Fertility assessment and investigations are commissioned where:

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:

• the woman is aged 36 years or over
• there is a known clinical cause of infertility or a history of predisposing factors for infertility.

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:

• For female same-sex couples failure to conceive after six (6) privately funded cycles of artificial insemination within the past 12 months, in the absence of any known cause of infertility, should be the indication for NHS funded fertility investigation.
• For male same-sex couples failure to conceive after six (6) privately funded cycles of artificial insemination within the past 12 months or 12 months with vaginal intercourse, in the absence of any known cause of infertility, should be the indication for NHS funded fertility investigation.

Eligibility criteria for assessment, investigation and treatment apply as set out in this policy.

Individual treatments commissioned are as set out below:

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:

• they have been trying to get pregnant through regular unprotected sexual intercourse for a total of two (2) years or;
• they are using artificial insemination to conceive and have not become pregnant after 12 cycles – at least six (6) of these cycles should have been using intrauterine insemination
• they require donor sperm for a clinical indication (see Donor insemination)

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 chances 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

• When considering the number of fresh and frozen embryos to transfer in IVF treatment, single embryo transfer should be undertaken if two (2) or more top quality embryos are available.
• No more than two (2) embryos should be transferred per transfer episode.

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:

• people who are unable to, or would find it very difficult to, have vaginal intercourse because of a clinically diagnosed physical disability or psychosexual problem who are using partner or donor sperm;
• people with conditions that require specific consideration in relation to methods of conception (for example, after sperm washing where the man is HIV positive).

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:

• do not routinely offer intrauterine insemination, either with or without ovarian stimulation (exceptional circumstances include, for example, when people have social, cultural or religious objections to IVF)
• advise them to try to conceive for a total of two (2) years (this can include up to one (1) year before their fertility investigations) before IVF will be considered.

For IUI for donor insemination for clinical indications, see Donor Insemination below.

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.

The couple should only be offered ICSI if:

• there are few sperm in their semen or they are of poor quality, or;
• there are no sperm in their semen (either because of a blockage or another cause) but there are sperm in their testes which can be recovered surgically, or;
• they have already tried IVF but there was no fertilisation of the eggs or no embryos suitable for transfer (see Abandoned IVF or ICSI cycles).

Donor insemination for clinical indications

Donor insemination is funded for:

• azoospermia
• severe deficits in semen quality in couples who do not wish to undergo ICSI
• where there is a high risk of transmitting a genetic disorder to the offspring
• where there is a high risk of transmitting infectious disease to the offspring or woman from the man, and
• severe rhesus isoimmunisation.

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.

• Donor sperm required for a clinical indication may be used for:
  • one (1) cycle of IVF or
  • unstimulated IUI followed by one (1) cycle of IVF, if IUI is unsuccessful. There will be no requirement for a couple to undergo a specified number of cycles of unstimulated IUI before receiving IVF. Up to six (6) cycles of unstimulated IUI may be offered dependent on the availability of donor sperm. or
  • three (3) cycles of stimulated IUI followed by one (1) cycle of IVF, if IUI is unsuccessful.
• Before starting treatment by donor insemination it is important to confirm that the woman is ovulating. Women with a history that is suggestive of tubal damage should be offered tubal assessment before treatment.
• Women with no risk factors in their history should be offered tubal assessment if clinically indicated.

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:

• premature ovarian failure
• gonadal dysgenesis including Turner Syndrome
• bilateral oophorectomy
• ovarian failure following chemotherapy or radiotherapy, and

Also where there is a high risk of transmitting a genetic disorder to the offspring.

Egg donors

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 for clinical reasons prior to egg retrieval
• There was no fertilisation of the eggs or no embryos suitable for transfer

One further IVF cycle will be funded after an abandoned cycle. ICSI may be offered if clinically appropriate (see ICSI for criteria). Further IVF cycles will not be funded after any subsequent abandoned cycle.

Abandoned fresh embryo transfer

After oocyte retrieval, if a fresh embryo transfer is not possible for clinical reasons, storage for up to one year and up to two frozen embryo transfers will be funded for the NHS cycle.

Abandoned frozen embryo transfer

If a frozen embryo transfer was intended but is not possible for clinical reasons and the treatment is cancelled prior to warming the embryo, storage for up to one year and one further frozen embryo transfer will be funded.

Cryopreservation for preserving fertility

Cryopreservation for preserving fertility is covered by a separate policy.

Surrogacy

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.

Same-sex couples

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.

Eligibility Criteria

Eligibility Criteria for NHS Funded Fertility Assessment

Previous sterilisation – Neither partner sterilised, even if sterilisation has been reversed.

Previous assisted conception – Couples who have not previously received NHS funded assisted reproduction techniques (as defined below).

Eligibility Criteria for NHS Funded Assisted Reproduction Techniques

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).

The couple should be aware that although they may meet eligibility criteria for treatment, their clinician may decide that it is not clinically appropriate for them to receive assisted reproduction.

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. There is insufficient evidence currently to suggest nicotine replacement therapies or electronic cigarettes (e-cigarettes) have a negative effect on the outcome of assisted reproduction techniques and therefore patients who use them should not be excluded from NHS treatment.

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 licencing 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 –

• There should be no living children from the current relationship, and
• At least one partner must have no living children from previous relationships.

This includes biological and legally adopted children and offspring who are adults.

Relationship – The stability of the relationship is very important for the welfare of children; couples must be in a stable relationship for at least two years to be entitled to receive NHS-funded assisted reproduction techniques.

Previous assisted conception – The couple has not previously received NHS-funded assisted reproduction techniques. This applies unless failure of NHS-funded IUI is required to access IVF.

Referral Instructions

Supporting referral guidelines

• South Devon and Torbay fertility clinical referral guideline
• Western fertility clinical referral guideline

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 NHS Devon upon receipt of a completed application from the patient's GP, consultant or clinician. Applications cannot be considered from patients personally.

Patient Information

Individual Funding Request (IFR)

Date of publication: 7 January 2019

This replaces the previous policy published in 22 November 2017