Male GPs are less likely to refer eligible patients for IVF, research by a fertility charity suggests, raising concerns about access to NHS-funded treatment.
The Progress Educational Trust’s (PET) report highlights “utter confusion” and a lack of knowledge among GPs about eligibility criteria for NHS-funded treatment, which it says is exacerbating the so-called IVF postcode lottery. GPs typically make the initial referral to fertility clinics, meaning that they play a crucial role in access.
“For NHS treatment, GPs are the main initial gatekeeper. If you’re not getting pregnant, that’s who you go to for advice and support,” said Sarah Norcross, the director of PET. “It struck me that, when people have a known cause of infertility, male GPs still weren’t passing them on.”
The report is based on a survey of 200 GPs and commissioners across England, carried out by an independent research company, which investigated knowledge of national fertility guidelines and criteria they use for referral decisions.
The National Institute for Health and Care Excellence (Nice) is reviewing its fertility guidelines, which have not been updated in 20 years. It currently recommends that women under 40 years should be offered up to three full cycles of IVF on the NHS, if they or their partner are infertile.
However, GPs’ day-to-day decisions are constrained by local criteria, set by commissioning groups, and only about 10% meet the Nice guidelines. Many areas offer only one funded IVF cycle.
Even given regional variation, the PET report suggest GPs are sometimes not referring eligible patients, and it found that a doctor’s age and gender could play a role.
In the case of a known cause of infertility or reduced fertility (which would automatically make a patient eligible under Nice guidelines) 52% of male GPs said they would refer for treatment compared with 73% of female GPs. For patients who had tried to get pregnant through regular unprotected sex for one year, 57% of male GPs said they would refer, compared with 66% of female GPs. Younger and less experienced GPs were also more likely to refer patients for IVF treatment.
There also appeared to be lack of clarity about the defined completion point of an IVF cycle, with only 16% of GPs correctly identifying that it is “when all viable embryos are transferred”, as stated in the Nice guideline.
“These survey results show that there is utter confusion over the current Nice fertility guideline,” said Norcross. “Our results should send a strong message to the government, NHS England, the women’s health ambassador and commissioning bodies. The lack of understanding of the guideline by GPs is making the postcode lottery worse.”
The survey found a majority of GPs (54%) stated that they had seen a change in referral criteria, with almost all access requirements set by local commissioning groups becoming more restrictive in the past two years.
“Sadly, over the last three years, we have seen a huge drop in support for people requiring fertility treatment,” said Prof Adam Balen, of the University of Leeds, a former chair of the British Fertility Society. “Not only are couples finding it very difficult to get an appointment with their GP, but when they do, there is a huge lack of knowledge about testing – and a reluctance to initiate investigations, and refer for treatments – despite clear national guidelines.”
Nearly three-quarters of GPs have received a complaint about access to fertility treatment, with 10% having received more than 10 patient complaints in the past 12 months.
Prof Kamila Hawthorne, the chair of the Royal College of GPs, said: “It is clear from this survey that the complexity of fertility treatment pathways across the country, and how this relates to Nice guidance, can cause confusion, both amongst GPs and patients – and this needs to be addressed. GPs understand how distressing fertility issues can be for patients and the impact these can have on many aspects of their health and lives, and will do what they can, in accordance with local policies, to support them, based on their individual circumstances.”
Hawthorne added that the criteria by which GPs should refer patients are set by local policies, decided by integrated care boards (ICBs), which in many areas do not align with Nice guidance. “In England, it is ICBs that determine how many cycles of IVF can be offered to a patient on the NHS, not GPs,” she said.
Prof Geeta Nargund, a senior NHS consultant and medical director at Create Fertility, said: “For the one in seven couples who have difficulty conceiving, the PET survey findings are both shocking and deeply worrying. Already, these couples have to navigate an IVF postcode lottery, which leaves many patients priced out of fertility treatment and unable to access treatment simply due to where they live. That there is also significant inconsistency and misunderstanding in how GPs are interpreting Nice guidelines suggests that even couples who are entitled to NHS-funded fertility treatment might be missing out.”
Prof Richard Anderson, co-director of the Centre for Reproductive Health at the University of Edinburgh, said that the wide variation in eligibility criteria across England needed to be addressed. “It’s an appalling situation,” he said. “In Scotland, we’ve got equal pathways across the whole country. You can understand how GPs could get confused.”
He added that GPs ought to be “enthusiastically referring” eligible patients to ensure they accessed treatment. “When the bottleneck gets pushed down to the GP level, that’s going to worsen inequality,” he said.
