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6 March 2013

UK: Updated guidelines revise treatment recommendations for people with fertility problems

People who are experiencing fertility problems should be able to get the most appropriate and effective medical treatment earlier, according to updated guidelines published on 20 February by the National Institute for Health and Care Excellence (NICE).

The updated guideline makes a number of recommendations to ensure people who are having trouble conceiving receive only the most effective treatments and in a more timely manner.

For instance, it recommends that people with unexplained infertility, mild endometriosis or mild male factor infertility should attempt to conceive through regular vaginal intercourse for two years rather than receive intrauterine insemination (apart from specific groups as outlined in the guideline). This is because new evidence in this area shows that this treatment is no better at achieving a live birth than people attempting to conceive through regular vaginal intercourse.

However, the updated guideline recommends IVF treatment for eligible women who have been unable to conceive after two years of regular vaginal intercourse (or 12 cycles of artificial insemination). This is one year earlier than was previously recommended.

The update also confirms that women aged 40-42 years who have not conceived after two years of regular unprotected intercourse or 12 cycles of artificial insemination (where six or more are by intrauterine insemination), should now be offered one full cycle of IVF, with or without intracytoplasmic sperm injection (ICSI), provided the following criteria are fulfilled: they have never previously had IVF treatment; there is no evidence of low ovarian reserve; there has been a discussion of the additional implications of IVF and pregnancy at this age. Previously, NICE did not recommend IVF for women older than 39.

The guideline’s previous recommendations relating to the use of oral ovarian stimulation agents have been updated and, for the first time, the guideline includes groups of people such as same-sex couples, those who carry an infectious disease (such as Hepatitis B or HIV) and those who are unable to have intercourse (for example, if they have a physical disability). The updated guideline also makes recommendations for people who are preparing for cancer treatment who may wish to preserve their fertility.

Other new or updated recommendations include:

• For people with unexplained infertility, mild endometriosis or ‘mild male factor infertility’, who are having regular unprotected sexual intercourse:
- do not routinely offer intrauterine insemination, either with or without ovarian stimulation (exceptional circumstances include, for example, when people have social, cultural or religious objections to IVF)
- advise them to try to conceive for a total of 2 years (this can include up to one year before their fertility investigations) before IVF will be considered

• Women aged under 40 years who have not conceived after two years of regular unprotected intercourse or 12 cycles of artificial insemination (where six or more are by intrauterine insemination), should be offered three full cycles of IVF, with or without ICSI. If the woman reaches the age of 40 during treatment, the current full cycle should be completed but no further cycles offered.

• Do not offer oral ovarian stimulation agents (such as clomifene citrate, anastrozole or letrozole) to women with unexplained infertility.

• When considering the number of fresh or frozen embryos to transfer in IVF treatment:
- For women aged under 37 years: In the first full IVF cycle use single embryo transfer; in the second full IVF cycle use single embryo transfer if 1 or more top-quality embryos are available. Consider using 2 embryos if no top-quality embryos are available; in the third full IVF cycle transfer no more than 2 embryos.
- For women aged 37-39 years: In the first and second full IVF cycles use single embryo transfer if there are 1 or more top-quality embryos. Consider double embryo transfer if there are no top-quality embryos; in the third full IVF cycle transfer no more than 2 embryos.
- For women aged 40-42 years consider double embryo transfer.

Sir Andrew Dillon, NICE Chief Executive, said: “Infertility affects more people than you might think; around one in seven heterosexual couples in the UK. It is a recognised medical condition that can occur at any age and for a variety of reasons, such as endometriosis, polycystic ovary syndrome or naturally low ovarian reserve. The good news is that, thanks to a number of medical advances over the years, many fertility problems can be treated effectively. It is because of these new advances that we have been able to update our guideline on fertility, ensuring that the right support, care and treatment is available to those who will benefit the most.”

Tim Child, Consultant Gynaecologist and Director of the Oxford Fertility Unit, was part of the Guideline Development Group (GDG) that developed the updated guideline on behalf of NICE. He said: “Recommending IVF treatment for a very select group of women over 40 was not a decision that was taken lightly. When a woman reaches her mid-30’s her fertility begins to decline, even more so from her late 30’s. However, many women do conceive naturally in the 40-42 year age group, but for those who can’t, and who have been diagnosed with the medical condition of infertility, then improvement in IVF success rates over the last decade mean that we are now able to offer cost effective treatment with a single IVF cycle. This decision was taken after considerable discussion and close analysis of the available evidence.”

Clare Lewis-Jones, GDG member and Chief Executive of Infertility Network UK, said: “NICE clinical guidelines are widely regarded as best practice by healthcare professionals throughout England and Wales, and demonstrates the level of care to which the NHS should aspire. It is often the case that conditions that are viewed by some as ‘lifestyle choices’ should not be given the same priority as others. However, it is important to remember that infertility is a medical condition that needs medical intervention to treat it. The recommendations in this updated guideline are based on a thorough analysis of the best available evidence and I hope this will give the NHS a new push to make fertility services more available to those who need them.”

Although the NHS is not legally obliged to follow NICE clinical guidelines, they are considered to be best practice.

Updated NICE guidelines revise treatment recommendations for people with fertility problems. National Institute for Health and Care Excellence, 20 February 2013

Full guideline - Fertility: Assessment and treatment for people with fertility problems. National Institute for Health and Care Excellence, 20 February 2013

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