Fertility Treatment

What is fertility treatment?

Fertility treatment is the use of medical intervention techniques to aid the natural process of conception.

Most people seeking fertility treatment are not entirely 'infertile'; rather one or more parts of their reproductive systems are impaired, and they therefore require medical help to conceive. This is referred to as 'sub fertility' as opposed to 'infertility'.

For men, the most common cause of 'sub fertility' is due to poor sperm quality. For women the matter is more complicated and can be caused by a number of factors.

Fertility treatment is provided in the UK by individual clinics around the country, specialising in different forms of treatment and providing a variable quality of service and price. High-tech treatments, such as in vitro fertilisation (IVF) and treatments using donor sperm, eggs and embryos, are regulated in the UK by the Human Fertilisation and Embryology Authority (HFEA).

Different causes of infertility or sub fertility require different intervention techniques. The most frequently used treatments are: ovulation induction (hormone treatment); artificial insemination, using the partner's sperm and intra-uterine insemination; surgery to improve blocked or damaged fallopian tubes; gamete intra fallopian transfer; IVF; intra cytoplasmic sperm injection; donor insemination; and surgical sperm recovery.

Background

Fertility treatment has been at the cutting edge of medical science throughout the 20th Century. The year 1928 saw the first sperm counts taken and the first hormonal induction of ovulation. The first children conceived through Artificial Insemination were born in 1934 in the USA.

In vitro maturation of animal oocytes was proven to be possible in 1939, but it was not until 1978 that the first 'test tube baby', Louise Brown, was born. The first Preimplantation Genetic Diagnosis baby was born in 1990 and the first intra cytoplasmic sperm injection baby was born in 1992.

The Human Fertilisation and Embryology Authority (HFEA) was set up under the 1990 Human Fertilisation and Embryology Authority Act to license those providing fertility treatments and conducting fertility research, including the NHS, and began work in 1991.

Clinics and researchers are obliged to adhere to the HFEA Code of Practice, and are subject to inspection. The Human Fertilisation and Embryology Authority also provides information and guidance for prospective parents seeking to undergo fertility treatment. It is also required to ensure clinics "take account of the welfare of any child who may be born as a result of the treatment (including the need of that child for a father), and of any other child who may be affected by the birth".

The Human Fertilisation and Embryology Authority also has an explicit role in promoting public debate about fertility treatment and medical research.

The 1990 Act was amended in 2001 to allow the use of embryos for stem cell research and to provide for its regulation.

February 2004 saw the publication of national guidelines on fertility treatment by the National Institute for Clinical Excellence (NICE), with the aim of providing consistent NHS fertility treatment across the country.

In January 2004, the Government changed the rules for egg and sperm donation, ruling that children conceived through fertility treatment would have the right to know who their biological parents were. But, egg and sperm donors would have no obligation to meet with their biological children, or provide them with financial support. The new rules came into effect in April 2005, and are not retroactive, so children conceived before this date would not be able to access details about egg and sperm donors.

The number of sperm donors has been falling for a number of years, but although this was expected to get worse once donors lost their anonymity, there is no evidence to back this up. The shortage has prompted clinics to look overseas for sperm donors. If the number of sperm and egg donors fails to keep up with demand, there is some concern that couples will travel overseas to receive treatment, where fertility treatment is sometimes not as tightly regulated as in the UK.

Controversies

Fertility treatment is a highly controversial area of medicine: it can be medically risky for participants and is frequently very emotionally exacting; it is expensive; and the development of new techniques raises complex and controversial ethical questions. More widely, it generates debate about the international regulation of medical research and the commodification of human life itself.

Few, however, would question the right of couples to seek medical assistance if they are having difficulties conceiving, and many of the techniques described are widely accepted. Today, IVF treatment is relatively commonplace, but in 1985, a Private Member's Bill sponsored by Enoch Powell was almost successful in outlawing all research on human embryos altogether, mirroring the current debates about stem cell research.

Controversies arising from evolving fertility treatment keep the subject near the top of the media agenda: advancing technology permits older parents to conceive, the sperm of dead fathers to be used, and the precise characteristics of babies to be 'designed'. The heart of the problem is where the line between fertility treatment, cloning and genetic engineering lies.

One scandal arose in 2003 when black twins were born to a white couple at a Leeds IVF clinic – prompting extensive judicial activity to establish their actual legal parenthood. In January 2005 a 66 year-old Romanian woman gave birth to a daughter after fertility treatment, making her the oldest mother in the world. The case provoked controversy, with some terming the woman involved as 'selfish'.

The availability of fertility treatment on the NHS, and its alternatives, is also a matter of controversy. Access to services can be difficult to secure, and many prospective parents have to use expensive private clinics. While the poor do not have this option, the range of services available to the rich outside the UK and its regulatory environment raises questions about the commercialisation of reproduction and the ethics and motivations of 'rogue' doctors.

The National Institute for Clinical Excellence's 2004 guidelines aimed to address availability problems by recommending that every couple be given access to IUI and IVF treatment. However, the Government's response – on cost grounds – that IVF treatments be limited to one course per couple caused widespread disappointment, particularly in view of the fact that the first course was often unsuccessful and useful for diagnostic purposes only.

The role played by the HFEA in setting ethical boundaries has also caused controversy, particularly in cases involving genetic screening of embryos. When, in November 2004, the HFEA granted the first licence to a clinic to screen embryos for diseases they might develop as adults, it was accused of taking a major ethical decision behind closed doors.

The clinic involved in the controversy wanted to test embryos for the genetic mutation that causes familial adenomatous polyposis coli (FAP), which strikes in the early teens. It causes multiple rectal and colon cancers and most people with the condition end up having their colons removed. Although there are strong arguments for embryo selection for this disease, critics worry that if genetic selection is allowed, it will be the beginning of a slippery slope towards outright genetic engineering.

Issues of consent rose to prominence when Natallie Evans lost her court battle to be implanted with embryos created in a former relationship. Her ex-boyfriend refused to allow Ms Evans to attempt to carry their unborn child to term, despite consenting to the original fertility treatment. The case went all the way to the European Court of Human Rights, which upheld the British courts' original decision that consent can be withdrawn up until the point the embryos are implanted. Ms Evans argued the ruling violated her right to a family life.

The debate over fertility treatment shows no signs of abating, with each new scientific advance heralding a fresh wave of controversy. Among the most controversial proposals was the creation of hybrid human-animal embryos, which scientists claimed was necessary to provide sufficient material for research.

In 2007 the government announced plans to overhaul fertility legislation in light of the many technological developments that had arisen over the previous two decades. The subsequent Human Fertilisation and Embryology Act 2008 mainly amended the 1990 HFEA Act. The new Act included measure to ensure that all human embryos outside the body, and all “human-admixed” embryos created from a combination of human and animal genetic material for research would be subject to regulation; to ban sex selection of offspring for non-medical reasons; and to recognise same-sex couples as legal parents of children conceived through the use of donated sperm, eggs or embryos.

Also in 2008 the Department of Health established an Expert Group on Commissioning NHS Infertility Provision with the aim of identifying barriers to the implementation of the NICE fertility guideline and helping NHS commissioners in their decision-making on infertility treatment provision. In its interim report the Group's recommendations included the establishment of a "clinical pathway" and a "national tariff" for regulated fertility services. The final report was published in January 2010.

More recently plans to abolish the Human Fertilisation and Embryology Authority have attracted some controversy. The Coalition government elected in May 2010 promised to reduce bureaucracy and cut costs by a 'bonfire of the quangos' – arm's length bodies funded by Whitehall. The Health Secretary, Andrew Lansley, consequently carried out a review of the Health Department's ALBs and concluded these could be reduced from 18 to between eight or ten, one of the casualties being the HFEA.

The Public Bodies Act , which received Royal Assent in December 2011, enables the Government to either abolish or merge certain public bodies, including the HFEA, when it is ready to do so. 

Statistics

Around one in six or seven couples may have difficulty conceiving. This is approximately 3.5 million people. However, the number of couples who are actually infertile is low, around 5%.

About 85% of couples will conceive naturally within one year if they have regular unprotected sex.

For every 100 couples trying to conceive naturally:
• 20 will conceive within one month
• 70 will conceive within six months
• 85 will conceive within one year
• 90 will conceive within 18 months
• 95 will conceive within two years

For couples who have been trying to conceive for more than three years without success, the likelihood of pregnancy occurring within the next year is 25% or less.

Source: NHS Choices – 2012
 

Quotes

“Assisted reproduction is a fast developing field whose regulation raises fresh challenges on an almost daily basis. It is a privilege to preside over that regulation. I am determined that this crucial work is continued to the highest of standards during this period of change.”

Prof Lisa Jardine on her re-appointment as chair of the HFEA for the period January 2011- January 2014