A Research Of Infertility: the NHS Relationship With With Laws of Treatment

Introduction

Concern about infertility has hugely affected many people in all different types of ways. Infertility is the inability of a woman to conceive or to have a successful live birth. The word health organisation defines infertility as: “Infertility is a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse”. However many definitions of infertility are not thorough and are different between counties which causes issues. Therefore estimates concerning prevalence of infertility differ across countries and communities. In-Vitro fertilisation is offered to couples on the NHS who have tried to have regular unprotected sex for two year. Infertility is caused by a variety of things and some medications can cure some infertility but other cases are much more complicated. IVF can therefore offer hope to many couples. It has been argued that the medicalisation of infertility has caused medical professionals to ignore the psychological impact of infertility and the stigmatisation that they face. The aim of this project is to investigate infertility and how the NHS deals with laws regarding IVF treatment. The objective for this project is to provide information on different types of infertility as well as causes and risks. Additionally, there will be an analysis on the diagnosis of infertility and the different types of treatment available. There will be a discussion on various changes on how IVF treatments are accessible to those living in the UK and issues surrounding the topic of IVF. Lastly, I will mainly be focusing on how the NHS manages infertility, diagnosis and accessibility in the UK.

Methodology

A variety of primary and secondary sources were used to provide evidence for how age affects infertility and IVF treatment on the NHS.

Primary Research

Two types of primary research were used; an interview and a questionnaire. Qualitative primary research was carried out in the form of an interview. The interview was conducted with a midwife who worked in the maternity ward. A variety of questions were asked to get an understanding on IVF on the NHS, including how much it costs on the NHS as well as the processes of the infertility treatment. The answers from the questionnaire were valid as they came from a healthcare professional. Therefore, the interview was able to give me honest results about particular facts surrounding infertility.

A Quantitative questionnaire was carried out in addition to primary research. The purpose of the questionnaire was to get an idea of what people from different ages know about infertility and the comparisons of views from people who have children and those who have not got children. 50 questionnaires were distributed among classmates, work colleagues, friends, and hospital patients. The results from this questionnaire were quite valid as I distributed the questionnaire to a large quantity of people. The results from this questionnaire will count for the majority of answers about infertility.

Secondary Research

A web page by Babycentre was used to provide evidence about how age affects infertility. A graph was used to identify the percentage of the likelihood of infertility and the likelihood of pregnancy in women. This web page had a trusted authority as it was approved by the Babycentre Medical Advisory Board. The purpose of the web page was to provide facts and data about the relationship between age and fertility. The web page was very current as it was last reviewed in 2018 which makes the web page very reliable.

A source from fertility fairness provided evidence of how many NHS providers offer IVF if either parent has a living child. A diagram was used to show evidence of the accessibility of infertility treatment to different types of couples. This webpage was from a trusted authority because its from a new’s company therefore this information can be seen as highly reliable. The purpose of the webpage was to explain how IVF couples on the NHS face social rationing. Finally, the webpage was published in 2018 which makes it a very current source and therefore useful in my investigation.

Limitations

The limitations of this project were trying to persuade people to fill in my questionnaire. As most of the people I distributed my questionnaire to were either students or colleagues, they were extremely busy so it was difficult to find people who had the time to complete my questionnaire.

Timeline

A planning schedule form was created where different tasks for specific days were filled. This allowed me to structure my project thoroughly and organize my time well so that I can complete the project effectively.

Ethical Considerations

One of the ethical considerations I had to be aware of when conducting my primary research is not doing harm to anyone who participated in my questionnaire. I had to make sure that my questions were not too personal and allowed people to answer them without feeling offended. In my investigation, I was aware that there was an element of risk since the outcomes of my research were uncertain. I had to take time beforehand to think about the ethical implications that my question could summon and how I would protect people.

Therefore, I decided to make my questionnaire anonymous, concealing people's identity in order to maintain confidentiality so I was the only one who had access to the results. I also recorded all my observations and any actions I intended to take in my timeline. Overall, I think I managed my ethical considerations well as I was able to get informed consent from all the participants because I thoroughly explained my research to them and told them what they will have to do and why and finally, how this information was going to be used and who will have access to it. When conducting the interview with a midwife, I was aware that I had to keep the information confidential such as the hospital she worked in. Finally, to improve my investigation, I could have focused on a larger group of people instead of focusing on one social group. I could have asked strangers on the streets to get different viewpoints from colleagues and classmates. I’ve therefore learnt that it is unethical to choose participants from one particular social group unless the research is specifically about that group.

Investigation

What is infertility? Infertility is the inability of a fertile woman to conceive after 12 months of regular unprotected sex according to UCLA Health (2019). Around 1 in 7 couples are infertile in the UK, this is about 3.5 million people. Infertility occurs in both men and women. This definition is very similar to the WHO’s definition of infertility which is the inability to achieve a clinical pregnancy after 12 months of regular unprotected sexual intersourse. It can also be seen as the inability of a non- contracepting sexually active woman to give birth.

What are the types of infertility? There are two types of infertility: primary and secondary.

• Primary Infertility: when a couple has tried conceiving in 12 months without birth control, this is a psychological condition in couples that have never been able to conceive.
• Secondary infertility: when a couple has had successful normal pregnancies in the past but can no longer conceive.

Sub-infertility is when a couple is less fertile than the average couple. It means that the couple needs to try a lot harder and longer than an average couple in order to conceive. A couple that is unsuccessful in trying for a child after a certain period of time is sometimes said to be subfertile, meaning less fertile than a typical couple. Some people are faced with unexplained infertility where the reason for the infertility is not clear.

What can make you at risk of becoming infertile? The most common risk of becoming infertile is age. As we get older, fertility in women gradually declines usually for women in their late thirties and onwards. This may be due to health problems that the woman has already endured or her quality of eggs. A source from Helen A. Carcio revealed that the likelihood of getting pregnant within one year decreased with age. Additionally, it also showed that the likelihood of infertility increases with age. Currently, female fertility peaks at age 24 and diminishes after 30 whilst male fertility peaks at 25 and declines after 40. The results from my primary research provided evidence that infertility in women diminishes after 30.

As men age, their testosterone levels decrease as well as the concentration which could lead to low sperm counts. Low sperm counts can be due to many environmental factors such as radiation and exposure to pesticides. Heavy alcohol users are also at high risk of becoming infertile. Additionally, an unhealthy lifestyle which causes you to be overweight or underweight can cause infertility. Being underweight increases the risk of infertility especially in those who are suffering from eating disorders because they follow a very strict diet. Other risk factors include sexually transmitted infections.

What are the causes of infertility? There are a variety of causes of infertility. Many people believe that infertility is a women's problem but only one third of women are infertile in the UK. In women infertility could be due to how ovaries function or problems with the fallopian tubes caused by a blockage after an infection. Common causes for infertility in women are due to ovulation disorders such as endometriosis. Women must have unblocked tubes that allow sperm to reach the eggs and the sperm must be able to fertilise the egg when they meet. Additionally, the fertilised egg must be able to become implanted in the woman’s uterus and must be of good quality.

In this process, mucus in the cervix becomes thinner allowing the transport of the sperm to the egg. Poor mucus can cause problems when conceiving, around the womb, women have fibroids which are non-cancerous which could cause issues such as blocking the fallopian tubes. Additionally, anovulation can occur which is the failure of eggs or inability of the ovaries to produce and release an egg. Many factors can contribute to anovulation such as stress, weight loss and the excessive production of prolactin and polycystic ovaries. Approximately 35% of women experience anovulation at some point during their lives. The origin of this hormonal disorder may be in the hypothalamus, a part of the brain that controls hormonal function, the pituitary gland, or in the ovary itself.

Endometriosis

Endometriosis is a common chronic disorder of ovulation where the lining tissue grows outside the uterus damaging the ovaries and fallopian tubes. Endometrial tissue is displaced during the menstrual cycle and becomes trapped which leads to heavy and painful periods. This can cause inflammation and pain and therefore lead to infertility in women. It can be inherited from family and currently 1,5 billion women in the UK are living with this condition.

In men, many factors affect infertility such as sperm quality and movement of sperm to the egg. Azoospermia affects the inability to produce sperm and Oligospermia which is the production of low sperm count. Different issues can affect the sperm because perm cells can die before reaching the egg. Therefore, the damage of sperm can affect the quality of semen. Sometimes, infertility can be caused by chromosomal abnormalities or cystic fibrosis.

Effects of Drugs on Infertility

Research shows that miscarriages are more frequent in women who are tobacco users. Also men who use tobacco are at risk of getting a low sperm count and erectile dysfunction which may result in them being infertile. Smoking can cause infertility in men blocking the production of sperm and decreasing the size of a man's testicles. In women, smoking can change the cervical mucus, thus affecting the way the sperm reaches the egg. Marijuana may disrupt a woman's ovulation, Marijuana use affects men by decreasing the sperm count and quality of sperm. Heroin and cocaine induces similar effects. Heavy drinking can cause infertility and disorders related to ovulation in women. In men, heavy drinking can decrease sperm concentration and cause sexual dysfunction. Too much exercise may cause a disruption in the ovulation cycle in women, causing miscarriages and in men, it could lower the sperm count. Additionally Obesity can affect infertility and weight disorders such as bulimia and anorexia can also disrupt ovulation cycle.

Statistics

Research by Drakeley (2017) showed that many people were unaware that fertility actually decreased with age. A survey was given to some young adults between the ages of 16 and 25 year olds and the results showed that people were very unaware about infertility. Also, in 2016, studies showed that 2-3% of births each year are due to In-vitro fertilisation (IVF). In the UK, the average age for a woman having IVF is now 35 years. In addition, studies show that between the periods of 1930-1990, the sperm counts in men have halved causing the number of infertile men to double. This decline is still continuing and scientists are trying to find out why that is the case. Additionally, research shows that only 55% of people having treatment are single or in same sex relationships. In the UK, unexplained infertility accounts for around 25% of cases of infertility.

There is evidence of associations between infertility and indicators of socioeconomic status. Experience of infertility was most common among women with a degree and lowest among those with no academic qualifications while no statistically significant association was observed among men. Prevalence was also higher among those in managerial, professional and technical employment compared with those in routine occupations. No association was found between infertility and area-related deprivation at interview among women or men. A national survey of sexual attitudes and lifestyles was taken between 2010 and 2012 by about 15,00 men and women. The results showed that almost 13% of women and 10% of men said that they had experienced a period of infertility at some point in their lives.

Infertility may cause psychological effects such as a couple being anxious to conceive which may increase sexual dysfunction. Additionally, a couple may have many marital disagreements especially when making medical decisions which will impact their relationship. Additionally, it may trigger some mental illnesses to occur such as depression and stress. In many cultures, the inability to conceive bears a stigma. In closed social groups, a degree of rejection may cause anxiety and disappointment. It has been suggested that in some countries, infertility can be seen as a form of disability.

Infertility Diagnosis

Doctors need to be able to diagnose infertility by understanding a couples sexual habits however, these procedures may be expensive. Additionally, many medical plans do not reimburse procedures associated with fertility treatment. In addition, there is a no guarantee that the procedures will be successful. My primary research can be used to provide evidence for the reimbursement of fertility treatment. I conducted an interview with a midwife from the maternity ward. The results from the interview clarified that most medical plans for IVF on the NHS do not provide any money back guarantee. Additionally, the results from the interview stated the expense of NHS IVF cycles which was £2000 per cycle.

Tests for male fertility try to identify whether the ejaculation of sperm is impaired through physical exams. These tests include genetic testing or testicular biopsy. Tests for women try to identify whether the fertilised egg can travel to the uterus and become implanted through physical examinations. These tests include ovulation testing and hysterosalpingography.

Infertility Treatments

Fertility medicines are given to help women with ovulation problems, these medications include Clomiphene and Tamoxifen.

Treatment for Women

Fallopian tube surgery: The fallopian tube prevents the blockage of the perm to the egg or the fertilised egg to the uterus. Fallopian tube surgery can try and correct this. This procedure can be done using microsurgical techniques.

Intrauterine insemination (IUI): During this procedure, healthy sperm is placed into the uterus at the time of fertilization.

In Vitro-Fertilisation

Assisted conception can be used in order to create a pregnancy artificially. During this procedure, mature eggs from the woman are stimulated and retrieves and are fertilised with a man's sperm in a dish in a lab. The fertilised embryo is then implanted back into the woman's uterus .

Additionally, evidence from my primary research (*SEE APPENDIX 1) showed that there are other alternatives to IVF. The midwife from the interview stated that gamete intrafallopian transfer (GIFT) can be used which has the first two same steps as IVF. Another procedure, zygote intrafallopian transfer (ZIFT), combines elements of IVF and GIFT.

Treatment for Men

Men can sometimes improve their infertility by altering their lifestyle choices such as taking medication and reducing harmful substances such as alcohol use as well as improving timing and frequency of intercourse. Treatments for men include surgery to reverse sperm blockages to restore fertility. Additionally, in some cases, repairing a varicocele may improve the chances of a successful pregnancy.

IVF Treatment on the NHS

In 2016, most IVF treatments were funded by the NHS. However, there have been significant differences across the UK. Many countries have special frameworks which make laws about fertility treatment. The most common framework is the Human Fertilisation and Embryology Authority (HFEA) which is the UK’S regulator for fertility and embryo research. However, local clinical commissioning groups (CCG’s) in England differ significantly and many have reduced the number of NHS IVF cycles offered to women under 40. Additionally, the number of CCG’s following the national guidelines which is to provide 3 NHS- funded INF cycled has dropped significantly. Currently, there are 7 CCG’s who have completely removed NHS funded IVF treatment while 7% are thinking of reducing fertility treatment. Therefore, couples in need of IVF on the NHS are faced with the postcode lottery because the availability for NHS funded IVF is decreasing and there is a divide between the north and south sides of the UK. Additionally, some CCG’s have specific age restrictions and do offer NHS IVF treatment to women between 35-42 years old, This goes against the National Institute for Health and Care Excellence (NICE) guidelines which states that eligible women under 40 should be offered 3 full IVF treatments on the NHS. Therore, the postcode lottery creates inconsistent decisions, bias and causes widespread inequality.

However, the National Institute for Health and Care Excellence (NICE) guidelines are currently being emphasised in aim to end the postcode lottery and support couples suffering with infertility. Currently, some areas have seen to improve such as Scotland where there was a large increase in NHS funded IVF. Additionally, Northern Ireland and some English regions have seen as increase. However the East of England is still rapidly reducing the number of NHS funded IVF treatments.

Results and Findings

My primary research results showed that 30% of participants between the ages of 25-35 who already had children wanted more children. This shows that many people still hope to have another child even though fertility in women diminishes after 30. Therefore this means that many people will be highly unlikely to get IVF on the NHS if they fail to conceive naturally. Additionally, 10% of participants were unaware of how expensive IVF treatment is. This shows that there is a lack of awareness and facilities suffering from IVF. In addition, 60% of applicants who completed my questionnaire were unaware of the postcode lottery associated with IVF. This shows that man IVF couples are unaware their ability to access IVF treatment depends hugely on their income instead of illness.

Additionally, my primary research results provided evidence for my investigation. In the interview, the midwife was able to clarify that IVF treatment is £2000 per cycle which shows that IVF treatment is very expensive. Additionally, the midwife provided information that most costs were non-refundable as IVF is by change. In addition, the midwife confirmed that infertility deteriorates after the age of 30.

A web page by Babycentre showed the following results: Overall, the graph showed a general increase of infertility as the ages increased while a general decrease was shown for the likelihood of getting pregnant. The graph showed that young women from that young women from the ages of 20-24 were most likely to get pregnant. However, women between 35-39 only had a 36% chance of becoming pregnant. The purpose of this web page page was to provide information on how age affects infertility. This source was from a web page from the baby centre medical advisory board which was a trusted authority. Babycenter is an online media company based in San Francisco that provides information on conception, pregnancy, birth and early childhood development and expecting parents and its medically reviewed information. The information from this webpage was published in 2018 which makes it relevant and current source.

A source from fertility fairness provided evidence of how many NHS providers offer IVF if either parent has a living child. These were the following results: The Source showed that around 80% of the NHS providers offered IVF treatment if the couple had no living children between them or previous relationships. Additionally, around 10% of NHS providers give IVF treatment if at least one partner has no living children. Around 4% of NHS providers offer IVF treatment if neither partner has a child living with them. Around 4% of NHS providers offer INF treatment if there are no children living with the couple. Finally, around 2% of NHS providers offer IVF treatment if the couple has no living children from their current relationship. This source was from BBC News which is an operational business division of the Broadcasting Corporation responsible for the gathering and broadcasting of news and current affairs, therefore this source had a trusted authority. The purpose of this online newspaper article was to give information on how Couples in need of IVF on the NHS are facing social rationing. The online newspaper article was published in 2018 which makes it quite current and relevant.

Conclusion

In conclusion, infertility treatment on the NHS has shown to be unfair due to different laws and regulation across the UK which has caused inequality for infertile couples. Infertile problems do face a variety of mental issues and also puts a strain on the relationship between infertile couples. Additionally, information is lacking about important characteristics and pathways of fertility. Also, fertility fairness is working hard end the postcode lottery approach to IVF treatment.