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This is a summary of the NEW Devon CCG commissioning policy for the provision of NHS funded Assisted Conception.
Commissioning policy: Assisted Conception
A woman is of reproductive age and has not conceived after one (1) year of unprotected vaginal sexual intercourse. In the absence of any known cause of infertility, she should be offered further clinical assessment and investigation along with her partner.
Earlier referral will be offered for specialist consultation to discuss the options for attempting conception, further assessment and appropriate treatment where:
To ensure that same-sex couples are informed of appropriate and safe self-funding attempts they should have access to professional consultation and advice in reproductive medicine, to obtain information and advice on the options available to them.
Access to NHS funded investigations is commissioned in same-sex couples once subfertility has been established:
Eligibility criteria for assessment, investigation and treatment apply as set out in this policy
In Vitro Fertilisation (IVF)
If IVF is a possible treatment, the woman's doctor should first discuss with her the risks and benefits of IVF treatment, in line with the Code of Practice produced by the Human Fertilisation and Embryology Authority (HFEA) www.hfea.gov.uk
Women aged under 40 years
If the woman is aged under 40, they should be offered one (1) cycle of IVF if:
However, if tests show that there appears to be no chance of the woman conceiving naturally, and that IVF is the only treatment that is likely to help, they should be referred straightaway for IVF.
No woman may receive an NHS funded IVF cycle if she has previously received a total of three (3) cycles, whether self- or NHS-funded. This is because the chance of having a baby falls with the number of unsuccessful cycles of IVF.
The woman's doctor should also take into account how the woman has responded to any previous IVF treatment and what the outcome was when deciding how effective and safe further IVF would be for that individual.
If a woman turns 40 during a cycle of IVF, they can finish the current cycle. They will still be able to have up to one frozen embryo transfer episode from their most recent episode of ovarian stimulation since this counts as part of the same cycle.
A 'cycle' of IVF is defined in this policy as one (1) fresh and one (1) frozen implantation of embryos. A frozen embryo transfer episode will only be available if there are embryos generated from the fresh cycle suitable for freezing.
The NHS in Devon will fund cryopreservation of embryos remaining for up to 1 year as a result of IVF treatment. Patients who wish to store embryos beyond one year would be required to fund the storage themselves.
Embryo transfer strategies in IVF
Intrauterine insemination (IUI)
Unstimulated IUI will only be funded under the circumstances below.
Consider up to twelve (12) cycles of unstimulated intrauterine insemination as a treatment option in the following groups as an alternative to vaginal sexual intercourse:
For people in same-sex couples who have not conceived after six (6) cycles of privately funded donor or partner insemination, despite evidence of normal ovulation, tubal patency and semen analysis, the NHS will offer six (6) cycles of unstimulated intrauterine insemination procedures before IVF is considered.
For people with unexplained infertility, mild endometriosis or 'mild male factor infertility', who are having regular unprotected sexual intercourse:
Intracytoplasmic sperm injection (ICSI)
For some men, their sperm are not capable of fertilising eggs in the usual way. If this is the case, they and their partner may be offered a procedure called intracytoplasmic sperm injection (ICSI), in which a single sperm is injected directly into an egg. A man should only be offered ICSI if:
If a man is unable to ejaculate it is possible to obtain their sperm using surgical sperm recovery. They should be offered the chance to freeze some of their sperm for possible use at a later date.
TESA (Testicular Sperm Aspiration) and PESA (Percutaneous Epididymal Sperm Aspiration) can be used as clinically indicated. MESA (Microsurgical Sperm Aspiration) is not funded.
Donor insemination is funded for:
Also following IVF egg retrieval when no living sperm produced on day of treatment. The tariff covers transport of sperm; and storage for the NHS funded cycle only.
Cryopreservation of abandoned cycles
If treatment is abandoned after oocyte retrieval and the embryos cannot be replaced. Storage for up to one (1) year and replacement of frozen embryos for the NHS funded cycle.
Ovarian reserve testing
Antral Follicle Count (AFC), Anti-Mullerian Hormone (AMH) or Follicle-Stimulating Hormone (FSH) testing will be funded for the targeted treatment of individual women.
Drug use should be in line with National Institute for Health and Care Excellence (NICE) Clinical Guideline 156 on Fertility.
Receiving egg donation
The use of egg donation is funded for:
Also where there is a high risk of transmitting a genetic disorder to the offspring.
Egg donors should be screened for both infectious and genetic diseases in accordance with the 'UK guidelines for the medical and laboratory screening of sperm, egg and embryo donors' (2008). The NHS will not fund the payment of egg donors. Egg sharing is funded as long as the NHS does not subsidise treatment for the donor beyond that which is required for treatment of the recipient.
Abandoned IVF or ICSI cycle
An additional cycle to be funded where the cycle has been abandoned prior to egg retrieval or cryopreserved replacement. This includes where the cycle was abandoned due to hyperstimulation.
Cryopreservation for preserving fertility
Cryopreservation for patients undergoing treatments such as chemotherapy for cancer or radical surgery which may make them sterile, as well as patients who are about to start teratogenic treatment likely to continue for their reproductive life, is covered by a separate policy on cryopreservation for preserving fertility.
If required due to congenital absence of the uterus or malignancy. Funding is approved for the creation of embryos and storage for five years or until implantation has been performed (whichever is the sooner). Funding is not approved for finding a suitable surrogate or for treatments that are not routinely commissioned.
If a same-sex couple has a diagnosed fertility problem on investigation then their sub-fertility will be treated. However NHS funding will not be available for donor sperm for female same-sex couples or surrogacy arrangements for male same-sex couples. This is on the basis that unless they are medically sub-fertile their childlessness is due to the absence of gametes of the opposite sex. The clinician should discuss with the couple the feasibility and preparedness of the other partner trying to conceive before proceeding to interventions involving the sub-fertile partner.
Previous sterilisation – Neither partner sterilised.
Previous assisted conception – Couples who have not previously received NHS funded assisted reproduction techniques (as defined below).
The term 'assisted reproduction techniques' refers to treatments designed to lead to conception by means other than sexual intercourse, and includes intrauterine insemination (IUI), in vitro fertilisation (IVF), intracytoplasmic sperm injection (ICSI) and donor insemination (DI).
Age – Restricted to women aged up to 40 years.
Weight – Women must have a BMI (body mass index) of more than 19 and less than 30; Men must have a BMI of less than 30.
Smoking – Both partners should be objectively confirmed non-smokers.
Welfare of the child – The welfare of any resulting children is paramount. In order to take into account the welfare of the child, the clinician should consider factors which are likely to cause serious physical, psychological or medical harm, either to the child to be born or to any existing children of the family. This is a requirement of the licensing body, the Human Fertilisation and Embryology Authority (HFEA). There is an explicit and recorded assessment that the social circumstances of the family unit have been considered within the context of the assessment of the welfare of the child. This will include consideration of factors such as parental smoking, alcohol and recreational drug use.
Previous children – Restricted to couples with no children living with them, as their place of residency (where children are classed as under 18 years).
Relationship – A couple who are spouses or civil partners, or cohabiting as partners in a financially interdependent relationship.
Previous assisted conception – Neither partner has previously received NHS-funded assisted reproduction techniques. This applies unless failure of NHS-funded IUI is required to access IVF.
Commissioning policy: Assisted Conception
Where the circumstances of treatment for an individual patient do not meet the criteria described above exceptional funding can be sought. Individual cases will be reviewed by the appropriate panel of the CCG upon receipt of a completed application from the patient's GP, consultant or clinician. Applications cannot be considered from patients personally.
Northern, Eastern and Western Devon Clinical Commissioning Group South Devon and Torbay Clinical Commissioning Group
Date of publication: 17 March 2016
This replaces the previous policy published in April 2015