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Reproduction

Please see below for the policies relating to reproduction. To view the policy, patient leaflet and additional information, please click on the relevant heading.


  • 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.
  • Gamete retrieval

    What is a gamete?

    Gametes are sex cells. The male gametes are sperm, and the female gametes are eggs. Conception (getting pregnant) happens when a man's sperm fertilises a woman's egg.

    What is gamete retrieval?

    Gamete Retrieval is the extraction of gametes (by surgical or non-surgical methods) which can then be stored for future use.

    What is cryopreservation?

    Cryopreservation is the process of storing biological material at extremely low temperatures (below zero). At these low temperatures, all biological activity stops, including the biochemical reactions that lead to cell death and DNA degradation.

    Why do we need these procedures?

    In certain circumstances, a man or a woman’s fertility may be compromised for a number of reasons:

    • Certain types of treatment (e.g. cytotoxic therapy) which permanently prevents the individual producing gametes (eggs/sperm), OR
    • Certain types of treatment (e.g. cytotoxic therapy) which permanently causes genetic abnormalities in the eggs/sperm
    • The ovaries or testes may, in certain clinically required circumstances (e.g. to prevent the spread of disease), need to be surgically removed which results in infertility
    • The patient has premature ovarian failure.

    Patients undergoing treatments such as chemotherapy for cancer or radical surgery may be made sterile by such treatments. Where there is a significant likelihood of making a patient permanently infertile as an unwanted side-effect of NHS funded treatment (including gender reassignment), those patients will be eligible - under the Birmingham and Solihull CCG commissioned pathway - for gamete retrieval and cryopreservation to preserve fertility, as long as they meet the eligibility criteria.

    Treatment

    This may be done by storing gametes (eggs/sperm), prior to treatment. Following the completion of the NHS funded treatment, these gametes may be used to assist conception.

    **If the patient requires CCG funding for assisted conception, then the patient will be required to evidence how he/she meets the currently commissioned Assisted Conception Policy.

    Patient eligibility criteria

    • The patient must be permanently registered with a Birmingham and Solihull CCG GP practice, AND
    • The patient must have no living children. The aim of this is to give priority to individuals with no existing living children. An adopted child has the same status as an individual’s biological child. However, self-funding for gamete retrieval and storage is still possible, AND
    • Upper age restrictions for both men and women will be in line with those patients funded for fertility services under the Assisted Conception policy in place at the time of the funding request (currently a woman must be under the age of 40 and a man must be under the age of 55 years. There is no lower age limit).

    AND the patient must meet ONE of the following clinical criteria:

    • The patient must be undergoing NHS funded treatment which is likely to render the patient permanently infertile e.g. cytotoxic therapy, OR
    • The patient is at immediate risk of premature ovarian failure, OR
    • The patient has a diagnosed chromosomal abnormality which is likely to render the patient permanently infertile, OR
    • The patient’s ovaries/testes are going to be removed as part of NHS funded treatment, AND
    • The funding application must be supported by the NHS consultant providing their care, AND
    • The patient has NOT undergone a previous sterilisation or reversal of sterilisation procedure.

    Gamete retrieval and cryopreservation will not be funded where the patient has previously undergone elective sterilisation (vasectomy or the fallopian tubes are blocked or sealed to prevent the eggs from reaching the sperm and becoming fertilised).

    ALL funding renewals for gamete storage will be considered in line with the ages specified in the Assisted Conception Policy in place at the time of application.

    Advice and guidance

    Patients may choose to self-fund storage once NHS funding ceases within the terms of the Human Fertility and Embryology Act 1990.

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

    What is reversal of female sterilisation?

    Female sterilisation is an operation to permanently prevent pregnancy (also called operative occlusion of the fallopian tubes). The fallopian tubes are blocked or sealed to prevent the eggs from reaching the sperm and becoming fertilised.

    Depending on the method used, you would either have a general or local anaesthetic. It is a permanent procedure and is 99% successful. The reversal of female sterilisation is surgery to try and reconstruct the fallopian tubes, but it does not guarantee the return of a woman’s fertility.

    Not normally funded treatment or procedure

    The reversal of female sterilisation is not routinely commissioned as sterilisation is deemed to be a permanent method of contraception. 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 guidance

    • For more information, search for ‘can I get a sterilisation reversal on the NHS’ at www.nhs.uk
    • Choosing Wisely UK is part of a global initiative aimed at improving conversations between patients and their doctors and nurses.

    Or visit the following websites:

    Treatment policy for patients covere

  • Reversal of male sterilisation

    What is reversal of male sterilisation?

    Reversal of male sterilisation is a surgical procedure which involves re-joining the sperm-carrying tubes that were cut or blocked during a vasectomy.

    It’s possible to have a vasectomy reversed. Reversal of male sterilisation is rarely funded by the NHS as the success rates of the procedure are not very high and there is no guarantee that the patient’s fertility will return.

    Not normally funded treatment or procedure

    The reversal of male sterilisation is not routinely commissioned. 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 guidance

    • For more information, search for ‘can I get a sterilisation reversal on the NHS’ at www.nhs.uk
    • Choosing Wisely UK is part of a global initiative aimed at improving conversations between patients and their doctors and nurses.

    Or visit the following websites:

  • Vasectomy

    What is a vasectomy?

    A vasectomy (male sterilisation) is a surgical procedure to cut or seal the tubes that carry a man's sperm to permanently prevent pregnancy.

    It's usually carried out under local anaesthetic, where the patient is awake but does not feel any pain, and takes about 15 minutes. In rare cases general anaesthetic may be used where the patient is asleep during the operation.

    Treatment

    There are two types of vasectomy, a vasectomy using a scalpel (surgical knife) and a no-scalpel vasectomy.

    A vasectomy using a scalpel (surgical knife): With the vasectomy that uses a scalpel (known as a conventional vasectomy) the doctor first numbs the scrotum with a local anaesthetic.

    They then make two small cuts in the skin on each side of the scrotum to reach the tubes that carry sperm out of the testicles (called vas deferens). Each tube is cut and a small section removed. The ends of the tubes are then closed, either by tying them or sealing them using heat. The cuts are stitched, usually using dissolvable stitches that go away on their own within about a week.

    A no-scalpel vasectomy: The no-scalpel vasectomy has the doctor first numbing the scrotum with local anaesthetic. They then make a tiny puncture hole in the skin of the scrotum to reach the tubes.

    This means they don't need to cut the skin with a scalpel. The tubes are then closed in the same way as a conventional vasectomy, either by being tied or sealed. There's little bleeding and no stitches with this procedure. It's thought to be less painful and less likely to cause complications.

    Patient eligibility criteria

    The CCG will fund vasectomy in the following circumstances:

    • The patient (and where possible, the partner) has given fully informed consent for the permanent sterilisation procedure and have been informed that reversal of sterilisation is not available on the NHS and reversal of sterilisation has poor success rates, AND
    • Minimally invasive vasectomy is the first choice of procedure under local anaesthetic in a commissioned community clinic setting, AND
    • The patient has been fully informed of the post-operative follow-up and post procedure semen analysis.

    Vasectomy will be funded in an in-patient setting under general anaesthetic ONLY in the following circumstances:

    • The patient is allergic to local anaesthetic OR
    • The patient is taking anticoagulants or antiplatelet medications and risk of bleeding is high OR
    • The patient has anatomic abnormalities, i.e. there is an inability to palpate and mobilize both vas deferens or large hydroceles or varicoceles OR
    • There is past trauma which has resulted in scarring of the scrotum.

    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 guidance

    Local vasectomy service

    The local vasectomy service is provided by the British Pregnancy Advisory Service, BPAS Birmingham South, 162 Station Road, Kings Norton, Birmingham B30 1DB.

    Although your initial consultation may take place either face-to-face at the clinic, or over the telephone, treatment always takes place at BPAS Birmingham South. There is no need to visit your GP first, you can self-refer by calling 03457 30 40 30, or email This email address is being protected from spambots. You need JavaScript enabled to view it.

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