Dáil Éireann Debate, Tuesday - 30 April 2024
685. Deputy Róisín Shortall asked the Minister for Health if he will consider changes to the age and body mass index limits for fertility treatment; if clinicians have discretion to treat patients over those limits in certain circumstances (details supplied); and if he will make a statement on the matter. [19032/24]
Amharc ar fhreagraAs 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., the six Regional Fertility Hubs located across the country) and then, where necessary, AHR (assisted human reproduction) treatment (e.g., IVF (in-vitro fertilisation) 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 treatments and interventions.
Phase Two of the roll-out of the Model of Care relates to the introduction of AHR treatment, including IVF, provided through the public health system at tertiary level.
Funding has been made available to support access to AHR treatment via private providers. As well as IVF and ICSI, this allocation is also being used to provide, in 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. Criteria which prospective patients should meet in order to access fully-funded AHR services and the services to be initially funded were agreed by the Department and NWIHP and discussed at Cabinet in July 2023.
The approach adopted by the Department of Health in relation to defining clear parameters regarding clinical criteria for AHR is in line with 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. More details on public fertility services, 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/
The criteria were developed and finalised following engagement and consultation with experts in the field of reproductive medicine, taking into account 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.
In relation to the clinical parameter of age, as advised by the clinical experts in the HSE, it is important to note that age affects the fertility of both women and men. Fertility starts to reduce after the age of 30 and this reduction happens faster after the age of 35. 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. Secondly, the chance of genetic or chromosomal abnormalities rises significantly over the age of 40.
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 chances 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, it should be noted that women presenting with high BMIs are at a high risk of reproductive health complications, as are their babies. The risk of sub-fecundity and infertility, low conception rates, miscarriage rates, and pregnancy complications are increased in women with raised BMI, in both natural and assisted conceptions. Furthermore, reproductive outcomes for all fertility treatments are poor in this cohort. Obesity may impair reproductive functions by affecting both the ovaries and endometrium. It is because of these safety concerns and poor outcome facts that it is recommended, in line with the UK, the BMI parameters for intending birth mothers are a minimum of 18.5 kg/m2 and a maximum of 30.0 kg/m2.
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 AHR treatment scheme 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 Report Stage in the Dáil – is finalised.
It should be noted that some of the criteria to be met in order to avail of the secondary fertility care services at the Regional Fertility Hubs have broader parameters. These Hubs can successfully manage a significant proportion of patients presenting with fertility-related issues at this level of intervention without requiring them to undergo often extremely invasive and arduous IVF or ICSI treatment.
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.
