GPs will be able to offer fertility treatment on the NHS to women aged over 40 for the first time, under a new NICE guideline which GP leaders have warned many CCGs will struggle to implement within current budgets.
The updated guideline – published today – says women aged 40 to 42 years should be offered one cycle of IVF if they have not been able to conceive after two years of regular unprotected vaginal intercourse, but only if they meet certain criteria. In its previous guidance in 2004, NICE did not recommend IVF for women older than 39 years.
The criteria for referral include that the women have never previously received IVF treatment, there is no evidence of a low ovarian reserve, and there has been a discussion of the implications of IVF and pregnancy at this age.
The new guideline also says couples should be advised to try and conceive through unprotected vaginal intercourse – or 12 cycles of artificial insemination -for a total of two years before considering IVF, rather than three years as formally recommended.
Dr Tim Child, consultant gynaecologist and director of the Oxford Fertility Unit, and part of the group that developed the guideline on behalf of NICE, said: ‘The outcome of this is to prevent people waiting an extra year which lowers fertility.’
GPs will be the key first point of contact for couples with fertility problems under the new guideline, with a woman of reproductive age, where there is not a known cause of infertility, offered further clinical assessment and investigation along with her partner if she has not conceived after one year of unprotected vaginal intercourse.
Women aged over 36, or with a known clinical cause or history of predisposing factors, should be fast-tracked for a consultation with a specialist, the new guideline recommends.
The guideline also states that intrauterine insemination (IUI) should no longer be recommended except in exceptional circumstances where patinets have social, cultural or religious objections to IVF, as it is no better at achieving a live birth than regular vaginal intercourse.
Dr Clare Searle, a GP in Hertfordshire who was part of the Guideline Development Group, said the guideline set out a clear pathway of care to enable GPs to help couples with infertility problems.
She said: ‘This guideline should help GPs to actively manage the possibility of infertility in people, from offering lifestyle advice to referring people for further investigations. The guideline sets out a clear pathway of care for GPs and other healthcare professionals to follow. This will help identify infertility problems in a timely manner and give people access to the most effective, appropriate treatments.’
But leading GPs warned many CCGs facing constrained budgets would find it difficult to implement the guidance in full.
Dr Charles Alessi, chair of the National Association of Primary Care and interim chair of NHS Clinical Commissioners, said CCGs would have to assess priorities in their area.
‘If there is enough resource within the system of course one welcomes it,’ he said. ‘One has to be very careful because we don’t live in a world of expansion, we live in a world of contracting resources. Prioritising one treatment directly takes money away from other areas.’
‘There are different types of NICE guidelines. Everything is based on evidence as interpreted by NICE and this is used by CCGs to assess priorities. So CCGs have to assess NICE guidance, but it does not mean CCGs have to implement what NICE says. People are going to have reasons why they’re not going to do it based upon their population’s needs.’
Dr Chaand Nagpaul, a GPC negotiator, said the Government should consider increasing CCG budgets if they wanted expanded access to fertility services to be widely implemented.
He said: ‘We know CCGs are going live with an unprecedented level of efficiency savings through the Nicholson challenge and QIPP. If the Government wishes to see NICE guidelines implemented as part of national policy they will need to look at at topping up CCGs’ budgets. CCGs cannot square this impossible financial circle and magically provide expanded services.’
Dr Sarah Jarvis, a GP in Hammersmith, west London, and former RCGP spokesperson on women’s health, said: ‘I don’t think CCGs will fund it as a priority. NICE guidance is supposed to be aspirational. I suspect CCGs will pick and choose the bits that suit them. So they’ll use it as an excuse to stop funding IUI but not do the bit where they offer an IVF cycle to women over 40.’
What does the guideline mean for GPs?
– Women aged 40 to 42 years should be offered one cycle of IVF if they have not been able to conceive after two years of regular unprotected vaginal intercourse
– Couples should be advised to try and conceive through unprotected vaginal intercourse (or 12 cycles of artificial insemination) for a total of two years, rather than three as formerly recommended, before considering IVF
– Intrauterine insemination (IUI) is no better at achieving a live birth than regular vaginal intercourse and should no longer be recommended, except in exceptional circumstances such as when people have social, cultural or religious objections to IVF
– The guideline also removes the recommendation to offer ovarian stimulation agents such as clomifene citrate, anastrozole or letrozole, as there was no evidence their prescription increased the rates of live births.
Source: NICE updated guideline on fertility, 2013