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Referral for IVF

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					                                               REFERRAL FOR IVF
                                     CHECK LIST FOR ELIGIBILITY FROM 01.12.09

                          OXFORDSHIRE PCT                                HAMPSHIRE PCT
                          MILTON KEYNES PCT                              ISLE OF WIGHT PCT
                          BUCKINGHAMHSIRE PCT                            PORSTMOUTH CITY PCT
                          BERKSHIRE EAST PCT                             SOUTHAMPTON CITY PCT
                          BERKSHIRE WEST PCT


To access NHS treatment for IVF cycle complete this checklist and send one copy with the referral letter to the provider
unit and a further copy to:

South Central Specialised Services Commissioning Group, Omega House, 112 Southampton Road, Eastleigh,
Southampton SO50 5PB. (Fax No: 023 8065 2976)

Patients must not be offered an appointment until eligibility and funding has been confirmed by Specialised Services on
behalf of the PCTs.

Name of Referrer (please print):                                     Patient’s GP:
Referring Hospital:                                                  Address:
Address/Tel:
                                                                     Tel No:                         Fax No:
Post Code:                                                           Post Code:



Provider choice:                       *       OXFORD
                                       *       CHILTERN
                                       *       CARE NORTHAMPTON
                                       *       WESSEX FERTILITY
                                       *       SALISBURY FERTILITY

* Please circle as appropriate


Female Patient:                            Dob:                      Male Patient:                     Dob:
PCT:                                       Age:                      PCT:                              Age:
NHS No:                                                              NHS No:
Provider’s Patient Reference:                                        Provider’s Patient Reference:
Address:                                                             Address:

Post Code:                                                           Post Code:
Tel/Mobile No:                                                       Tel/Mobile No:




PS11d IVF Referral Form Nov 2009.doc                                                                                Page 1
of 4
Oxfordshire Policy Statement No. 11d applies
Criterion                                                                                                Yes / No      Eligibility

NICE Clinical Practice
Has the couple gone through the primary and secondary care sub-fertility pathways appropriate to
them before IVF is considered?                                                                                      No = excluded
http://www.nice.org.uk/guidance/CG11/niceguidance/pdf/English (summary)
http://www.nice.org.uk/guidance/CG11/guidance/pdf/English (full guideline)


Duration of infertility
Do the couple have unexplained infertility of > 3yrs duration?                                                      No = excluded
or
Does the couple have a diagnosed cause of absolute permanent infertility (which precludes any                       No = excluded
possibility of natural conception) of > 1 yr duration? If so, please provide specific details.
(Same sex couple or single person: 10 failed insemination cycles or diagnosed fertility problem )


Does the female partner have an FSH < 12m iu/l (taken day 2-5 of menstrual cycle)                                   No = excluded


Age of woman at time of cycle starting
At the time of treatment, will the female be aged 30 to 34 years inclusive?                                         No = excluded
    or
At the time of treatment, will the female be aged 35-36 years inclusive and will treatment commence                 No = excluded
before 01.12.10?


Previous infertility treatment
Has the patient ever received previous IVF or ICSI treatment funded by the NHS?                                     Yes = excluded


Has the patient received more than 2 previous cycles of IVF or ICSI, whether NHS or privately                       Yes = excluded
funded?


Women in same sex couples or a woman not in a partnership
Is the woman demonstrably sub-fertile?                                                                              No = excluded

(10 unsuccessful cycles of IUI will be accepted as evidence of unexplained infertility)


If the woman is demonstrably sub-fertile, has the possibility of the other partner receiving treatment              No = excluded
before proceeding to interventions been discussed?

(NHS funding is not available for insemination facilities (IUI with donor sperm) for fertile women
who are single or part of a same sex partnership).


Childlessness
Does either partner have a living child (including adopted) from their relationship, or from any                    Yes = excluded
previous relationship?


Sterilisation
Has either partner been sterilised?                                                                                 Yes= excluded


BMI
Does the female have a BMI range between of 19 - 29.9 for at least six months before receiving any                  No = excluded
treatment?


Smoking
Are both partners non-smokers for at least six months before receiving any treatment?                               No = excluded
PS11d IVF Referral Form Nov 2009.doc                                                                                           Page 2
of 4
Oxfordshire Policy Statement No. 11d applies
HFEA Code of Ethics
Is there any reason to think this couple will not conform to the HFEA Code of Ethics? This includes       Yes = excluded
consideration of ‘welfare of the child which may be born’.




STATEMENT TO BE SIGNED BY THE REFERRER

I confirm that all the above access criteria have been met and this couple is therefore eligible for NHS funded IVF
treatment.

Referrer’s signature:        __________________________________________


Date of referral:            ______________________


    *    Please delete as appropriate.


    *    Oxford Fertility Unit, Institute of Reproductive Sciences, Oxford Business Park North, Oxford OX4 2HW
         Tel: 01865 782800        Fax: 01865 595223

    *    The Chiltern Hospital, London Road, Great Missenden, Bucks HP16 OEN
         Tel: 01494 890890      Fax: 01494 089250

    *    Care Centres for Assisted Reproduction, 67 The Avenue, Northampton NN1 5BT
         Tel: 01604 601606     Fax: 01604 603275

    *    Dr Sue Ingamells, Wessex Fertility Ltd, Anglesea House, 72-74 Anglesea Road, Southampton S015 5QS
         Tel: 023 8070 6000    Fax: 023 8077 5288

    *    Salisbury Fertility Centre, Salisbury NHS Foundation Trust, Salisbury, Wiltshire SP2 8BJ
         Tel: 01722 417224       Fax: 01722 325373



STATEMENT TO BE SIGNED BY THE COUPLE

I confirm that the information we have given is correct.


First partner’s signature:             ___________________________________


Date:                                  ______________


Second partner’s signature:            ___________________________________


Date:                                  ______________

PS11d IVF Referral Form Nov 2009.doc                                                                                  Page 3
of 4
Oxfordshire Policy Statement No. 11d applies
PS11d IVF Referral Form Nov 2009.doc           Page 4
of 4
Oxfordshire Policy Statement No. 11d applies

				
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