome (a common cause of infertility), weight gain is a core associated symptom. Should these patients be denied the possibility of parenthood?
In researching this topic, I have been left wondering whether the purpose of such restrictions is to provide some justification, even if arbitrary, for denying worthy candidates treatment.
IVF is becoming more successful and safer, but it is being funded less and less, and often based on harsh, perhaps even non-sensical, criteria.
After my presentation, I asked a fellow medical student to share their thoughts on what they’d learnt. They reported an important change in the way they thought of funding in the NHS — something they had assumed to be far more equitable and without such extensive local control over funding decisions. My guess is that most medical students will become increasing aware of such harsh realities as they progress through their career.
Preparing for this presentation reaffirmed my view that fertility is an exciting speciality with much promise for patients both now and in the future. But, on a less optimistic note, I’m glad to have had my eyes opened early about the true extent of funding discrimination within the NHS.