State-funded IVF: Hands of bean counters all over crude cut-off criteria

The groundbreaking announcement by Minister for Health Stephen Donnelly that Assisted Human Reproduction (AHR) treatment will be publicly funded for the first time in the State will be broadly welcomed.

Until now, couples of limited means were unable to access private treatment; by closing off this economic barrier to conception, the Government has largely levelled the playing field for reproductive medicine in the Republic.

Despite being designed by experts from the Health Service Executive’s (HSE) National Women and Infants Health Programme (NWIHP), the hands of the bean counters in the Department of Health are all over the announcement. Mr Donnelly himself told RTÉ's News At One that “really it’s about targeting the resources ...”

This has resulted in rather crude cut off criteria for the scheme, including at the age of 41 for a woman seeking help and the questionable use of body mass index (BMI) as an exclusion criterion.

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Mercifully, earlier indications that couples with an unknown cause of infertility would be excluded from the programme, have not been carried through to the final document. Of the one in six couples who experience infertility in this country, about 25 per cent have an unknown cause. This would have been an iniquitous exclusion had it come to pass.

Access to publicly-funded AHR treatment will be available for those individuals who have previously undertaken a maximum of one previous IVF cycle and where all embryos created as part of that cycle have been used. Again this smacks of penny pinching - the success rate after one cycle is low, while in Britain it can be funded for up to three cycles.

“The BMI of an intending birth mother must be within the range of 18.5kg/m2 – 30.0kg/m2,” the criterion also state. But the National Institute for Health and Care Excellence (NICE), in the UK, which provides evidence-based guidance for health and social care, does not recommend blanket BMI limits for either male or female patients when it comes to accessing fertility treatment.

Aside from adding to the stigma and bias we know affect people who are obese, there is also a fundamental scientific problem with using BMI as an accurate measure of adiposity. Put simply, BMI cannot differentiate fat mass from lean mass, or subcutaneous (good) fat from visceral (bad) fat.

[ Publicly-funded AHR: How will it work and how can people avail of it? ]

[ Age and BMI cut-offs criticised as move to publicly fund AHR set to help 3,000 couples annually ]

Worldwide, medical experts have been calling for BMI to be sidelined as an indicator of disease or death. They want to see the introduction of a new measure that is causal rather than correlational, is consistent across variation in fat distribution and, ideally, easy to assess. It is now accepted that the focus should now be on fat distribution rather than weight.

So rather than create rigid criteria based on an outmoded measure of obesity, those behind the scheme would have better served the Irish public by adopting any weight-based treatment criteria on a case-by-case basis. This could easily be achieved by using the stepped care model outlined elsewhere in the AHR programme. It’s not too late to move to a more sensitive, individualised and caring approach for couples seeking help under publicly-funded fertility treatment.