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Subfertility_Dept_2__article_Sept_09

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					SUBFERTILITY
Peter A. Greenwood MA. FRCOG., Person Responsible and Lead Clinician,
                                                                                                   Peter A. Greenwood MA FRCOG
Fertility Clinic (HFEA Centre 190), James Paget University Hospitals
                                                                                                          Consultant Gynaecologist
                                                                                                   and Director of Fertility Services
                                                                                                   James Paget University Hospital
                                                                                                                       Lowestoft Road
                                                                                                                      Gorleston-on-sea
                                                                                                                     Norfolk NR31 6LA
                                                                                                                     Tel: 01493452209
                                                                                                                    Fax: 01493452366
                                                                                                 Email: fertilityclinic@jpaget.nhs.uk




         The role of the NHS in helping                                                      funding continued to be determined by
         childless couples with fertility                                                    local purchasers.
         concerns to become parents has
been debated for many years. Couples                                                            Landmark progress was made in
with no children may be healthy and                                                          August 2008 when the East of England
infrequent users of NHS facilities                                                           Specialised     Commissioning     Group
compared with couples with children but                                                      (EESCG) announced the provision of 3
may be subject to lifelong psychological                                                     fresh cycles and up to 6 embryo transfers
stress and grieving if they try for, but fail                                                for eligible couples. This newly funded
to have, their own children. The NHS has                                                     programme was to cover a population
recently experienced increased funding so                                                    base in excess of 5 million. The IVF
that treatment for ill health is adequately                                                  contract was put out to tender and the
catered for and greater funding of health                                                    successful IVF clinics were Bourn Hall
promotion aims to reduce future                                                              Clinic (BHC), Leicester Royal Infirmary,
individual morbidity. In contrast, infertility                                               Oxford,      Hammersmith      and     St.
treatment, where the intention is to                                                         Bartholomews. It is noteworthy that only
create a family and a new healthy                                                            one of these Units is based inside the
individual, has for many years been                                                          catchment area (BHC). 4 Units that were
notoriously underfunded.                                                                     unsuccessful in the tender process are
                                                                                             based within the Region.
  The development of In Vitro
Fertilisation (IVF) treatment in the late                                                       The role of the General Practitioner (GP)
1970’s and early 1980’s caused a                                                             in the initial assessment and management
massive increase in the potential for                                                        of the subfertile couple is very
successful treatment for many couples                                                        important.The referral of a couple from
but a large increase in the costs of             Peter A. Greenwood                          Primary Care is to the local Secondary
Infertility treatment. A further ‘great                                                      Care provider for NHS investigation and
leap forward’ was the introduction of               The National Institute for Clinical      treatment. The local provider acts as the
sperm injection IVF in the early 1990’s          Excellence (NICE) addressed the issue of    gatekeeper to the Tertiary Care Clinic
which opened up the potential to                 Subfertility and published its Report in    providing NHS IVF treatment Licensed by
successfully treat male factor infertility.      2004. The Report gave guidance as to        the Human Fertilisation and Embryology
Initially IVF treatment was high cost            when IVF treatment was appropriate,         Authority (HFEA). Initial assessment and
with low success rates and the growth            lifestyle factors that a couple could       simple investigations should be started in
in the Service in the UK was mainly              address to improve their fertility and an   Primary Care. This will reduce the length
through private clinics. Success rates           assessment of what reasonable provision     of time the couple have to wait before an
gradually improved and costs were                of IVF treatment through the NHS should     appropriate treatment plan is developed
reduced and local purchaser groups               be. The recommendation was 3 fresh          for them. If the couple present to the GP
were left to decide whether to fund IVF          cycles of IVF where various eligibility     within the first year of trying for a family,
treatment through the NHS. Variations            criteria were fulfilled. The Government     simple investigations may provide early
in funding priorities throughout the             felt that funding 1 cycle of IVF would be   reassurance of normality and delay
country led to inequity between areas            a good start but confused the issue         referral. Providing reassurance without
funding no treatment and areas funding           around childlessness by suggesting that     investigation can on occasion lead to late
1 or more cycles and the access criteria         either partner having a child might         diagnosis of the cause of subfertility e.g
that were applied.                               preclude State funding. The provision of    unexpected azoospermia.




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   The couple presenting with fertility         reproductive        history   including     all   impaired. The negative aspects to that
concerns should see their GP together.          pregnancies and outcomes and pelvic               approach are clearly the             possible
This demonstrates immediately that the          infections or abdominal surgery. The              premature commitment to having a family
desire to start a family is a joint decision,   menstrual history may be crucial in defining      and the anxiety and guilt that may be
that the ‘problem’ is shared and may            the cause of subfertility if there is             caused in the female if the fertility screen
allow the GP to highlight well-being            established oligo- or amenorrhoea. The            suggests a deficient ability to procreate.
issues that should be addressed jointly to      male history is limited to any clear medical
improve the fertility of the couple.            problems or history of testicular injury. A          The influence of the NICE Clinical
                                                semen analysis is essential before referral to    Guideline has been positive and
  The NICE Clinical Guideline – Fertility       a Secondary Care Unit and if abnormal may         progressive. Although funding for Fertility
assessment and treatment for people             direct early Specialist involvement.              treatment has remained poor in many areas
with fertility problems (February 2004)            Subfertility is defined as failure to          of the UK, the existence of a widely
gives excellent guidance for interested         conceive for 2 years despite regular sexual       accepted      road-map     for   effective
practitioners from the Primary Care level       activity where there is no clear cause in         management has led to Primary Care Trusts
through to Tertiary Care. It is in Primary      either partner. There is growing anxiety          (PCT) imposing appropriate Service
Care that advice about live-style and           about declining female fertility with age         Specifications on the Secondary Care
general health should be initiated. Both        due to a tendency for couples to delay            Clinics. Although Clinicians in Secondary
partners must be advised to achieve a BMI       attempts at conception until their careers        Care Units would claim that they already
between 19 and 30, smoking cessation            are firmly established. There is a need for       follow NICE Guidance this development
must be supported, sensible alcohol             early referral to Secondary Care for couples      allows the whole process to be more
intake is also important. All women trying      where the woman is 35 or over because of          transparent to clients, purchasers and
for a pregnancy should take daily folic         the decline in success rates with any form        providers with outcomes recorded and
acid supplements and Rubella immunity           of treatment in the late 30’s. There have         monitored.
must be tested.                                 been recent calls for women to consider a
                                                health/fertility screen from the age of 30 in       Norfolk PCT has awarded a Secondary
  The woman should be asked about               order to allow earlier attempts at achieving      Care contract to two providers, the James
previous  contraceptive  methods,               pregnancy if fertility is found to be             Paget University Hospital in Great




 James Paget University Hospital




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Yarmouth and the Queen Elizabeth                 The EESCG has set up a robust pathway           patient to attend the local Unit for 5 of the
Hospital in Kings Lynn. This allows some      for referral from Secondary to Tertiary care.      visits including the egg retrieval with only
patient choice and both Units have to         A detailed Proforma has to be completed            one visit to Bourn Hall for the Embryo
comply with the 6 week wait for               fully at the time of referral but this speeds up   replacement. Analysis of outcomes over the
outpatient appointments and the 18            the whole process of accessing NHS                 past 10 years indicate no significant
week wait for treatment. The benefit to       entitlement for the couple. The couple have        reduction in the success rate for IVF with
the Units is that the referral from Primary   a choice of referral to 5 different Providers      such an arrangement. The benefits to the
Care involves the submission of a detailed    but this choice is clearly influenced by ease of   couple are the reduced disruption to their
Proforma including basic infertility          access and success rates at the different          daily routine and the continuing contact
investigation results. Although this aspect   Units. All 5 Providers work to the same            with the team responsible for their initial
may be resisted by some GP’s because of       Service Specification and Single Embryo            Secondary level care.
the extra work involved it is beneficial to   Transfer policy as determined by the
the      couple     and     their   further   Commissioners.                                       It is clear that the outlook for subfertile
management. It is often possible to                                                              couples through the NHS is improving.
determine the treatment plan for the             The award of Contracts to 4 Units outside       The role of Primary Care is to institute
couple from the initial appointment in the    the Region has led to disquiet within East         early investigations and to encourage the
Fertility Clinic using the details of the     Anglia. Access to treatment can be improved        couple to adopt a healthy lifestyle, in
Primary Care assessment and adding a          by the provision of Transport and Satellite        order to be ready for a healthy pregnancy.
Trans-vaginal Ultrasound Assessment of        arrangements where the majority of the             The onward referral for Tertiary care is the
the pelvis. The Proforma also draws the       cycle of treatment can be provided locally,        responsibility of the Secondary provider in
attention of the GP to negative lifestyle     leaving the crucial embryology and Embryo          discussion with the couple. This
factors so that these can be addressed by     Transfer to the central IVF Unit. A Transport      arrangement allows the maintenance of
the couple before attending the Clinic        IVF arrangement has been in existence for          good liaison between the Secondary and
and further health advice when they           15 years between the James Paget University        Tertiary providers to the benefit of the
attend is not unexpected.                     Hospital and Bourn Hall Clinic and allows the      couple and the continuity of their care. ■




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