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6 May 1998 : Column 656

Infertility Treatment

11 am

Mrs. Caroline Spelman (Meriden): I am glad that the House has an opportunity to debate this subject today. It needs to be discussed in a spirit of extreme sensitivity, for there is no doubt that those who suffer the problems of infertility suffer a silent pain within society. I hope that I shall not give offence by what I say today, and I hope that colleagues will make their contributions in a similar spirit.

Natural fertility in human beings is relatively poor; we are not an efficient species. There is only a 20 to 25 per cent. chance of conception in each natural cycle. If those facts and the spontaneous rate of natural abortion were better understood, some of the pain of dashed expectations and the grief of miscarriage might be allayed. In society, pressure on couples is great. Before they are married, people ask why they are not married. If they are married, people ask why they do not have children. If they have one child, people ask why they are not having a second child. Against that background, a significant group suffer the pain of childlessness.

The causes of infertility are various. About one third can be attributed to problems experienced by the woman, and about 20 per cent. to problems associated with the man. A surprisingly high number of cases--some 30 per cent.--remain unexplained. This fact alone should galvanise the Government to redouble their efforts to investigate why the level of unexplained infertility is so high.

I should present my credentials at the start of the debate. I am not a scientific specialist on the subject. I know that others in the Chamber are, and they will talk more about the scientific aspects of the available treatments. I come to the debate very much as a mother, who is fortunate to have three children. However, I have gone through the problem of finding it very difficult to conceive and the strain that that places on a marriage, as both my husband and I were investigated to find who might be at fault. As in that 30 per cent. of cases, after all the examinations of genetic incompatibility and so on, the reason remained unclear. I have been there, but I have not experienced the degree of pain of those who reach the end of the process and are still unable to conceive.

One in six couples in the UK will experience difficulties in conceiving at some point in their reproductive lives. The extent of public funding for infertility treatments varies from region to region. Most infertility patients are either forced to seek private treatment to conceive, or at least are expected to contribute to the cost. One of the reasons that motivated me to apply for this debate is that my health authority--a relatively small authority--offered no assisted reproductive treatment in 1996-97. Effectively, no treatment was available to my constituents. This year, it is available, but only by extra-contractual referral. The budget for ECR is very restricted, so the prospect for the people I represent remains bleak.

For many couples, the only way in which to achieve successful conception is through techniques such as assisted reproductive techniques, or techniques that occur outside the human body, such as in vitro fertilisation. I will concentrate on IVF, but not to the exclusion of other available treatments.

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According to the report of the fifth national survey of NHS funding for infertility services, almost one quarter of health authorities in the UK funded none of the modern assisted conception techniques such as IVF. Obviously, my authority would have been one of those. It is interesting that the recommended level of provision is 40 cycles of IVF treatment per 100,000 of the population. That was the recommended level in the Effective Healthcare Bulletin. That compares with the actual figures, which show that no health authority in the UK is providing that level of treatment.

The range is great. Scotland comes nearest to the recommended figure, with 27.5 treatments per 100,000 of population. Wales is next, with 23 treatments per 100,000. I will not go through the entire list but, around the middle, Anglia and Oxfordshire offer 13.6 treatments per 100,000. Another reason why I have chosen this debate is that the west midlands has the worst result, with only3.5 treatments per 100,000. Northern Ireland publicly funds no modern treatments at all.

Underpinning the NHS provision is the principle that clinicians should have reasonable freedom to use their clinical judgment in respect of the treatment that they consider to be best for their patients, but patently it is difficult to see how there can be clinical freedom where the health authority has banned the treatment. The clinician can still recommend the modern treatment, but it will depend on a patient's capacity to go privately. The cost to the NHS of an IVF cycle--including drugs--is between £1,500 and £1,800. However, some units are able to provide treatment for as little as £1,000.

The cost of private care is significantly higher, and is estimated at £2,500 on average. Those figures are well beyond the pocket of many people. Thus, there is discrimination on economic grounds, as well as by region. The cost is not out of line with NHS treatments for other non-life threatening conditions, large though the sums may seem.

The main point of my speech is to call for equitable funding for infertility treatment throughout the NHS. It is manifestly unfair that one's postcode should determine access to treatment. The current fragmented nature of the availability of fertility treatment is cost ineffective, and the variable waiting lists tend to reduce the chance of success. The regional variation in eligibility criteria produces inequality, confusion and controversy about what help is available. My purpose today is to try to convince the Minister that cost-effective investigation and treatment should be offered routinely by health authorities in preference to some of the older treatments available, which have lower rates of success.

We need to achieve uniform provision and a full range of infertility investigations throughout the country. I draw the attention of the House to a written answer in Hansard in respect of infertility services. The Minister said:

I very much hope that we shall hear news on that today.

If the existing money were better spent, a great deal could be achieved with little, if any, extra expenditure. Clearly, national guidelines are needed. Few authorities

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do not have some form of eligibility criteria for IVF treatment. Only 8 per cent. of all health authorities did not have such criteria in 1996. Of the 66 authorities that use those criteria, 99 per cent.--nearly all--specify a limit on a woman's age and the majority have an age limit of between 35 and 40. One health authority offers IVF treatment to women up to the age of 43. The age limit is crucial for two reasons. First, the later age of childbearing in women may well mean that they wake up to the fact that they have an infertility problem only when they are approaching, or have even passed, the age of 40. Secondly, IVF treatment is much more successful in younger women and the success rate tails off as the woman increases in age. Perhaps it is not surprising that the age limit restrictions placed on the male are higher. In those authorities that place an age limit on the male, it tends to lie between 45 and 60.

Of the authorities that provide IVF treatment, 49 per cent. have criteria related to the length of a couple's relationship--one region in Scotland sets a minimum of five years--most have criteria based on the number of previous children and 67 per cent. have them based on the number of previous cycles of assisted conception, while 88 per cent. put a limit on the number of cycles that will be funded. It varies from one to three cycles.

Throughout the country, there is a wide range of eligibility criteria. The system is just as discriminatory if one is in a health authority that borders on another where such an age restriction applies. Women are well aware of the biological clock ticking and it is most unfortunate for those who find themselves on the wrong side of the border. Candidates may try to get over the postcode criteria by moving into an authority that would be able to meet their needs because of its different criteria. Health authorities perceive that problem and strenuous efforts are being made to clamp down on it. The inequality and variation in the criteria could encourage people to try to buck the system in that way.

To pre-empt the criticism that Opposition parties always ask for more money without saying where it could come from, I suggest to the Minister that a cost-effective way in which to improve access to and the availability of infertility treatment could be to reduce the number of centres and so raise success rates at those that remain. There is definitely a correlation between lower success rates and the number of cycles. That is not an uncommon phenomenon in health provision--the higher throughput tends to improve the success rates of treatments. Again, there is a surprising variation in the number of live births per egg collection at centres that provide IVF treatment. Hon. Members will see what I mean if I provide a few examples. Bourn Hall clinic has a 22 per cent. success rate of egg collections that led to pregnancy; the assisted conceptions clinic in Bath has a higher rate at 25.7 per cent.; Holly house, which is another well-known centre, has a comparable rate of 23.7 per cent.; the Nurture centre in Nottingham has a rate of 24.3 per cent.; and the centre in Leeds has a 23.2 per cent. success rate. Those figures are clustered and are probably close to the optimum being achieved in the country. However, other centres have a significantly lower success rate--for example, Glasgow with 5.6 per cent., Salford with 2.6 per cent. and, according to my figures, south Manchester which has a zero rate--that certainly gives us cause for concern.

Elsewhere in the health service, a similar phenomenon exists with other types of treatment. The higher the number of cycles, the more cases are treated successfully

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and the opportunity for teaching and imparting the skills that lead to success is also greater. The only difficulty with this sort of treatment is that, by its very nature, the patient cannot be too far from the treatment centre. Perhaps we could think in terms of regional centres of excellence with a good success rate. In concentrating funding in that way, we could achieve more treatments with a better success rate without spending more in absolute terms.

I crave my colleagues' indulgence, but I cannot conclude my contribution to this debate without flagging up some of the associated ethical issues, and I am about to stray into some controversial areas. I have no desire to block the way for others less fortunate than I to benefit from the advances that science brings, but some of those scientific advances have already given rise to abuse and the law has to be reviewed continually to take them into account. Only last weekend, in The Sunday Times of 3 May, we read the publicity about the fact that 300,000 embryos may have been used for research without explicit parental consent, which has caused distress to the parents and donors involved and must raise the question whether the laws in force are adequate to prevent abuse.

The use and subsequent treatment of spare embryos poses a general ethical problem, which stems from the very fact that more embryos have to be generated because the success rate for implantation is only 20 to 25 per cent. In most cases, a maximum of three embryos only can be implanted because of the higher risk of multiple pregnancy posed by that method of treatment, which can result in the need for a selective reduction in the number of embryos. That can cause considerable distress to the patient involved, apart from the ethical question of balancing the statistical probability of success with the prospect of having to reduce selectively a life so created.

An extreme example of what can go wrong was the Mandy Allford case, in which the number of successful implantations was exceptionally high--it had been artificially increased by a fertility drug. It was so high that in the end, none of the babies survived. That unacceptable waste of human life must raise the question whether the laws are adequate to protect the intrinsic worth of human life.

Another area of concern is the origin of the products of conception. In some cases, a donor is essential, either for eggs or for sperm, but, as yet, little research has been carried out into the psychological effect on the parent and/or the child, or indeed the donor, of that aspect of infertility treatment. The law on that aspect came under scrutiny with the Diane Blood case. She wanted to use the sperm of her deceased husband to create new life. Baroness Warnock made the position expressly clear when she said:

A way round the law was found in that highly publicised case, however, when Mrs. Blood was permitted to seek treatment abroad. I ask the Minister whether that does not, to some extent, undermine the safeguards that Baroness Warnock had in mind.

Cloning is a recent development connected with the treatment of infertility and IVF in particular--it means creating a genetically identical human being. I have the good fortune to serve on the Select Committee on Science

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and Technology, and my colleagues on the Committee devoted much attention to that subject in a previous Session of Parliament, but it is a continually moving science. We have the example of Dolly the sheep, cloned from an adult using the method of nuclear replacement. If that technique is further developed, the unique genetic identity of a family could be undermined. Surely a couple who plan to have a family should not, ethically, be able to plan for that family's genetic characteristics.

Some may regard cloning as a way in which to replace a lost child or adult, but that would be a form of cheating death. It would also affect the integrity of the family unit by blurring parent-child distinctions--for example, if I could clone my husband, the clone would be a twin, not our child. If we allowed such a technology to develop, we would be moving away from our concept of how a unique life is generated.

We must ask whether the law is moving at the same pace as technology, and what we really want for the human race. Egg cells, such as those used in the cloning of Dolly the sheep, have 46 chromosomes--a full complement of genetic information to create new life. We need a wider international ban on nuclear replacement techniques.

Two other ways in which to deal with infertility and its difficulties give rise to ethical considerations--surrogacy and adoption. The concept of surrogacy is not unknown in history--there is a biblical instance which, although perhaps not a good example, shows that the practice was known in ancient times. Surrogacy has been publicised in modern times because it is commercially available in some countries. It is hard to prevent commercial surrogacy--although it is illegal in this country, we know from the media of people who have managed to get round the law.

My fundamental objection to surrogacy is the curious relationship that develops as the host mother has to dissociate herself from the child whom she carries for nine months. The psychological problems that arise when the mother has to part from the child are well publicised--some surrogate mothers find parting very difficult, which causes heartbreak and pain to the couples. The question who is responsible if the surrogate child is born handicapped has not been put to the test in law, but we need to deal with it as part of our general consideration of the problems of childlessness.

For many couples, adoption is the only solution to unresolvable infertility problems. Many of us know from experience that adoption can be difficult. There are few new-born babies available for adoption, and couples face a long and hard process if they choose to adopt. I should be glad if more were done to make that process easier, in human terms, without compromising the integrity of protecting the needs of the child at the centre.

I hope that, by evoking some of the more complex and controversial ways in which to deal with childlessness, I have not distracted the House from my basic premise that more should be done to give equal access to couples who need fertility treatment. We all understand that rationing is a feature of public health provision, but to decide who should receive treatment on the basis of a postcode is patently unjust--the disparity in eligibility criteria between health regions that offer treatment is an injustice. I urge the Minister most strongly to consider

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ways in which equal access to infertility treatment could be ensured, and to establish national guidelines for eligibility.

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