Cathal Crowe
Question:399. Deputy Cathal Crowe asked the Minister for Health if there are plans to expand the parameters of the publicly-funded IVF scheme (details supplied); and if he will make a statement on the matter. [7311/24]
View answerThursday, 15 February 2024
Questions (399)
Written answers
As the Deputy may be aware, a commitment to “introduce a publicly funded model of care for fertility treatment” is included in the Programme for Government.
The Model of Care for Fertility was developed by the Department of Health in conjunction with the HSE’s National Women & Infants Health Programme (NWIHP) in order to ensure that fertility-related issues are addressed through the public health system at the lowest level of clinical intervention necessary.
This Model of Care comprises three stages, starting in primary care (i.e., GPs) and extending into secondary care (i.e., Regional Fertility Hubs) and then, where necessary, tertiary care (i.e., IVF and ICSI (intra-cytoplasmic sperm injection)), with patients being referred onwards through structured pathways.
Phase One of the roll-out of the Model of Care has involved the establishment, at secondary care level, of Regional Fertility Hubs within maternity networks, in order to facilitate the management of a significant proportion of patients presenting with fertility-related issues at this level of intervention. Patients are referred by their GPs to their local Regional Fertility Hub, which provides a range of secondary treatments, and both medical and surgical interventions
Phase Two of the roll-out of the Model of Care relates to the introduction of assisted human reproduction (AHR) treatment provided through the public health system at tertiary level. In particular, the first steps have been taken towards achieving the ultimate objective of Government, which is a wholly publicly-provided fertility service.
As an interim measure, funding has been made available to support access to AHR treatment via HSE approved private providers, following a comprehensive tender process, from September 2023. As well as IVF and ICSI, this allocation is also being used to provide, initially through private clinics, IUI (intrauterine insemination), which can, for certain cohorts of patients, be a potentially effective, yet less complex and less intrusive treatment.
Referrals for AHR treatment by private providers commenced in the week beginning September 25th 2023 after details of how the new initiative would be initially rolled out – including regarding the set of criteria which prospective patients should meet in order to access fully-funded AHR services and the specific services to be initially funded – were brought to Cabinet in July 2023. The criteria were developed and finalised further to engagement and consultation with experts in the field of reproductive medicine, with the clinical parameters of the access criteria including the assessment of such areas as age, body mass index (BMI) and other health and well-being elements.
These clinical parameters were reviewed in the context of both the potential success or otherwise of the advanced fertility treatment itself but also the health and well-being of the intending birth mother and any resultant pregnancy, inclusive of the management of maternity care, delivery and health of any child.
More details on public fertility services generally, including information on the new publicly-funded AHR treatment initiative, are available from the HSE at: www2.hse.ie/conditions/fertility-problems-treatments/fertility-treatment/.
Specifically in relation to the clinical parameter of age, it is important to note that age affects the fertility of both women and men. Women are born with all the eggs they are going to have. Fertility starts to reduce after the age of 30 and this reduction happens faster after the age of 35. By the age of 43 or 44, most of a woman’s eggs will be of poor quality and, while possible, it is very rare to get pregnant.
The reason for the reduced fertility is two-fold. The first reason is related to the fact that poorer quality, older eggs are less likely to lead to pregnancy. Even if they do, the chance of miscarriage is increased in older women because things are more likely to go wrong with older eggs. Secondly, the chance of genetic or chromosomal abnormalities rises significantly over the age of 40. The evidence indicates that women aged between 40-42 have only a 10% success rate with AHR compared to a 33% success rate for women aged under 35 years old.
It should be noted that age can also increase the risk of certain complications during pregnancy. This includes miscarriage, pre-eclampsia, gestational diabetes or having a baby with a chromosomal abnormality. It is for these known risks and the significantly reduced changes of successful treatment that a defined parameter regarding the age of the intending birth mother was established for the purposes of publicly-funded AHR services.
Specifically in relation to the clinical parameter of BMI, extremes of BMI are associated with decreased natural fecundity and increased rates of infertility. Possible aetiologies in both under- and over-weight women include oligo- or anovulation, changes in endometrial receptivity, and diminished oocyte quality or competence.
When availing of AHR treatment, women with high BMI may demonstrate lower pregnancy rates, lower live birth rates, and higher miscarriage rates following IVF, ICSI, or frozen embryo thaw/transfer cycles. High BMI has also been associated with increased odds of IVF cycle cancellation and reduction in number of oocytes retrieved. It has been shown that the probability of pregnancy is reduced by 5% per unit of BMI exceeding 29 kg/m2. This association between higher BMI and lower fertility rates has been shown in several studies.
Meanwhile, underweight women who conceive using AHR treatments are at increased risk of miscarriage, preterm birth, and low birth weight babies. The extremes of maternal BMI have been shown to decrease success rates of fertility interventions and increase maternal–fetal morbidity. It is for these reasons, that defined parameters (upper and lower) regarding the BMI of an intending birth mother was established for the purposes of publicly-funded AHR services.
The approach adopted by the Department of Health in relation to defining clear parameters regarding specific clinical criteria for AHR is in line with many European and international counterparts, allowing for necessary accountability for the cost-effectiveness use of public funds, and the safety of patients and any consequent pregnancy that may result.
The access criteria and the scheme generally will be kept under review as new evidence becomes available, an understanding of how the service provision is working in practice emerges, and when the AHR legislation – currently at Committee Stage in the Dáil – is finalised.
My Department and the Government are focused, through the full implementation of the Model of Care for Fertility, on ensuring that patients receive care at the appropriate level of clinical intervention and then those requiring, and eligible for, advanced AHR treatment such as IVF will be able to access same through the public health system.
The underlying aim of the policy to provide a model of funding for AHR, within the broader new AHR regulatory framework, is to improve accessibility to AHR treatments, while at the same time embedding safe and appropriate clinical practice and ensuring the cost-effective use of public resources.