Controversies of In-Vitro Fertilization and IVF Tourism
Definition of infertility and its prevalence
Infertility is defined as failure of pregnancy after one year of regular intercourse between man and woman. The prevalence (1) of infertility in UK was 12.5% among woman and 10.1% among man. Infertility can be treatable if the cause is due to infection but most of the time it needs to be treated with IVF. There is an increasing prevalence of infertility in the UK and around the world and I shall explain the reasons later in the article because it is directly related to the matter of public interest.
In-vitro fertilization (IVF) (2)
IVF is a kind of assisted reproductive technique. It is a fertilization process by extracting ova, retrieving sperm sample and then combined them outside the body manually in laboratory. The embryo was then transferred to the uterus. It was allowed to grow in the laboratory for six days and the best embryo will be chosen for transfer. Growth hormones will be given to prepare the uterus for receiving the embryos.
Legal rights and interests of prospective parents
I personally support the continuation of provision of IVF services in the NHS health care system. Their human rights in obtaining the IVF services are enshrined in the following laws. The Human Rights Act 1998 (2) protects UK citizens and residents against the acts or omissions of public authorities that contravene their rights. The Article 142 of European Convention on Human Rights (ECHR) and the Human Rights Act 1998 also prohibit the discrimination so as to protect the exercise of the relevant human rights. The respect of human dignity and self-determination (3) are also protected in ECHR and the Human Rights Act 1998. It is true that the human rights is not absolute, so I listed the justifications (2) for protection of human rights in access of IVF as follows:
It is in accordance with laws and with a legitimate aim: reproductive rights is a subset of human rights at the United Nation’s 1968 International Conference on Human Rights, it stated that “Parents have a basic human rights to determine freely and responsibly the number and spacing of their children.”
It is necessary in a democratic society: protected by Article 12 of ECHR (the rights to marry and found a family) and the reproductive rights stated above.
Also, IVF ensures direct bloodline of the embryo and this cannot be replaced by the role of adoption. Owing to the fragility of the human embryo and the fear of use of embryo in human cloning, embryo use is heavily regulated in the UK and Europe. While I agreed that embryo research should be regulated but allowance should be given to those infertile couples. There are laws regulating the assisted reproduction (3) in the UK that is the Part 2 of the Human Fertilization and Embryology Act 2008. The Human Fertilization and Embryology Authority (HFEA) is the responsible body in carrying out the relevant regulations.
According to the UK Regulations (2), clinics must be licensed by the HFEA. The laws allow embryo freezing, ovum and sperm donation and embryo screening for inherited diseases. UK has also approved the use of hybrid embryos for medical research. The maximum embryos created for implantation in women under 40 will be two and the maximum embryos allowed for women over 40 will be three. UK is looking at moving to single embryo implantation system. There is no anonymity for donors and the limit of children per donor is ten. UK laws allow treatment for Lesbians and single women as well as married women. Most of the NHS services allow one cycle trial and women must meet certain criteria.
A matter of public interest
Public interest (4) is defined as the welfare of the public as compared to the welfare of a private individual or company. The government recognizes the promotion of and protection of this interest in the general public. Whether the access to IVF summons a claim of public interest depends on the following rationales:
Based on the information of prevalence provided above, it is quite common and the trend is increasing. Factors contributing to its high prevalence include male factors (impotence, oligospermia, abnormal sperms, etc.), female factors (pelvic inflammatory disease such as chlamydia infection, blocked Fallopian tube, use of contraceptives, etc.), and social factors (financial reasons such as the need to establish careers first, late marriage, advance age of child bearing, environmental toxins such as pesticides).
The impact of increasing prevalence of infertility can be political or social. The political impact is it affects the rights of succession and this is especially important in the royalty and the wealth. The social impact for the general public will be lack of financial support from the next generation after retirement. They may need to rely on social welfare for financial support if they are not financially independent. With the shifting of the population pyramid to a narrow base of youngsters, the financial burden from the seniors to the government and the youngsters will be increased.
These rationales supported the claim that it is of important public interest. Ethically, infertility is usually involuntary and the couples already need to bear the psychological stress from the community and the family. By the virtue of compassion, we should provide assistance to them. Also, from a consequentialist point of view, the provision of IVF can decrease the negative impacts to the society as stated above.
Rights of access and resources allocation
According to the Article 353 of the European Union Charter of Fundamental Rights, “everyone has the right of access to preventive health care and the right to benefit from medical treatment under the conditions established by national laws and practices.” Infertility is a medical problem, the NHS, as a health care organization should not neglect its importance and existence. As long as the patient has the right of residence and not a burden to the social assistance system of the state, he/she should be granted the rights of access to health care and IVF in this case.
It is always true that if the couple can afford the private IVF service, they should not rely on the NHS. But the truth is most of them cannot afford it because it is a relatively expensive procedures involving highly specialized care. Based on the principle of equality and priority setting in accordance with the prevalence of the medical condition (the prevalence of infertility is quite high), proportionate amount of resources should be allocated to the IVF. Nowadays, The NHS many a time decided the resources allocation according to the National Institute for Health and Care Excellence (NICE) guidelines. The NICE (5) does have guideline on treating infertility especially endometriosis and it allows up to three times of attempt of IVF in women aged 23 to 39 if the couples are infertile for up to three years. This proves that NICE does believe that this is a medical concern for the UK community. While I accepted that an age limit should be set, but the complete denial of access to the IVF services in England is unacceptable. It is true that as the age advances, the success rate of IVF decreases.
Other reasons for granting the access to IVF
Most of the times, people are from middle to lower income groups and they may not have much savings. So, if the NHS does not fund the IVF procedures, they may need to join the expensive private IVF services. Since the chance of success decreases with advancing age of the women, they need even need to attempt for several times in order to get pregnant. This may not be financially sustainable for most couples and they may even leave with debts and the worst case without an heir at the same time. This may be a huge gamble for them. The NHS, as a publicly funded organization, may be able to control the cost better as compared with the privately owned clinics. In fact, the actual cost of IVF may not be as high as believed. The high cost is due to the high exploitation rate in the private market that runs commercially. Owing to these situations, the only one who gets the benefits may be the clinic or the medical doctor in-charge. The cost is especially high in well-developed countries such as UK. This is another reason we should continue to offer IVF in the public NHS.
Besides the point that IVF assists those who are unable to conceive due to various causes, the low occurrence rate of the side effect such as Ovarian Hyperstimulation Syndrome (OHSS) and the relatively high success rate as compared with other assisted reproductive techniques are other supporting reasons for granting its access. Also, those unused embryos can be donated to other infertile couples. With the assistance of pre-implantation genetic diagnosis (PGD), couples can conceive without fear of the inherited genetic diseases.
Restrictions of access to IVF by the NHS (2)
According to the NHS, each cycle of IVF has a cost of up to 8,000 pounds at the very beginning but usually it costs 5,000 pounds per cycle. The cost can be even higher if you have inherited genetic diseases (carrier genes) and need to carry out pre-implantation genetic diagnosis (PGD). PGD is a technology used to choose embryos not affected by genetic defects. PGD will cost about 2,000 pounds to 4,000 pounds for each cycle of IVF. The success rate of IVF varies according to age but on average it is about 40%. The use of frozen ova will be cheaper. In the private market, there will be a discount rate if you carry out multiple attempts. So, sometimes it is believed that the chance of success is by luck. Currently, the NHS does not make the decision based on NICE guidelines but it was decided by the Clinical Commissioning Groups and they have a stricter criteria than the recommendations by the NICE guidelines mentioned above. The NHS now tends to restrict the age limit to 30-35 due to the highest success rate in this age group.
The NHS of England (2) has made the following restrictions since the beginning of 2017:
Swidon: cut from 3 treatment cycles to 1,
West Cheshire: cut from 3 treatment cycles to 1,
Eastern Cheshire: cut from 3 treatment cycles to 1,
South Cheshire: cut from 3 treatment cycles to 1,
Vale Royal: cut from 3 treatment cycles to 1,
Wirral: cut from 3 treatment cycles to 1,
Croydon: only granted for ‘exceptional’ cases,
South Worcestershire: from 2 to 1,
Redditch and Bromsgrove: from 2 to 1,
Wyre Forest: from 2 to 1,
Redbridge: 1 embryo transfer for 23 to 39,
Barking and Dagenham: 1 embryo transfer for 23 to 39,
Havering: 1 embryo transfer for 23 to 39,
Bristol: fertility treatment for 30 to 35,
North Somerset: fertility treatment for 30 to 35,
South Gloucestershire: fertility treatment for 30 to 35,
East and North Hertfordshire: only granted on ‘exceptional’ cases,
Herts Valleys: only granted on ‘exceptional’ cases,
West Essex: only granted on ‘exceptional’ cases,
Cambridgeshire and Peterborough: only granted on ‘exceptional’ cases,
Richmond: only granted on ‘exceptional’ cases.
It is concluded that the arguments against IVF will be its low success rate due to its variation with age, rare but severe side effect such as Ovarian Hyperstimulation Syndrome (OHSS), risk of multiple pregnancy (health risk, psychological and financial stress), higher risk of ectopic pregnancy, higher risk of prematurity and low birth weight of the babies, high cost, and unethical to choose embryos for the reason of gender preference.
Owing to the restrictions of access to IVF by the NHS and high cost of IVF in the UK private markets, the fertility tourism is another choice for local infertile couples. The most welcomed countries will be Spain and India. The cost is much lower and the regulations are good in these two countries.
Spain (6) has a national health system and it is free to all local residents. The Spain government allows ovum donation and embryo donation so many UK citizens are willing to travel to Spain for fertility treatment. The average cost for IVF (own embryos) is only 3,700 pounds in Spain. They claim to have a high success rate. According to their reproductive laws, single women are eligible. There is no law about the upper age limit but most will only accept age up to 50. They are anonymous for ovum and sperm donations. Each donor is only allowed to have six children and maximum three embryos are allowed to be transferred each time. PGD was allowed but gender selection was not allowed. No surrogacy was allowed. All clinics are inspected and regulated by regional governments and some have ISO accreditation.
India (7) is one of the most affordable destinations for IVF. The average cost for IVF in India is 2,900 pounds. In India, clinics need to be registered by the State Accreditation Authority. There are Code of Practice to control the staff, facilities, confidentiality, consent, use of embryos, research, and storage of embryos. Those single women are allowed to receive IVF. They need to provide adequate information to the couples. The records on the information such as genetic information should be kept for up to 10 years. The clinics must be translucent on its operation.
Arguments for IVF in older women
Women in support of this claimed that maturity is an advantage in parenting. Women are well prepared in their career and financially more affordable for child bearing at their older age. Also, there are successful cases in postmenopausal women to get pregnant.
There are reasons to act against IVF in older women. They believe parents may die at their children’s young age and it is bad for the welfare of the child. They fear that people will push the age limit too much to an even advanced age. Also, child bearing at an older age is of higher risk to both the women and the babies.
G.T. Laurie, S.H.E. Harmon, and G. Porter. (2016) Law & Medical Ethics. Tenth Edition.