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§ Mrs. Caroline Spelman (Meriden)I am glad that the House has an opportunity to debate this subject today. It needs to be discussed in a spirit of extreme sensitivity, for there is no doubt that those who suffer the problems of infertility suffer a silent pain within society. I hope that I shall not give offence by what I say today, and I hope that colleagues will make their contributions in a similar spirit.
Natural fertility in human beings is relatively poor; we are not an efficient species. There is only a 20 to 25 per cent. chance of conception in each natural cycle. If those facts and the spontaneous rate of natural abortion were better understood, some of the pain of dashed expectations and the grief of miscarriage might be allayed. In society, pressure on couples is great. Before they are married, people ask why they are not married. If they are married, people ask why they do not have children. If they have one child, people ask why they are not having a second child. Against that background, a significant group suffer the pain of childlessness.
The causes of infertility are various. About one third can be attributed to problems experienced by the woman, and about 20 per cent. to problems associated with the man. A surprisingly high number of cases—some 30 per cent. —remain unexplained. This fact alone should galvanise the Government to redouble their efforts to investigate why the level of unexplained infertility is so high.
I should present my credentials at the start of the debate. I am not a scientific specialist on the subject. I know that others in the Chamber are, and they will talk more about the scientific aspects of the available treatments. I come to the debate very much as a mother, who is fortunate to have three children. However, I have gone through the problem of finding it very difficult to conceive and the strain that that places on a marriage, as both my husband and I were investigated to find who might be at fault. As in that 30 per cent. of cases, after all the examinations of genetic incompatibility and so on, the reason remained unclear. I have been there, but I have not experienced the degree of pain of those who reach the end of the process and are still unable to conceive.
One in six couples in the UK will experience difficulties in conceiving at some point in their reproductive lives. The extent of public funding for infertility treatments varies from region to region. Most infertility patients are either forced to seek private treatment to conceive, or at least are expected to contribute to the cost. One of the reasons that motivated me to apply for this debate is that my health authority—a relatively small authority—offered no assisted reproductive treatment in 1996-97. Effectively, no treatment was available to my constituents. This year, it is available, but only by extra-contractual referral. The budget for ECR is very restricted, so the prospect for the people I represent remains bleak.
For many couples, the only way in which to achieve successful conception is through techniques such as assisted reproductive techniques, or techniques that occur outside the human body, such as in vitro fertilisation. I will concentrate on IVF, but not to the exclusion of other available treatments. 657 According to the report of the fifth national survey of NHS funding for infertility services, almost one quarter of health authorities in the UK funded none of the modern assisted conception techniques such as IVF. Obviously, my authority would have been one of those. It is interesting that the recommended level of provision is 40 cycles of IVF treatment per 100,000 of the population. That was the recommended level in the Effective Healthcare Bulletin. That compares with the actual figures, which show that no health authority in the UK is providing that level of treatment.
The range is great. Scotland comes nearest to the recommended figure, with 27.5 treatments per 100,000 of population. Wales is next, with 23 treatments per 100,000. I will not go through the entire list but, around the middle, Anglia and Oxfordshire offer 13.6 treatments per 100,000. Another reason why I have chosen this debate is that the west midlands has the worst result, with only 3.5 treatments per 100,000. Northern Ireland publicly funds no modern treatments at all.
Underpinning the NHS provision is the principle that clinicians should have reasonable freedom to use their clinical judgment in respect of the treatment that they consider to be best for their patients, but patently it is difficult to see how there can be clinical freedom where the health authority has banned the treatment. The clinician can still recommend the modern treatment, but it will depend on a patient's capacity to go privately. The cost to the NHS of an IVF cycle—including drugs—is between £1,500 and £1,800. However, some units are able to provide treatment for as little as £1,000.
The cost of private care is significantly higher, and is estimated at £2,500 on average. Those figures are well beyond the pocket of many people. Thus, there is discrimination on economic grounds, as well as by region. The cost is not out of line with NHS treatments for other non-life threatening conditions, large though the sums may seem.
The main point of my speech is to call for equitable funding for infertility treatment throughout the NHS. It is manifestly unfair that one's postcode should determine access to treatment. The current fragmented nature of the availability of fertility treatment is cost ineffective, and the variable waiting lists tend to reduce the chance of success. The regional variation in eligibility criteria produces inequality, confusion and controversy about what help is available. My purpose today is to try to convince the Minister that cost-effective investigation and treatment should be offered routinely by health authorities in preference to some of the older treatments available, which have lower rates of success.
We need to achieve uniform provision and a full range of infertility investigations throughout the country. I draw the attention of the House to a written answer in Hansard in respect of infertility services. The Minister said:
We will challenge and address variations which are not based on the health needs and wishes of local people. We will aim for maximum consistency while still allowing appropriate local and individual responsiveness. We are currently considering what further advice the NHS should be given on infertility service provision." —[Official Report, 19 January 1998; Vol. 304, c. 394.]I very much hope that we shall hear news on that today.If the existing money were better spent, a great deal could be achieved with little, if any, extra expenditure. Clearly, national guidelines are needed. Few authorities 658 do not have some form of eligibility criteria for IVF treatment. Only 8 per cent. of all health authorities did not have such criteria in 1996. Of the 66 authorities that use those criteria, 99 per cent. —nearly all—specify a limit on a woman's age and the majority have an age limit of between 35 and 40. One health authority offers IVF treatment to women up to the age of 43. The age limit is crucial for two reasons. First, the later age of childbearing in women may well mean that they wake up to the fact that they have an infertility problem only when they are approaching, or have even passed, the age of 40. Secondly, IVF treatment is much more successful in younger women and the success rate tails off as the woman increases in age. Perhaps it is not surprising that the age limit restrictions placed on the male are higher. In those authorities that place an age limit on the male, it tends to lie between 45 and 60.
Of the authorities that provide IVF treatment, 49 per cent. have criteria related to the length of a couple's relationship—one region in Scotland sets a minimum of five years—most have criteria based on the number of previous children and 67 per cent. have them based on the number of previous cycles of assisted conception, while 88 per cent. put a limit on the number of cycles that will be funded. It varies from one to three cycles.
Throughout the country, there is a wide range of eligibility criteria. The system is just as discriminatory if one is in a health authority that borders on another where such an age restriction applies. Women are well aware of the biological clock ticking and it is most unfortunate for those who find themselves on the wrong side of the border. Candidates may try to get over the postcode criteria by moving into an authority that would be able to meet their needs because of its different criteria. Health authorities perceive that problem and strenuous efforts are being made to clamp down on it. The inequality and variation in the criteria could encourage people to try to buck the system in that way.
To pre-empt the criticism that Opposition parties always ask for more money without saying where it could come from, I suggest to the Minister that a cost-effective way in which to improve access to and the availability of infertility treatment could be to reduce the number of centres and so raise success rates at those that remain. There is definitely a correlation between lower success rates and the number of cycles. That is not an uncommon phenomenon in health provision—the higher throughput tends to improve the success rates of treatments. Again, there is a surprising variation in the number of live births per egg collection at centres that provide IVF treatment. Hon. Members will see what I mean if I provide a few examples. Bourn Hall clinic has a 22 per cent. success rate of egg collections that led to pregnancy; the assisted conceptions clinic in Bath has a higher rate at 25.7 per cent.; Holly house, which is another well-known centre, has a comparable rate of 23.7 per cent.; the Nurture centre in Nottingham has a rate of 24.3 per cent.; and the centre in Leeds has a 23.2 per cent. success rate. Those figures are clustered and are probably close to the optimum being achieved in the country. However, other centres have a significantly lower success rate—for example, Glasgow with 5.6 per cent., Salford with 2.6 per cent. and, according to my figures, south Manchester which has a zero rate—that certainly gives us cause for concern.
Elsewhere in the health service, a similar phenomenon exists with other types of treatment. The higher the number of cycles, the more cases are treated successfully 659 and the opportunity for teaching and imparting the skills that lead to success is also greater. The only difficulty with this sort of treatment is that, by its very nature, the patient cannot be too far from the treatment centre. Perhaps we could think in terms of regional centres of excellence with a good success rate. In concentrating funding in that way, we could achieve more treatments with a better success rate without spending more in absolute terms.
I crave my colleagues' indulgence, but I cannot conclude my contribution to this debate without flagging up some of the associated ethical issues, and I am about to stray into some controversial areas. I have no desire to block the way for others less fortunate than I to benefit from the advances that science brings, but some of those scientific advances have already given rise to abuse and the law has to be reviewed continually to take them into account. Only last weekend, in The Sunday Times of 3 May, we read the publicity about the fact that 300,000 embryos may have been used for research without explicit parental consent, which has caused distress to the parents and donors involved and must raise the question whether the laws in force are adequate to prevent abuse.
The use and subsequent treatment of spare embryos poses a general ethical problem, which stems from the very fact that more embryos have to be generated because the success rate for implantation is only 20 to 25 per cent. In most cases, a maximum of three embryos only can be implanted because of the higher risk of multiple pregnancy posed by that method of treatment, which can result in the need for a selective reduction in the number of embryos. That can cause considerable distress to the patient involved, apart from the ethical question of balancing the statistical probability of success with the prospect of having to reduce selectively a life so created.
An extreme example of what can go wrong was the Mandy Allford case, in which the number of successful implantations was exceptionally high—it had been artificially increased by a fertility drug. It was so high that in the end, none of the babies survived. That unacceptable waste of human life must raise the question whether the laws are adequate to protect the intrinsic worth of human life.
Another area of concern is the origin of the products of conception. In some cases, a donor is essential, either for eggs or for sperm, but, as yet, little research has been carried out into the psychological effect on the parent and/or the child, or indeed the donor, of that aspect of infertility treatment. The law on that aspect came under scrutiny with the Diane Blood case. She wanted to use the sperm of her deceased husband to create new life. Baroness Warnock made the position expressly clear when she said:
we do not believe it is in the best interests of the child to be conceived without a living father or mother as this may give rise to profound psychological problems".A way round the law was found in that highly publicised case, however, when Mrs. Blood was permitted to seek treatment abroad. I ask the Minister whether that does not, to some extent, undermine the safeguards that Baroness Warnock had in mind.Cloning is a recent development connected with the treatment of infertility and IVF in particular—it means creating a genetically identical human being. I have the good fortune to serve on the Select Committee on Science 660 and Technology, and my colleagues on the Committee devoted much attention to that subject in a previous Session of Parliament, but it is a continually moving science. We have the example of Dolly the sheep, cloned from an adult using the method of nuclear replacement. If that technique is further developed, the unique genetic identity of a family could be undermined. Surely a couple who plan to have a family should not, ethically, be able to plan for that family's genetic characteristics.
Some may regard cloning as a way in which to replace a lost child or adult, but that would be a form of cheating death. It would also affect the integrity of the family unit by blurring parent-child distinctions—for example, if I could clone my husband, the clone would be a twin, not our child. If we allowed such a technology to develop, we would be moving away from our concept of how a unique life is generated.
We must ask whether the law is moving at the same pace as technology, and what we really want for the human race. Egg cells, such as those used in the cloning of Dolly the sheep, have 46 chromosomes—a full complement of genetic information to create new life. We need a wider international ban on nuclear replacement techniques.
Two other ways in which to deal with infertility and its difficulties give rise to ethical considerations—surrogacy and adoption. The concept of surrogacy is not unknown in history—there is a biblical instance which, although perhaps not a good example, shows that the practice was known in ancient times. Surrogacy has been publicised in modern times because it is commercially available in some countries. It is hard to prevent commercial surrogacy—although it is illegal in this country, we know from the media of people who have managed to get round the law.
My fundamental objection to surrogacy is the curious relationship that develops as the host mother has to dissociate herself from the child whom she carries for nine months. The psychological problems that arise when the mother has to part from the child are well publicised—some surrogate mothers find parting very difficult, which causes heartbreak and pain to the couples. The question who is responsible if the surrogate child is born handicapped has not been put to the test in law, but we need to deal with it as part of our general consideration of the problems of childlessness.
For many couples, adoption is the only solution to unresolvable infertility problems. Many of us know from experience that adoption can be difficult. There are few new-born babies available for adoption, and couples face a long and hard process if they choose to adopt. I should be glad if more were done to make that process easier, in human terms, without compromising the integrity of protecting the needs of the child at the centre.
I hope that, by evoking some of the more complex and controversial ways in which to deal with childlessness, I have not distracted the House from my basic premise that more should be done to give equal access to couples who need fertility treatment. We all understand that rationing is a feature of public health provision, but to decide who should receive treatment on the basis of a postcode is patently unjust—the disparity in eligibility criteria between health regions that offer treatment is an injustice. I urge the Minister most strongly to consider 661 ways in which equal access to infertility treatment could be ensured, and to establish national guidelines for eligibility.
§ Mr. Fraser Kemp (Houghton and Washington, East)I shall be very brief, as I know that a number of hon. Members want to speak. I listened carefully to what the hon. Member for Meriden (Mrs. Spelman) said, and I congratulate her on bringing this issue before the House—one of the great strengths of the House is that such issues can be discussed.
I want to contribute to the debate because of two of my constituents, who have twice visited me at my surgery. They are decent, law-abiding folk who wanted the national health service to provide infertility treatment. They had spent £2,924, which was all their money—they are ordinary people in ordinary jobs—to obtain drugs and support privately, as, unfortunately, the health region that covers my constituency would not allow them to receive treatment on the NHS.
One of the great tragedies is that the couple would have been eligible for treatment if they had lived in the neighbouring health authority. Such circumstances cause great upset and heartache. We often read in local newspapers of cases in which couples are successfully treated for infertility and have children, but those stories can cause pain to others—they feel robbed because they cannot receive treatment because of where they live.
I understand that a balance must be struck between local decision making and national criteria, but a fundamental principle of the national health service must be equality of access to services, irrespective of where people live. I have taken this matter up with my hon. Friend the Minister, who wrote to me in October saying that the Government supported that principle and were determined to implement it. She also said that fertility treatment was an area of concern.
I believe that anything less than equality of access undermines the basic principle of the national health service. If people are denied support, but see others who live two or three miles away receiving that support, they will lose confidence in the system. We know from personal experience of the heartache that infertility causes couples. I am glad that many of the one in six who need support finally have children, but many of those who need specialist help cannot afford to go privately.
We must deal with access issues as well as research issues as quickly as possible, not only for my two constituents, but for the one in six couples who need infertility treatment. The Government should act decisively and put a stop to the nonsense that eligibility for treatment is assessed on postcode, not on need.
§ Mr. Andrew Lansley (South Cambridgeshire)I congratulate my hon. Friend the Member for Meriden (Mrs. Spelman) both on securing this debate and on the sensitive and intelligent way in which she introduced it. She highlighted the importance of the issue, which is further illustrated by the fact that some 35,000 couples undertake infertility treatment privately every year, often incurring significant financial hardship. The issue is not 662 simply about money, however; indeed, as the hon. Member for Houghton and Washington, East (Mr. Kemp) said, many couples would willingly spend more if they could.
I hope that those who read or hear about the debate will realise that we are sensitive to the difficulties that many couples face. The national health service is not only for those who are ill; it must promote public health and remedy what might properly be called disease. Before we even discuss public policy, we need to understand the importance that many couples attach to the issue—they believe that their well-being is bound up with their ability to choose whether to have children.
My hon. Friend the Member for Meriden made an important point about the increasing likelihood of success with some infertility treatments. She rightly mentioned the Bourn Hall clinic, which is in my constituency. On a recent contract that the clinic undertook for a health authority, 50 per cent. of the 90 couples involved were able to have a child. That illustrates how the technology is moving on.
We are presented with a paradigm of the problem facing the NHS generally: technology is achieving higher success rates and giving greater incentives to seek treatment, and treatments such as intracytoplasmic sperm injection are drawing into infertility treatment patients who might otherwise have felt that it was futile. That is exacerbating demand on the NHS in the longer run.
My hon. Friend and the hon. Member for Houghton and Washington, East are right: the availability of treatment should not be determined by one's geographical location. In Cambridge and Huntingdon health authority, only 16 couples, out of a population of half a million, are currently contracted for fertility treatment, and no further couples are being accepted on the waiting list. The treatment will effectively be unavailable in the area.
In many health authorities, general practitioners may be able to help couples by prescribing fertility drugs, even though the couples are paying for the clinical procedures. The average cost for the procedures is about £1,600, and for the drugs about £500. Cambridge and Huntingdon health authority now issues strong guidance to general practitioners not to prescribe the drugs. The difficulties and costs are clearly greater in some parts of the country than in others.
We must recognise that the different eligibility criteria in different areas are not necessarily based on clinical assessments. They are often driven by sympathy, which of course I do not despise, rather than clinical assessment of the best circumstances in which to treat couples. We must consider what the NHS should be providing for the population as a whole—to be blunt, that is a rationing issue and a political issue which Ministers must decide—and what it is there to do.
We must all accept that any health authority, and indeed any general practitioner, must set priorities. We cannot intervene and say that one treatment must be provided in any circumstances, but the fact that infertility treatments are available only in certain areas means that the NHS loses its force as a national health service, serving the whole population.
I strongly endorse my hon. Friend's point that there is a case for national guidelines and for bringing together the NHS Executive, the Human Fertilisation and Embryology Authority and the British Fertility Society to establish 663 some basic national eligibility criteria, while recognising that priorities in individual areas may make it impossible to standardise completely throughout the country.
§ Ms Sally Keeble (Northampton, North)I am grateful for the opportunity to speak in this debate, because my daughter is a test-tube baby and I know something of the personal pain of which other hon. Members have spoken.
While researching a book that I wrote on the subject, I spoke to many women about their experiences of fertility services. For many of them, after they had undergone a range of different treatments, the end result was the great happiness of having a baby; but for many, even if it worked out in the end, the price, physically, emotionally and financially, was very high.
I spoke to women who had been treated by two or three clinics or doctors at once, sometimes receiving different treatments, and to others who had spent almost all their adult lives on the treadmill of treatment—it is an emotional roller-coaster—until they finally gave up in despair, without ever having had a proper explanation of what had happened or why, and sometimes having suffered serious side effects.
I learned some lessons from that experience. One was about the desperate need for care that is based on need. At present, 90 per cent. of infertility treatment is in the private sector. Most of the clinics that the hon. Member for Meriden (Mrs. Spelman) mentioned are in the private sector and accept people only if they can pay. With private treatment, people literally shop around. I speak from experience: one picks up the telephone and asks the clinic how much it charges, what treatment it provides, what ages it caters for, what the waiting room is like, and many other questions.
By and large, one can get treatment provided that one can pay the bill, and that is a very big proviso. In researching my book, I spoke to many couples who had mortgaged their homes to raise the money to pay for repeated cycles of treatment over many years. People's ability to have a family becomes dependent on the size of their bank balance. I might be insufficiently new Labour, but I think that that is fundamentally wrong in a country with a national health service and a Government who are committed to equality.
I discovered that there was an urgent need for continuity of care, from diagnosis of the condition through to resolution. For many people, that is a long and painful journey which might end in adoption, in pregnancy, in a baby or in simply deciding to go and do something else with one's life. The one place in which the complex issues encountered by the one in six couples who have problems with fertility cannot be talked through and resolved is in private consulting rooms, because there is neither the time nor the space, and most people do not have the money.
Many women have complications as a result of the treatment. I spoke to a woman whose pregnancy turned out to be ectopic. Having been discharged by her private clinic, she was left traipsing around from one accident and emergency ward to another, trying to get help for her distressing, painful and dangerous condition.
I found out a great deal about the Russian roulette of access to services. As a Member of Parliament, I have a home in Northamptonshire and a home in Southwark. 664 In Northamptonshire, the health authority provides no fertility services, so people are forced to go private. In Southwark, one can get treatment, with certain limitations and provided that one is under 40. There is a stark contrast between the different health authorities' approaches.
The previous Labour Government had the great foresight to set up the Warnock committee, which considered all aspects of the new reproductive technologies and produced a report that was one of the great classics of medical ethics. It said a great deal about the ethical approach to the problems that the hon. Member for Meriden spoke about, and the principles have served us well down the years.
The Warnock report also had much to say about the provision of services, although that has been less publicised; it certainly has not been implemented. The report spoke of the need for us to think about national standards and a proper network of provision, so that we would not have the problems associated with the present patchwork quilt of services, under which what people receive depends on either their postcode or their bank balance.
Since the report came out, there have been changes, many of which have worked in favour of greater provision of infertility services. Success rates have increased and costs have come down. I believe that for the Labour party in government, infertility services represent one of the great pieces of unfinished business. It would be a fitting tribute to the work of the previous Labour Government if the present Labour Government completed the work begun all those years ago, and secured proper, fair and equitable access to fertility services for people throughout the country, with services clearly based on need and continuity of care. People's ability to have one of the most precious things in life, a family, would then be properly planned, fair and open.
§ Dr. Peter Brand (Isle of Wight)This is a debate about whether the NHS is really a national health service. Today, we should be offering congratulations on the enormous advances that have been made in the treatment of infertility—a tremendous clinical and scientific success story. Instead, we are debating the failure of the NHS, because the story is one of failure to provide fair access to services.
We have heard interesting examples from both sides of the House, and I welcome the realisation by politicians that we need to start talking realistically about rationing. Such decisions cannot be left to doctors; we cannot pretend that they are clinical decisions. There are clinical decisions to be made, about eligibility criteria for starting courses of in vitro fertilisation and for the investigation and treatment of infertility in general. However, a host of other eligibility criteria have been produced, and they have nothing to do with clinical practice.
Some eligibility criteria are based on the financial cycle. In my health authority area, one could have two cycles a year, but no more than four. We can imagine the sort of family planning that went into ensuring that one managed four consecutive cycles without falling foul of the rules. In the context of clinical practice, that is nonsense.
It is wrong for a local or regional health authority, or even for an individual GP, to start making value judgments about whether a couple is stable enough to 665 deserve such treatment. People should not pretend that that is a clinical decision. Such decisions are emotive and political, and they should be made by people who are politically accountable, yet the way in which the NHS is now structured gives no local accountability whatever. People cannot sack their health authority. They can write letters—to their local Member of Parliament, for example—but, at the end of the day, the only responsibility is for the bottom line, for coming in on budget.
The only accountability is at parliamentary level. If we are to have a national health service, it is right for the Minister to set out clearly what people's entitlement and expectations from the service are likely to be. I am not prejudging the issue, because it is for the Government to set out clearly what they are prepared to fund and to take the political consequences if they get it wrong.
If the Government set out clear entitlements, we shall be able to integrate the service between the private sector and the NHS, and introduce a proper policy whereby GPs can prescribe and give the injections that make the egg ready for IVF treatment—we are talking, in the main, about IVF. There would be a planned service so that people would not have the awful embarrassment of having to chase around seeing multiple agencies, and sometimes being devious, as the only way of achieving what they desperately want.
Such an integrated service would also stop people bankrupting themselves. They would know where they were with fertility treatment. So often, people have two treatments on the NHS and are so sure that a third one would work that they see whether they can raise the money, and go into debt. Even if they are successful, that is an awful way to start a family.
The mark of a civilised society is not only how it treats ill health but how it promotes health. I am glad that we have a Minister responsible for the promotion of health and well-being. Personally, I believe that there is a role for the state in ensuring that people can have babies and a family if they wish. We could indeed create the supportive society to which everybody pays lip service. However, to achieve that, we need to will the resources.
The Government could be brave and say, "That form of treatment is not an NHS responsibility, but we might make a contribution for people who cannot afford to pay," which would be a sort of means test in reverse. I would not support that view. I think that everyone should be entitled. However, I also know that many people who undergo IVF treatment are keen to make a contribution, which makes their baby even more valued.
Under the present system, either people get the treatment because they can afford it—or because they can borrow the money—or they get nothing. That is not the national health service that I believe in, and I do not think that it is the national health service that the Minister believes in, either.
§ Dr. Ian Gibson (Norwich, North)I congratulate the hon. Member for Meriden (Mrs. Spelman) on choosing the debate and on introducing it in a sensitive and erudite way. I should like to play a part in the debate by discussing fertility and the reasons for infertility, and what 666 we can do about it. I do not apologise for concentrating on male infertility, because, in my experience, there is still a misapprehension in Britain that most infertility is due to the woman. I want to put that myth to rest.
The evolutionary drive to pass on one's genes to the next generation is a powerful force. The hon. Member for Meriden mentioned the social influences on that process, in terms of getting married, having children and living happily ever after. Sadly, the biological processes of the production of sperm and egg do not always allow that to happen.
The hon. Lady also mentioned that one third of fertility disorders are attributable to the male. In my experience, the vast majority of cases investigated involve both male and female factors. There is a tendency for the official figures to underestimate the extent of the problem, as many couples do not seek help because of embarrassment or lack of funds. Many are reluctant to seek assistance.
Infertility is often regarded as a nuisance illness, but, in fact, it is a major source of depressive illness and psycho-social morbidity in the United Kingdom. In that sense, it makes heavy demands on medical and social services.
What are the causes of male infertility? There may be a deficiency in sperm numbers, a reduction in sperm motility, the production of abnormal forms of sperm—involving the size of the head, for instance—blood vessel abnormality around the testes, obstruction of the sperm ducts, testes hidden in the abdominal cavity, or, of course, impotence.
Some of those are caused by genetic factors, some by physical and surgical events—infections, through mumps, for example—and some by environmental causes such as heat. You will know, Mr. Deputy Speaker, that many people in Scotland advocate the wearing of kilts to protect sensitive organs from the effects of heat—I am not declaring an interest in kilt wearing, incidentally. Radiation also has a major effect on sperm production.
Drugs, alcohol and tobacco are also well known to have effects on sperm production. There is also increasing evidence of adverse trends in several measures of male reproductive health—in testicular cancer, for example. There is also the increasing use of environmental chemical contaminants that mimic oestrogen hormone-like activity. Although the causal relationship is by no means proven yet, and diet and life style might be equally important, findings about the effects of hormone-like chemicals on wildlife make one think that the so-called endocrine disruptors may be important factors affecting sperm production.
Questions have been asked about semen quality as sperm counts fall; there is international agreement on that point—about 20 per cent. of our population have so-called low sperm counts. If they want further details, I recommend that hon. Members read a good document produced this year by the Parliamentary Office of Science and Technology on hormone-mimicking chemicals.
What of the treatments that are now available? The media have recently been awash with reports on the miracle drug Viagra, which is crudely called, in that all-American way, the "Pfizer-riser" and which is exciting males across America to the extent that 40,000 prescriptions are issued every day and it has almost become a recreational drug. It is given for what we in the business call erectile dysfunction. Whether it will come 667 to this country and how it does so remains to be seen. There are also surgical methods, but few studies have been made of microsurgical techniques to loosen duct abnormalities, and little has been happening on what should be an exciting front.
Other exciting treatments are becoming available, including intra-uterine insemination, which has its problems, as hon. Members have pointed out; in vitro fertilisation, which has changed our whole concept of male infertility; donor insemination; and intracytoplasmic injection, the ICSI method, which is relatively new. Human need has been so desperate that people have been prepared to accept the latter treatment before full scientific tests have been carried out. That is part of the problem. Many babies have been born by that method, whereby a single sperm is delicately and skilfully put into an egg cell and, although few people have the necessary skill to do that, the technique is being developed throughout this country. Men can now father children by that technique, and success rates are high at Bourn Hall clinic in Cambridgeshire and at the Hammersmith hospital under a distinguished member of another place.
Centres are licensed according to ethical compliance and not treatment efficiency, so couples might be squandering both resources and their chance of parenthood in having to seek treatment in the private sector for about £2,000 per session; only the most affluent in our society can afford to do that. However, ICSI treatment means that 35 per cent. of infertile males get a viable pregnancy in a single cycle, which is better than the IVF record at this stage. It is a remarkable development and a success story in male infertility. Problems may yet be encountered with ICSI, and further studies are being carried out, but the babies born so far by the technology have no higher incidence of any detectable abnormality than the general population of babies born after in vitro fertilisation or natural events.
Since the introduction of the internal market, funding for infertility treatment has almost dried up, as purchasers tend to classify it alongside cosmetic surgery and the removal of tattoos. For many people, however, infertility is a dominating cloud over their lives and a source of marriage break-up. One patient I know in Norwich, who is now sterile, had his viable sperm stored before the introduction of the internal market in a BUPA hospital under NHS funding arrangements. He is unable to use that sperm, because there is now no NHS funding available for him to purchase it, so he has no access to his own genetic material.
Furthermore, for a long time now, no NHS funding has gone into infertility research, where there is much work to be done. Science will be able to overcome many of the problems with some of the techniques I mentioned, as long as the Government continue to fund the NHS and ensure that the internal market does not create an unequal distribution of resources.
§ Dr. Lynne Jones (Birmingham, Selly Oak)I am pleased that the hon. Member for Meriden (Mrs. Spelman) succeeded in obtaining this debate. Despite the fact that one in six couples will require some form of assistance to have a child, there seems to be little public sympathy for such people. One wonders why that is so, and one hopes that the debate will help to redress the balance.
668 Recently, Fay Weldon described women without children as:
These barren twigs on the tree of life, this stunted growth.She gave the impression that women were to blame for their failure to bear children. I am the mother of two children and was able to conceive when I and my husband decided that we wished to start a family, so I have no personal experience of infertility to contribute to the debate. However, I have encountered couples whose lives are completely dominated by their failure to have a much-wanted child and, like my hon. Friend the Member for Norwich, North (Dr. Gibson), I realise what a devastating impact infertility can have on their lives and their health.Why are the public so unsympathetic? A survey carried out by my local health authority revealed that there was little public support for funding for fertility treatment. Perhaps some of the publicity given to certain women who have received fertility treatment is partly to blame, but the fact remains that the majority of people who seek this form of medical intervention are from stable backgrounds—couples who have been together for some time and who want to start a family.
The other aspect of the lack of sympathy may he that there is such a stigma attached to the inability of a woman to conceive or of a man to father a child that the subject is not talked about much. Perhaps this debate will help to get people talking. It is excellent that two women Members of Parliament have spoken publicly about their own experiences; the more people are able to discuss the issues, the more public support will be generated. Whether or not there is public support, it is wrong that the availability of treatment varies according to the area in which one lives or whether one can afford to pay. I hope that, in her reply, my hon. Friend the Minister will give some hope that we will start to develop national guidelines for a comprehensive service in future.
In Birmingham today, a meeting is taking place between the health authority and the clinical directors of the relevant trusts to consider how to improve the service in Birmingham. At present, only £50,000 a year is allocated, which is about one tenth of what is needed. That leads to grave difficulty in deciding who should receive treatment and to enormous waiting lists. That is clearly unsatisfactory, so the health authority is looking at other services it provides. Many general gynaecological services relate to infertility and, if clearer protocols were drawn up in respect of access to such services, we might be able to release money for the provision of infertility services. There is also the question of where services are provided and the need to set up tertiary centres which, when funding becomes available, will be able to offer good prospects of success with staff who have the necessary experience to provide treatment.
I join other hon. Members in calling on the Government to look seriously at the problems relating to infertility treatment. If we are to have a genuinely national health service, as opposed to a national illness service, we should be providing national guidelines for a comprehensive sub-fertility service in this country.
§ Fiona Mactaggart (Slough)I reflected for some time before contributing to the debate, partly for some of the reasons mentioned by my hon. Friend the Member for 669 Birmingham, Selly Oak (Dr. Jones) such as the public view of infertility and the hostility of which infertile people are often victims. As a single infertile woman, I thought that perhaps I should not speak in the debate, using my experience of private fertility services. Like probably all single women in this country, I was unable to gain access to NHS fertility services, and I want to look at the quality of the services and whether things can be done to improve fertility services for all people in Britain.
This is an important issue because of the effect that sub-fertility can have on people's lives. It creates a feeling of powerlessness and confusion. It is connected to the Darwinian requirement to reproduce, which means that fertility is closely connected to one's identity. That is the main reason why, in so many people, sub-fertility leads to depressive illness and, consequently, high expense for the NHS.
It is wise and sensible for us to provide for that health obligation. It is clear that, at present, the health service is not doing that; it is failing in a number of ways. In many parts of the country, fertility treatment is absolutely inaccessible. Some time before I was elected, I attended a Berkshire health authority meeting considering the range of treatments not normally approved of by the health authority. I vividly remember speaking to a clinician who said that, in many cases, he felt that the health authority's decisions were wise because the treatments being excluded from funding were ineffectual. However, he felt strongly that it was wrong to exclude fertility treatment from funding, particularly IVF, because it is an increasingly effective clinical measure, as the hon. Member for Meriden (Mrs. Spelman) pointed out.
Another important issue is the provision of information. Many women feel that attempting to find out about treatment makes their situation and their confusion greater. Doctors are often not well informed, and women often have to undergo long, tortuous and confusing investigations, some of which are not particularly necessary and some of which are inefficient. After all that, they may find, as I did, that they have reached the end of road and that the NHS will no longer provide treatment. They then go through what can only be compared to trying to read the form of race horses by trying to work out which private clinic—if they can afford it—is the most appropriate.
My hon. Friend the Member for Northampton, North (Ms Keeble) described a much more efficient sounding approach than that which I experienced, but it is confusing and difficult. It is necessary to look under the statistics such as those quoted by the hon. Member for Meriden. Some centres where the statistics are not so good may take older women. It is difficult for the ordinary person seeking treatment to know what to do. There are failures in the quality of information across public and private provision. The health service should look at that.
The health service needs to provide better support for families to help them deal with the experience of treatment, which can be devastating for those involved. They need help to gain access to the most effective treatment. That is the responsibility of the Government. The Government should be centring treatment on the places where it works rather than adopting a scattergun approach, allowing people to carry out the treatment even if they are not excellent at it. It is a relatively expensive 670 provision and we have a responsibility to ensure that it is effective. It is no help to infertile couples to give them access to nearby treatment if it is ineffective. That must be a priority.
The Government need to deal with the issue of who should have access to treatment. It is not appropriate to leave it to individual doctors. However, sometimes the confusion created by individual doctors helps us to get through the moral decisions that we like to avoid taking. That is one of the reasons why Governments, health authorities and so on duck aspects of such decisions. We must take responsibility for that—it is our job. There should be a public debate about who should be eligible.
It is my view that there are cases where people who are not in standard relationships or stable marriages should be eligible for such treatment. Whatever view we reach, it should be debated publicly so that people know at the beginning of the heartache whether they have any chance of obtaining treatment or whether—to add to the horse racing analogy—they are betting on a blind horse and will not obtain treatment because of their age or their relationship.
There are other things the Government can do to help those who are sub-fertile. One of the things we are already doing, and which I welcome, is improving access to child care and introducing family-friendly employment policies, which make it more likely that women will try to have children at a younger age. I believe that one of the reasons for the fertility crisis is that women are having children later, and that is partly because of the structure of the labour market. If we can make it possible for women to start their families earlier, some of these problems may not arise.
My hon. Friend the Member for Norwich, North (Dr. Gibson) referred to the importance of tackling environmental policies which have an impact on fertility. The Government should be aware of that. I believe that improved sex education and sexual health among young people can help them to avoid conditions that can affect their fertility. In all those ways, there is a responsibility—it is a difficult responsibility to deal with well—for the Government to seek to improve the quality of fertility provision. We are failing women and men around the country and, as a community, we are paying the price of that failure in their depressive illnesses.
As the technology and quality of care improve, we have an opportunity to make a difference to such people's lives. We can give more couples access to treatment and improve the quality of it. We can ensure that people are informed about and supported through treatment when they can get it.
§ 12.8 pm
§ Mr. Patrick Nicholls (Teignbridge)If anybody had any lingering doubts about whether the reform that led to Wednesday morning debates would be worth while, they had only to listen to the standard of contributions to this debate. I am only sorry that time does not allow me to do justice to the eight excellent contributions we have heard. I thought that the contribution of the hon. Member for Slough (Fiona Mactaggart) was remarkable and I commend her for it.
I add my compliments to my hon. Friend the Member for Meriden (Mrs. Spelman) for having introduced this debate. When I was preparing my notes last night, 671 I realised that I should commend her not only for the choice of subject but for her courage in introducing a topic for an hour-and-a-half debate when it could be debated endlessly.
The subject raises a number of implications. My hon. Friend the Member for Meriden touched on some of the moral and ethical implications surrounding it; to have taken that on is remarkable. She gave due tribute to all attitudes and views without causing offence. If I achieve that, I shall have done well.
I shall concentrate my remarks on the way in which services are provided throughout the country and what might be taken into account if provision were to be made universal. The first problem is that there is no universal application, no universal guidelines and no rules or regulations. After making a proper assessment, health authorities purchase the services that they believe are necessary for looking after the health needs of the local population. That gives rise to substantial inconsistencies throughout the country, and, inevitably in such a system, there are disputes about treatments—I do not say that pejoratively, but use shorthand—that might be considered to be on the fringe.
A number of hon. Members referred to those disparities, which were summed up in a 1995 report by the National Association of Health Authorities and Trusts. It included a case study on in vitro fertilisation treatment: five authorities were not purchasing IVF, while others offered a limited service based on factors such as age, whether there was a child from a previous relationship, and how successful treatment was likely to be. The situation has worsened since then.
It may be helpful to discuss the attitude of two health authorities, not to criticise them, but because the criteria that they have adopted will resonate with hon. Members who have spoken. In May 1997, The Independent reported:
The Birmingham Health Authority is proposing to stop assisted-conception treatment on the NHS unless there are exceptional … circumstances …The plan … would mean that most childless couples in the area would have to seek help from private organisations".It added that the director of health
will present a paper … recommending that the authority backs the recent survey which concluded that routine NHS funding of fertility treatment should cease. Most people interviewed for the survey said cancer treatment should be well-funded, and saw assisted-conception services as having the lowest priority.A report published in March 1997 discussed North Wales health authority's decision that, from 1 April, women aged 36 and over in north Wales would not be referred for treatment and no treatment would be given to women aged 39 or over. It laid down other criteria, stating:
Only heterosexual couples who can prove they have been in a stable relationship together for at least two years will be considered and there must be no living children from their relationship.It also discussed the number of cycles of treatment for people who met the criteria.One can always challenge a health authority's judgment in those matters by using the NHS complaints procedure, but a health authority that has reached decisions on criteria that are intelligently arrived at, even if not accepted by everyone, could not be said to be in breach of its obligations. The Minister will correct me if I am 672 wrong, but I cannot recall any case, and my researchers have not discovered one, in which a health authority was successfully appealed against because of the way in which it restricts provision of infertility and IVF treatments. We are dealing with an inconsistent patchwork, which, given the way in which health services are developed locally, is inevitable.
What reasons are traditionally—I use that word deliberately—given by local health authorities for not producing this treatment? Some may say, "This is not an illness; it is a treatment." The hon. Member for Birmingham, Selly Oak (Dr. Jones), in a phrase that I shall use on other occasions without attribution so that I can take the credit for it, talked about having a national health service, not a national illness service. On whatever criteria are used, these services fall within a national health service. My hon. Friend the Member for Meriden talked about silent pain, which is a poignant phrase. No one reaches my age without friends and relatives going through that. The pain may be silent in public, but the anguish that it causes is dramatic.
Traditionally, it is said that the treatment is not very successful. One statistic, which tells only half the story, appears in a report by the Human Fertilisation and Embryology Agency that published birth rates for individual IVF clinics. In 1995–96, 15.1 per cent. of treatment cycles in the United Kingdom resulted in at least one live birth. Taking a superficial view, as people have done in the past, one might say that a health authority should not spend too much money on a process with an 85 per cent. failure record.
I was speaking to an eminent obstetrician last night to prepare for the debate, however, and he said that techniques are improving rapidly. My hon. Friend the Member for South Cambridgeshire (Mr. Lansley) has made the same point. In France, IVF treatments' take-home baby rate success factor—I do not know how the phrase goes in French, but it translates neatly into English—means that artificially replicating the number of treatments per cycle given to people going about these things in a more orthodox way gives a take-home baby rate similar to that achieved by natural process. That has clear implications, not only for what health authorities should do, but for what the Government should do.
The hon. Members for Isle of Wight (Dr. Brand) and for Selly Oak were correct to say that if we are to produce criteria, they should be political. We cannot ask doctors to decide whether treatment for people who are not in a stable relationship, who have been in a relationship for only a year or who are not part of a heterosexual couple, is a clinical need. Such decisions must be taken by politicians, not by clinicians. Uncomfortable judgments will have to be made. Rationing is accepted by hon. Members on both sides of the House, so in an age when resources are finite there will be inevitable difficulty about whether to put more money into cancer treatment or into fertility treatment.
Criteria should be laid down. I am not by nature a centrist, but it is difficult to envisage how that could be done other than centrally, by Her Majesty's Government. Hon. Members have talked about consistency of criteria and equality of access, but that cannot be provided locally. What criteria should be used? What is the relevance of age? Should the state fund techniques for women long past child-bearing age? What is the significance of the fact that couples may 673 have children? is there significance—I put it as neutrally as that—in a person seeking the reversal of an NHS vasectomy or sterilisation? What is the significance of a person being in a heterosexual relationship?
Polling evidence has been mentioned. The hon. Members for Selly Oak and for Slough talked about their incomprehension that the public could be so uncaring as to think that whether people have children is just one of those things. One opinion poll went the other way and said that 68 per cent. of people believed that IVF should be available on the NHS. I wonder whether they were asked how they would square that with other forms of treatment being unavailable.
The Government have to come to a decision. Had the Under-Secretary of State for Health, the hon. Member for Brent, South (Mr. Boateng), been replying to the debate, he would have had a couple of phrases ready. He says that he does not want to be lectured by Conservative Members. I shall not lecture the Minister: that may be necessary on other occasions, but it is unnecessary today. I commend her on her written answer of 19 January, which summed up the inherent contradictions. She said:
We will challenge and address variations which are not based on the health needs and wishes of local people. We will aim for maximum consistency while still allowing appropriate local and individual responsiveness.I do not want to be critical: I just want to share a problem with her. Are those two statements logically consistent? Can that be done?I am delighted that the Minister is replying to the debate, because she is the ideal person to deal with this subject. The current weight of opinion is for the matter to be addressed centrally. In her written answer, she said:
We are currently considering what further advice the NHS should be given on infertility service provision." — [Official Report, 19 January 1998; Vol. 304, c. 394.]That advice must be generated centrally and measured against criteria that we can debate. We shall doubtless agree on some issues and disagree on others, but I should be delighted to hear what the hon. Lady has to say about the matter.
§ The Minister for Public Health (Ms Tessa Jowell)I pay tribute to the hon. Member for Meriden (Mrs. Spelman) for securing this debate, and I commend the speeches that we have heard from both sides of the House on one of the most difficult issues facing the national health service. The concerns raised fall broadly into three areas.
First, it is important to tackle the present unacceptable geographical lottery in access to treatment by developing a coherent national framework that is predicated on fair access.
Secondly, we should ensure that the national health service has the capacity to keep pace with the rapid technological advances in fertility treatment. It is worth remembering that Louise Brown, the first test-tube baby, was born in 1978. I doubt whether any of us who can remember that time and the celebration that surrounded her birth would have predicted the innovations in 674 infertility treatment that have taken place in the intervening 20 years. We have every expectation that that pace of innovation and development will continue.
It is critical that new treatments, as they become available, are based on clear evidence of their proven effectiveness. Hardly an area of medicine and health care touches more raw nerves than treatment for infertility. That redoubles our obligation to ensure that the treatments that are available have been proved effective.
Thirdly, there is understandable concern about ethical issues. Medical technology is taking us into areas of great ethical uncertainty. I entirely agree with all those who have underlined the importance of ensuring that the ethical framework for protecting decency and the integrity of human rights are respected as we move fast to keep pace with new advances.
Those are the three strands of the case that has been developed in the debate. I shall briefly add to the good evidence that has been provided of the extent of the variation and inconsistencies in access to infertility services. The number of IVF treatments per 100,000 of the population varies. It ranges from just over 19 per 100,000 in the north-west region to 3.5 in the west midlands, with considerable variations in between. There are wide variations in the financial arrangements made by health authorities that provide IVF treatment. About 40 health authorities have specific contracts for IVF, but others offer the treatment within a block contract for general gynaecological services.
The upper age limit for women to have access to IVF also varies. In Scotland, the upper limit is 43, but it is as low as 34 in Leeds. We are determined to deal with the unacceptable variations in access to services, and to build a national health service that provides fair access to clinically effective services, including infertility services, where people live.
We shall redouble our efforts to tackle health inequality caused by uneven provision of services and the inequalities of those who suffer from poor health. That is central to our mission to rebuild the national health service. Tackling inconsistency is at the top of our list. The NHS White Paper is explicit in its commitment
to recognise that the NHS contribution must begin by offering fair access to health services in relation to people's needs, irrespective of geography, class, ethnicity, age or sex.We intend to achieve that aim through the development of a national performance framework. We want to ensure national consistency through new service frameworks as a guarantee of quality and access for patients. We intend to establish a national institute for clinical excellence to ensure that services are based on the best evidence of clinical and cost-effectiveness. We shall also review the arrangements for assessing the cost-effectiveness of new technologies, including drugs, and for encouraging their appropriate use. The new national arrangements will be linked to guidelines to inform local decision making. Equity will be at the heart of our policies.The hon. Member for Teignbridge (Mr. Nicholls) referred to my written answer. We are trying to provide a rational framework, but it will clearly take time. However, I can announce today that, as one of the first steps in tackling inequality in this area, we have commissioned the Royal College of Obstetricians and Gynaecologists to prepare clinical guidelines on the initial investigation and management of infertile couples in primary care services; 675 the management of infertility within local specialist services; and the provision of specialist and high-tech services. We expect the first two sets of clinical guidelines to be published in the summer and later this year, and the guidelines on specialist and high-tech services to be published in 1999. That will provide an important framework to deal with some of the inconsistencies in practice and the doubts about the clinical effectiveness of some of the current treatments.
I endorse the comments of hon. Members who expressed concern about the pressing demand for and the effectiveness of infertility treatment. The desire to have a baby at all costs, literally as well as figuratively, drives couples who may have had limited NHS treatment to spend enormous sums of money on private treatment, which is often not effective. A proper assessment would show that such treatment would never be effective in some cases. It is the stuff of heartbreak, and we want to provide a framework that provides some protection.
Let me deal briefly with four issues that underline the importance of an ethical framework. Ruth Deech, who chairs the Human Fertilisation and Embryology Authority, is preparing a robust rebuttal of the article in The Sunday Times, which was grossly misleading, and, as the hon. Member for Meriden rightly said, disturbing. Let me reiterate our concern about cloning.
§ Mr. Deputy Speaker (Sir Alan Haselhurst)Order. We must move to the next debate.