Improving global access to fertility care

Published 07 January 2020

A Campus meeting in December concluded that global access to effective fertility can be achieved, but only with the combined commitments of fertility education, affordable treatment, and the support of governments.

The solution to unequal access in fertility care lies in a package of approaches which include infertility awareness programmes, safe but affordable IVF, and a commitment from governments to respect human rights.

This was the consensus from the presenters at this ESHRE Campus meeting in December, which, while acknowledging this will not be achieved overnight, will require the cooperation of numerous groups, including medical societies, politicians and patient organisations. The consensus followed several lively open floor discussions among attendees and presenters, with everyone posing for a group selfie as part of a recently launched global fertility education campaign which ESHRE is partnering.

ESHRE's Past Chair Roy Farquharson emphasised the Society’s commitment to promoting access to evidence-based practice, engaging with patient organisations and maintaining reprovigilance to protect patients from ineffective treatments (eg, costly add-ons). In addition to publishing expert guidelines and recommendations, ESHRE’s vision is to set a global standard for practice and research through collaborative networks that accurately design and complete trials.

Initiatives to address need and improve access include the pharma industry's collaboration with societies to produce audits highlighting inequalities, charitable projects to raise awareness among policymakers about infertility, and public campaigns. Sören Ziebe presented details of a project he led in Denmark to highlight the effect of ageing on fertility for men and women in their 30s. His message was that greater fertility awareness is needed in schools, that childbearing should be made a national priority, and for men to be targeted too with fertility education.

Petra De Sutter, from University Hospital Ghent and a member of the European Parliament, highlighted the huge variation in fertility treatment eligibility criteria. Parts of Poland have taken the extreme view of setting up LGBT-free zones, whereas France has recently agreed to grant single women and lesbians state-funded treatment for the first time. This demonstrates the ‘ideological cleavage’ between political leaders on issues such as surrogacy, a topic on which even the Council of Europe has failed to reach a unified position. De Sutter pointed out the EU can influence, but only when ideology-driven agendas touch on human rights.

These differences should be set aside, she argued. Politicians and governments — not the market — have a hugely important role in regulation, as evidenced by the CRISPR baby scandal, and should be facilitating debate around innovation and trends in fertility treatment, according to De Sutter. They should also respect human rights and not let sexual orientation influence their decisions. As outlined by an ESHRE task force, any position on single, lesbian and gay couple rights should be considered in the light of scientific evidence.

There was also evidence that affordable treatments do offer a way forward in equalising access. As presented at ESHRE’s Annual Meeting, Willem Ombelet’s one-day diagnostic approach for The Walking Egg (TWE) programme, which has now progressed to a lab housed in a container on wheels, has resulted in 180 live births to date, with results appearing better than conventional IVF. What is urgently needed is government funding, volunteers and university support.

Low-cost mild ovarian stimulation protocols, as used by Ombelet and others in suitable patients, can also save money and reduce side effects without compromising success rates. Madelon Van Wely, from the University Medical Center of Amsterdam, in describing affordable stimulation protocols, concluded that the costs of IVF can be reduced by using lower doses of gonadotrophins through milder protocols and the concomitant use of clomiphene citrate or letrozole.(1)

A presentation by Guido Pennings, from the Bioethics Institute, Ghent, explored the ethics of IVF access concentrating particularly on the use of low cost IVF in low to middle income countries, even if (and when) efficiency is below standard. Does low cost also mean low quality, asked Pennings. However, after reviewing evidence he concluded that lower cost/lower quality treatment is acceptable when a large population is in need. Low-cost IVF maximises well-being and reduces inequality in health care, he said. 'A resource-sensitive approach takes into account the limited healthcare budget of a country and the opportunity costs of spending money on infertility treatment,' said Pennings.

In closing this two-day Campus meeting, co-ordinator of the SIG Global and Socio-cultural Aspects of Infertility Virginie Rozée called for further studies in fertility care to establish better ways of legally framing ART, to recognise infertility as a public health matter and to fight against discrimination.

1. Wang R, Kim B, Van Wely M, et al. Treatment strategies for women with WHO group II anovulation: systematic review and network meta-analysis. BMJ 2017; 356: doi: 10.1136/bmj.j138.

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