Fertility: how do we decide who deserves a baby?
New criteria to assess women eligible for IVF treatment may not solve old problems.
IVF on NHS for women over 40" ran one front-page headline last week. A casual reader of that and similar articles could have been forgiven for concluding that the rule banning women aged 40 or over from accessing state-funded fertility treatment is being scrapped. It isn't, but it might be.
The National Institute for Health and Clinical Excellence (Nice) has recently begun looking at whether its existing guideline on fertility needs to be updated. First issued in 2004, this medical world equivalent of a tablet of stone has always been tinged with controversy. Its main recommendation – that women aged 23 to 39 meeting set medical criteria should get up to three cycles of IVF on the NHS – is widely ignored by the local NHS organisations in England and Wales who are meant to approve it and foot the bill.
Others technically offer the three cycles, but cynically impose deeply unfair access criteria in order to limit those getting it, such as restricting it to only those aged 30-35 or banning any woman who is already a mother or any couple who have even one child between them, including from other relationships. Studies have shown that just 20% to 30% of England's 52 primary care trusts actually follow Nice's guidance. One cycle of IVF costs about £2,000, but many doctors believe it should not be an NHS service at all. Some see childless women as much less deserving than cancer patients seeking life-extending drugs. Others think they should foster or adopt a child to satisfy their desire to experience parenthood.
In an era when rapidly growing numbers of women are giving birth in their 40s, Nice's age limit of 39 strikes many as outdated, heartless and discriminatory – and thus possibly open to legal challenge. The organisation may now replace the existing age-based access to IVF on the NHS with a new system based on a woman's "ovarian reserve"– that is, how many eggs she has left.
Fertility experts are divided on this. Some say the job of deciding which women should receive state-funded IVF will become even more complicated and expensive if ovarian reserve tests become routine. And Dr Gillian Lockwood, a vice-chairman of the Royal College of Obstetricians and Gynaecologists, adds: "Nice seem to think that the best thing is to spend money on those with the best chance of a pregnancy; there is nothing fair about that at all." But Dr Allan Pacey, a spokesman for the British Fertility Society, argues that such a replacement system would be more just, scientific and likely to produce children. "What ovarian reserve testing does mean is that an unfortunate woman who has suffered an early menopause, say at age 28, might be denied NHS treatment with her own eggs, but a 42-year-old with the ovarian reserve of a 30-year-old be allowed it where currently she might not be. To my mind that seems arguably fairer."
Susan Seenan of Infertility Network UK agrees. "A 41-year-old could have a better ovarian reserve than a 35-year-old, so in some respects it's a better measure of potential success than an arbitrary age cut-off," she says. But any tests would need to be very accurate, to avoid depriving a woman of the chance of a child through a rogue result, Seenan adds. Ovarian reserve testing has come a long way in recent years. "It is now possible to identify those women who will do well at IVF in comparison with those who would do less well, or fail. It gives a better prediction of who might do well at responding to the IVF drugs, rather than relying on age alone," says Pacey.
Much of the coverage last week suggested that many women over 40 would benefit from a switch to ovarian reserve testing. Pacey doubts it. "I'm not sure this will be the case. Depending on where Nice set the cut-off it might actually mean that the effective age limit comes down under 40."
Even if 40-something would-be mothers do start receiving IVF on the NHS, their chances of that leading to a baby are slim. While 28.6% of under-35s undergoing IVF get a child, that drops to 10.6% of those aged 40-42, 4.9% for 43 and 44-year-olds and 0.8% for those over 44. New rights may not banish old problems.
Article: Denis Campbell The Observer, Sunday 4 July 2010
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