Assisted conception

What is assisted conception?

Assisted conception is a treatment to help patients who are experiencing infertility. This is when a couple cannot get pregnant (conceive) despite having regular unprotected vaginal sexual intercourse.

If a patient of reproductive age has not conceived after one year of unprotected vaginal sexual intercourse, in the absence of any known cause of infertility, they should be offered further clinical assessment and investigation along with their partner.

Over 80% of heterosexual couples in the general population will conceive within one year if:

  • The woman is aged under 40 years

AND

  • The couple have not used contraception

AND

  • The couple have regular sexual intercourse.

Of those who do not conceive in the first year, about half will in the second year (cumulative pregnancy rate over 90%).

There are two types of infertility:

  1. Primary infertility – where someone who's never conceived a child in the past has difficulty conceiving
  2. Secondary infertility – where someone has had one or more pregnancies in the past, but is having difficulty conceiving again. It is estimated that infertility affects one in six heterosexual couples in the UK.

In about one third of cases, disorders are found in both the man and the woman.

Scope for treatment

  • If a couple are requesting assisted conception treatment, then both partners in the couple must be registered with a Birmingham and Solihull GP
  • Assisted conception treatment for current serving personnel (Armed Forces) and their partners, as well as veterans who are in receipt of compensation for loss of fertility received as a result of service (partner of a veteran who is in receipt of compensation for loss of fertility) is funded by NHS England
  • Pre-Implantation Genetic Diagnosis (PiGD) is also funded (commissioned) through NHS England.

Patient eligibility criteria

Age

Age of female partner wishing to conceive

  • The age of the female patient at the time of treatment must be under 40 years of age
  • Where the patient is aged 38-39 years of age, the couple/single female should be offered referral to specialist NHS infertility centre for assessment without further delay
  • Referrals for NHS infertility treatment should be made on or before the patient’s 39th birthday to ensure relevant investigations can be completed, and treatment must have commenced prior to the females 40th birthday
  • The live birth rate for women up to and including 40 years of age is significantly higher than those aged 40 years and above.

Age of male partner wishing to conceive

  • The age of the male partner at the time of treatment must be under 55 years of age
  • The recommended age for sperm donors should be aged under 41.

Childlessness

NHS infertility treatment will NOT be funded if either partner has living children of any age; this includes an adopted child or a child (biological or adopted) from either the present or a previous relationship. Once accepted for treatment, should a child be adopted or a pregnancy leading to alive birth occur, the couple/individual will no longer be considered childless and will not be eligible for NHS funded treatment.

Previous infertility treatment

NHS infertility treatment will not be offered to people where either partner within the couple has already undertaken any previous infertility treatment for fertility problems, regardless of whether the treatment was funded by the NHS or privately funded.

Sterilisation

  • NHS infertility treatment will not be available if either partner within the couple has received a sterilisation procedure or has undergone a reversal of sterilisation procedure
  • Sterilisation is offered within the NHS as an irreversible method of contraception. Protocols for sterilisation include counselling and advice that NHS funding will not be available for reversal of the procedure or any fertility treatment consequently to this.

Body Mass Index (BMI)

Female patients wishing to conceive must have a body mass index (BMI) of less than 30 at the time of referral AND commencement of treatment. Support is available to optimise the patient’s BMI.

Smoking/vaping status

  • ONLY non-smoking (including non-vaping) females/couples will be eligible for fertility treatment; smoking (including vaping) must have ceased by both partners three months prior to referral for infertility treatment
  • Patients who smoke/vape are likely to reduce their fertility. Smoking cessation programmes are available to support their efforts in stopping smoking/vaping. In men who smoke/vape there is an association between smoking and reduced semen quality
  • Smoking in either partner can negatively affect the success of infertility treatment and smoking during pregnancy can lead to increased risk of adverse pregnancy outcomes. Passive smoking is likely to affect their chance of conceiving.

Once all of the above eligibility criteria have been met by the couple/single woman the following clinical circumstances must be met:

For all couples/single women

The presence of a known reproductive condition that renders a patient infertile or reduces fertility, such as premature ovarian failure which leads to early onset of menopause or lack of motility(asthenozoospermia).

For heterosexual couples

  • The failure to conceive after regular unprotected sexual intercourse for a period of two years

AND

  • The absence of known reproductive condition

OR

  • The failure to conceive after regular unprotected sexual intercourse for a period of one year

AND

  • The presence of a known reproductive condition which would prevent natural conception.

For female same-sex couples/single women

  • The failure to conceive after a minimum of six rounds of self-funded donor insemination

AND

  • The absence of any known reproductive condition.

For male same-sex couples/single men:

The local NHS commissioning organisation does not fund surrogacy arrangements or any associated treatments (including fertility treatments) related to those in surrogacy arrangements.

For couples where one partner has a known permanent physical disability

The permanent disability must prevent natural conception as defined by the following clinical situations:

  • Permanent physical disability which prevents sexual inter-course
  • An infection requiring sperm washing

AND

  • The couple have failed six rounds of NHS-funded artificial insemination or donor insemination

OR

  • It is not clinically appropriate to try artificial insemination or donor insemination, for example if one or both of the couple have known reproductive condition which would prevent or significantly reduce the chance of conception using artificial or donor insemination.

For the purposes of this policy disability is defined as: a permanent physical impairment which prevents sexual intercourse.

Treatment

Providing that ALL eligibility criteria are met the patients local NHS commissioning organisation will fund one fresh cycle of In Vitro Fertilisation (IVF) or Intra-Cytoplasmic Sperm Injection (ICSI).

Definition of a cycle of IVF/ICSI

The definition of a single treatment cycle for the purpose of your local NHS policy is as follows:

The replacement of a fresh embryo(s) derived from the initial cycle.

Frozen embryo transfers

Embryos that are not used during the fresh transfer will be quality graded and may be frozen for subsequent use for a period of 12 months. Following this period, the woman/couple may self-fund continued storage of the embryos. Use of frozen embryos is not funded by Birmingham and Solihull CCG.

Failed or abandoned cycles

It is acknowledged, that rarely, a cycle could fail at any time after commencement due to a number of reasons. For example, failure to retrieve an egg, failure to fertilise or a failure of embryos to develop, resulting in no embryo transfer to the uterus taking place. These are known risks of infertility treatment and will be fully explained to the patient along with the likelihood of success. Should any such issue arise, the cycle will have failed and Birmingham and Solihull CCG will not fund further cycles of IVF or ICSI.

Part-funding of cycles

The commissioner will not part-fund or co-fund assisted conception/infertility treatment for individuals or couples.

Use of previously stored sperm or eggs (gametes)

Where frozen sperm or eggs are available (in line with Birmingham and Solihull CCG's policy on sperm and egg retrieval and freezing of sperm and eggs) their use for infertility treatment will be allowed, if in line with specialist clinical input, where patients meet all other eligibility criteria listed above.

IUI and DI

Intrauterine Insemination (IUI) is one of the most simple and least invasive of fertility treatments. It involves placing prepared sperm into the uterus using a fine catheter, close to the time of ovulation. The procedure usually takes 5 to 10 minutes. IUI is can be used for artificial insemination or donor insemination (DI).

Artificial insemination or donor insemination (IUI and DI) is separate from IVF treatment, however, the couple/woman may then access IVF treatment if failure of IUI/DI has evidenced a reproductive condition that renders a patient infertile. IUI/DI is funded by Birmingham and Solihull CCG for the patients it has commissioning responsibility for in the following circumstances:

  • Permanent physical disability which prevents sexual inter-course
  • An infection requiring sperm washing.

Where a medical condition exists (such as permanent physical disability which prevents sexual intercourse or after sperm washing to prevent infectious disease transmission), IUI for up to six cycles will be funded for patients who meet the criteria listed above, followed by further IVF if the woman/couple continue to meet the criteria.

IUI and DI in same-sex relationships

Six cycles of IUI/DI must be self-funded as a treatment option for people in same-sex relationships. However, if six cycles of IUI/DI are unsuccessful and no reproductive conditions have been discovered, if clinically appropriate IVF will be funded for patients who meet the criteria listed above.

Donor sperm and eggs

Donor sperm

Up to six cycles of donor insemination (dependent on availability of donor sperm) will be funded for heterosexual couples where the male partner has no or low concentration of sperm.

Pre-implantation genetic diagnosis (PiGD)

PiGD is NOT funded by the patients local NHS commissioning organisation as this is the commissioning responsibility of NHS England.

Donor eggs

Donor eggs will be funded where the patient is eligible for treatment with donor eggs, in line with national recommendations:

  • The patient has experienced premature ovarian failure below the age of 35 (the woman is not producing eggs, having a period and no external factors have contributed towards this situation)
  • The patient has received cancer treatment (e.g. cytotoxic therapy) which has caused ovarian failure
  • The patient has a diagnosed chromosomal abnormality, for example Turner’s syndrome which affects the development of females
  • The patient’s ovaries have been removed.

Unfortunately, the availability of suitably matched donor eggs remains variable due to the characteristics of the recipient. There is, therefore, no guarantee that eligible patients will be able to proceed with treatment. The average waiting time is 18 months, but may be much longer for some patients. Patients who require donor eggs will be placed on the waiting list for an initial period of one year, after which they will be reviewed annually to assess whether the assisted conception policy eligibility criteria are still met.

Surrogacy

The patients local NHS commissioning organisation does NOT fund surrogacy arrangements or any associated treatments (including fertility treatments) related to those in surrogacy arrangements.

Single embryo transfer

Multiple births are associated with greater risk to mothers and children and therefore the patients local NHS commissioning follows national guidance to transfer a single embryo. This means (for patients who DO NOT meet the above criteria) the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG.

Advice and further guidance

  • For more information, search for ‘infertility’ at www.nhs.uk 
  • Choosing Wisely UKis part of a global initiative aimed at improving conversations between patients and their doctors and nurses.

Treatment policy for patients covered by NHS Birmingham and Solihull CCG