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Optimised patient pathway for infertility

Dr Moses Batwala, MSc Candidate by Research, Obstetrics and Gynaecology, University of Oxford; Honorary Consultant, Obstetrics and Gynaecology, London North West University Healthcare NHS Trust; Medical Director, IVF London 

moses.batwala@st-hildas.ox.ac.uk

Summary 

Difficulty conceiving affects approximately one in seven heterosexual couples in the UK.1,[A] Couples should be offered clinical assessment after unsuccessfully trying to conceive for 1 year.1 If a cause of infertility is uncovered, or if couples have tried unsuccessfully to conceive for 2 years, NICE recommends up to three full cycles of assisted reproductive technology (ART), the most common mode of which being in vitro fertilisation (IVF), in eligible women aged up to 40 years and one cycle in women aged 40–42 years.1

In practice, the number of NHS‑funded ART cycles offered in many areas has been reduced as a result of funding decisions made by local CCGs.2,3 In addition, couples can face long delays while investigations are conducted prior to referral for ART. During this time, their fertility may decline further, meaning that not only is their treatment less likely to be successful, but also that the NHS incurs increased costs associated with repeated cycles (if couples are eligible), further investigations, and additional follow-up consultations.4 Thus, it would be cheaper for the NHS if conditions are optimised for the woman to fall pregnant in the first cycle attempted.

This supplement describes the introduction of a one-stop fertility clinic in Oxford to optimise the pathway for couples presenting with infertility in primary care and reduce the time to referral for ART in a tertiary fertility centre. Preliminary data from a prospective observational study conducted by the Oxford University One-Stop Fertility Clinic Study Group comparing couples attending a one-stop clinic with those in the conventional pathway showed that couples attending a one-stop clinic spent around 280 days fewer in the investigative pathway before starting ART treatment compared with couples in the conventional pathway.5 This could lead to overall savings to the Oxfordshire CCG of approximately £430,000. Furthermore, the mean cost of investigations for couples attending a one‑stop fertility clinic was approximately £480 less than for those on the conventional pathway.5 Unexpectedly, couples attending a one‑stop clinic reported a lower quality of life (QoL) than couples in the conventional pathway.5

These potential cost savings for the Oxfordshire CCG may match those anticipated by reducing or ceasing funding of ART cycles. If CCGs can ‘ring fence’ and use the money saved by one‑stop clinics to maintain or increase the provision of ART cycles, it may have the additional benefit of reducing high multiple births (twins, triplets, and higher orders) resulting from couples going abroad for cheaper treatment, which can carry significantly higher costs for patients and the NHS alike.

[A] Same-sex couples and single women have not been included in this supplement because they follow a different infertility treatment pathway to heterosexual patients.

Introduction

Infertility is defined as failure to achieve clinical pregnancy after 1 or 2 years of regular unprotected intercourse.6 Approximately one in seven heterosexual couples in the UK experience a delay in starting a family despite regular unprotected intercourse over a 12-month period.1 Women’s natural fertility declines with age, significantly so after 35 years of age.6 The main causes of infertility and their prevalence are listed in Box 1. Problems affect both members of the couple in approximately 40% of cases.1

Box 1: Types of infertility and their prevalence in the UK1
  • Unexplained (no identified cause): 25%
  • Ovulatory disorders: 25% 
  • Tubal factor infertility (blocked or damaged tubes): 20% 
  • Male infertility (reduced sperm parameters or azoospermia): 30% 
  • Uterine or peritoneal disorders: 10%.

Approximately half of couples who do not conceive within 1 year will do so in the following year.1 However, ART may help couples who do not conceive after 2 years—or who have an absolute cause of infertility, such as bilateral blocked tubes or azoospermia—achieve pregnancy. IVF is an effective treatment irrespective of the cause of infertility.7 More than 68,700 IVF treatment cycles were carried out in the UK in 2018, with an average IVF birth rate per embryo transferred of 23%.2

Guidance on fertility treatment

Couples for whom there is no chance of pregnancy with expectant management, and for whom IVF is the only effective treatment for infertility, should be referred for ART immediately. For other couples who do not conceive after 2 years of unprotected intercourse or 12 cycles of artificial insemination, six of which should be intrauterine insemination, NICE recommends up to three NHS-funded full cycles of ART when the female partner is aged under 40 years, and one fully funded cycle for women aged 40–42 years.1

Since 2013, to decrease the frequency of multiple births (twins, triplets, and higher order), NICE has recommended that no more than two embryos should be transferred during any one cycle of IVF treatment, but if a top-quality blastocyst is available, then single‑embryo transfer should be used.1

Conventional fertility pathway

The conventional fertility pathway followed by couples affected by infertility is adapted by local CCGs from NICE guidance, which was published in 2013.1 A summary of this pathway from primary care to ART is outlined in the following sections.1,6

Primary care

A couple who present to their GP with difficulty conceiving will have investigations initiated if they have been trying for 12 months without success, unless there are mitigating circumstances.

The GP will usually take a full medical, sexual, and social history of both partners to establish adequate frequency of unprotected intercourse (the chances of conception increase with regular intercourse, e.g. every 2–3 days) and duration of trying to conceive of at least 12 months.

The GP may give lifestyle advice about modifiable risk factors, such as weight loss, smoking cessation, caffeine and alcohol consumption, and frequency and timing of intercourse, which may help some couples achieve a pregnancy naturally.

Primary investigations in couples who have not conceived after 1 year of regular intercourse may include those listed in Box 2.

Couples are reviewed at a second follow-up appointment with the GP and, if still not pregnant after trying to conceive for at least 12 months, referred to a secondary care NHS fertility clinic for further investigation and treatment. However, in real-life clinical practice, there are frequently more than two consultations/follow-ups to arrange and review investigations before the couple are referred to secondary care.

Box 2: Primary care infertility investigations 1,6

Both partners

  • Chlamydia screening

Men

  • Semen analysis

Women

  • Measurement of mid-luteal phase progesterone to test for ovulation, usually 7 days before anticipated menses
  • Measurements of follicle stimulating hormone and luteinising hormone to identify ovulation disorders
  • Thyroid function tests if symptomatic
  • Screening for rubella immunity if no records of immunisation
  • Cervical screening if not up to date.

Secondary care

Management in secondary care typically involves an initial consultation with a fertility specialist doctor or clinician. Depending on the findings of this consultation, the couple may be sent for further investigations including (but not limited to) the investigations listed in Box 3. According to NICE guidance, counselling should be offered before, during, and after investigations and treatment.1 However, in practice, counselling is usually only formally and proactively offered in tertiary rather than secondary care.

Patients may have further follow-up consultations to review the results of investigations into the cause of their infertility. The number of consultations patients should have, and over what period, are not specified in the NICE guidelines. 

Depending on the results of their investigations, and if the couples meet the local clinical CCG funding criteria,3 they can be referred for ART.

Box 3: Secondary care infertility investigations1,6,8

Men

  • Sperm assessment
  • If abnormality found, then more detailed examinations are conducted, such as microbiological tests, sperm culture, endocrine tests, urogenital tract imaging, or testicular biopsy

Women

  • HSG or, if appropriate expertise is available, HyCoSy to assess tubal patency
  • Laparoscopy and dye test if HSG or HyCoSy is suggestive of blocked fallopian tubes, or if the woman has a known existing pelvic pathology, such as previous chlamydia infection, pelvic inflammatory disease, endometriosis, or previous ectopic pregnancy
  • Pelvic ultrasound scanning if a pelvic pathology, such as fibroids, PCOS, or endometriosis, is suspected

Both partners

  • Further specialist investigations or blood tests where warranted, such as PCOS screening in women suspected of anovulatory cycles, or cystic fibrosis screening and karyotyping in men with azoospermia.

HSG=hysterosalpingography; HyCoSy=hysterosalpingo-contrast ultrasonography; PCOS=polycystic ovary syndrome

Tertiary care

Depending on funding and which ART pathways are available in a CCG, ART treatment will likely follow one of three routes.

Couples with an identified ‘absolute’ cause of infertility, such as a woman with bilateral blocked fallopian tubes, can be referred for immediate ART. 

Couples with ‘relative’ causes of infertility, such as reduced sperm count or ovulatory disorders such as polycystic ovary syndrome (PCOS), but who have not been actively trying to conceive for 2 years, are managed with other methods for 2 years before becoming eligible for NHS-funded ART:

  • expectant lifestyle management—for example, advice to lose weight and have regular intercourse
  • medical management—for example, clomifene citrate for ovulatory disorders
  • surgical management—for example, laparoscopic ovarian drilling for women with PCOS resistant to clomifene citrate. 

Couples who do not meet local criteria for ART funding may choose to: fund their own treatment via a private arrangement with a specialist clinic, either in the UK or abroad; continue to try to conceive naturally; apply for exceptional circumstances for CCG funding—for example, if there is a need to prevent genetic illness using ART and pre-genetic diagnosis;9 seek adoption services; or decide not to have any children.

Impact of delayed fertility treatment

Couples experiencing infertility and undergoing investigations and treatment may experience significant psychological distress.7

A woman’s age when she starts ART is the strongest predictor of pregnancy; the chances of success decrease with increasing age, particularly above 36 years.10,11 Sometimes, infertility investigations are carried out over several months and, in some cases, years; in some instances, tests may be unnecessarily repeated. Such delays in referring a woman for treatment may reduce a woman’s chance of conception, and are likely to impact negatively on a couple’s QoL.4,12

If local CCG policy criteria dictate that couples are ineligible for NHS funding because they exceed the age limits as a result of delayed investigations and referral, they may choose to pay for private fertility treatment. One cycle of IVF can cost couples around £5000, but there are additional costs for medicines, consultations, and tests.13 A survey carried out in 2018 found that 62% of patients who had private IVF treatment paid more than they had expected to.14 Only around 25% of couples experience a successful outcome after one ART cycle; therefore, paying for multiple cycles will have a substantial impact on a couple’s finances.15

Impact of CCG funding cuts

Despite clear guidance from NICE in relation to IVF provision, NHS funding varies across the UK by nation and region, amounting to a postcode lottery, with couples in some areas, particularly in parts of Scotland and Northern Ireland, able to access the NICE-recommended number of ART cycles, whereas others find themselves ineligible for treatment at all.2,3

As a result of funding cuts, many CCGs offer fewer IVF cycles than recommended and/or have reduced the age at which women are eligible for treatment. In 2017, an audit by Fertility Fairness found that only 12% of CCGs in England were offering three IVF cycles to eligible women under 40, and almost half of CCGs were not offering any IVF to women aged 40–42 years.16

ART treatment abroad

A proportion of patients choose to go abroad to access cheaper ART. Some overseas clinics are not regulated in the same way as UK clinics with regard to the number of embryos transferred to reduce multiple pregnancy rates; if two or more embryos are transferred to improve IVF success rates, couples risk multiple pregnancies (twins, triplets, or higher order). Multiple pregnancies are associated with elevated risks of morbidity and mortality for both mothers and babies:15 the risks associated with multiple pregnancies include miscarriage, elective foetal reduction, pre‑eclampsia, gestational diabetes, operative delivery, and extreme prematurity.

Cuts in ART funding in the UK are being made without addressing the cost of couples seeking treatment abroad. The best data available are from a study published in 2006, which highlights the problem. The study calculated that the direct cost to the NHS of a triplet pregnancy was £32,354, compared with £9122 for a twin pregnancy, and £3313 for a singleton pregnancy.17 Increased costs associated with multiple pregnancies are due to a higher than average number of hospital antenatal appointments, scans, and caesarean sections, and longer than average postnatal admission and neonatal admission in neonatal intensive care units, special care baby units, and postnatal wards in the case of high multiple birth pregnancies. The total cost to the NHS is likely higher because this does not account for costs associated with treating lifelong conditions such as cerebral palsy, developmental and learning problems, and respiratory illnesses that may be experienced by children of multiple births.17

In the UK, rarely are more than two embryos transferred in a woman undergoing ART, with single-embryo transfer preferred where viable, to reduce the multiple pregnancy rate.1 Since the Human Fertilisation & Embryology Authority introduced this policy in 2008, the multiple birth rate in the UK fell from 24% to 8%,2 and was accompanied by an increase in birth rates as a result of reduced risks to the mother and child.

If couples were better able to get NHS funding for ART, they may be less likely to go abroad for treatment; the cost to the NHS of treating multiple pregnancies and lifelong conditions experienced by children of multiple births would, therefore, be avoided. 

High multiple pregnancies in Oxford

A retrospective observational study conducted by the Oxford University One-Stop Fertility Clinic Study Group analysed patient data on all high multiple pregnancies (triplets or higher order) at the John Radcliffe Hospital in Oxford from 2010–2017.5 The aim was to investigate trends linked to ART treatment in the UK or abroad, and the effect on NHS finances and resources. 

During the 7-year period reviewed, 43 women with a high multiple pregnancy were managed at the John Radcliffe Hospital, of whom 42 were also delivered at the hospital. Figure 1 shows the number of high multiple births per year at the John Radcliffe Hospital.

Figure 1: Type of conception of high multiple births per year of birth at the John Radcliffe Hospital, Oxford

Figure 1: Type of conception of high multiple births per year of birth at the John Radcliffe Hospital, Oxford5

IVF=in vitro fertilisation; OI=ovulation induction

ART using either IVF or intracytoplasmic sperm injection (ICSI) accounted for 53% of all the high multiple births (n=23). 

Seven women (16%) had their ART abroad, and four women (9%) had their ART in the UK. For 12 women (28%), there was no information identifying the location at which they underwent ART treatment. 

High multiple pregnancies conceived by other means accounted for 47% of the cases and are categorised below.

Eleven women’s pregnancies (26%) were naturally conceived, and five women (12%) conceived following the induction of ovulation. 

There were a further four pregnancies (9%) where there was no information available as to mode of conception. These pregnancies may have been conceived via ART, naturally, or by ovulation induction; however, there is no information currently collected to verify this.

Preliminary data from the study showed that, in the 7 years analysed, high multiple pregnancies had an estimated direct cost to the NHS at the John Radcliffe Hospital of £1,203,908. Documented IVF‑conceived pregnancies accounted for 50.8% of this figure, costing £706,638. There is, therefore, a considerable cost associated with high multiple pregnancies to the NHS, particularly those resulting from IVF.

Case study

It has been shown that cost savings can be realised in making the investigative pathway more efficient.4 One-stop fertility assessment enables couples to have as many necessary investigations as possible performed within one visit, as well as time to discuss their treatment options with a reproductive medicine specialist, thereby reducing the number of consultations required to make a diagnosis and start treatment.4

Dr Moses Batwala (this article’s author) and his team at the Oxford Fertility Clinic entered into a Joint Working project with Merck Serono Ltd to analyse the differences between a one-stop fertility clinic and the conventional fertility pathway in Oxford. The aim was to reduce the cost of fertility investigations to the NHS and speed up patients’ access to ART from the time of their first presentation to their GP. The team analysed the conventional patient journey, documented the common steps, and designed the one‑stop clinic pathway to try and combine as many investigations as possible into as few visits as possible, with the aim of increasing efficiency while decreasing the duration of investigations. The investigations performed in both pathways are identical; however, in the one‑stop pathway, patients have one fewer GP consultation and one fewer fertility consultation. 

Figure 2 compares the journeys of couples who present to their GP with infertility via the conventional and one-stop pathways.

Figure 2: The conventional versus the one-stop fertility investigative pathways

Figure 2: The conventional versus the one-stop fertility investigative pathways5

ART=assisted reproductive technology; HyCoSy=hysterosalpingo-contrast ultrasonography

Local GPs were invited to refer patients to the new service, and advised that when a couple presents to the practice, they should perform all the necessary baseline investigations and immediately refer the couple to the one-stop clinic.

At the one-stop clinic, the male partner undergoes semen analysis and, if the results are normal, the female partner has a HyCoSy scan to assess tubal patency. In the same appointment, the couple are then reviewed by a fertility specialist with all their results and given a diagnosis. A management plan is agreed during the same clinic visit. If they have been trying to conceive for more than 2 years, they can be referred for ART (if eligible) in the same appointment. If their diagnosis shows that they would not be able to conceive naturally because of an ‘absolute’ cause of infertility, such as bilateral blocked fallopian tubes, they are referred for ART immediately, even if they have spent less than 2 years trying to conceive.

In the Oxfordshire CCG, approximately 900 new couples are seen in the NHS secondary fertility clinic for investigations and management every year (figure based on new consultations in the 2015–2016 business year at the Oxford Fertility Clinic). Therefore, reducing the number of consultations they need and avoiding duplication of blood tests and investigations will lead to considerable cost savings to the NHS. In addition, fewer consultations with GPs and consultants will allow clinicians to spend more time on other medical duties.

For patients, benefits of the one-stop pathway include fewer hospital appointments and journeys, and less time off work to attend appointments.

One-stop pathway outcomes

A study was carried out to assess the impact of the one-stop pathway.5 The study was based at the University of Oxford, in conjunction with the Oxford Fertility Clinic, a private fertility clinic, which at the time of the study provided the secondary NHS care and tertiary ART for eligible couples. Participants at Create Fertility in London, who attended an established one‑stop service at St Albans City Hospital in Hertfordshire, were also recruited into the one-stop arm of the study. 

A pilot review of 20 randomly selected patient files at the Oxford Fertility Clinic showed time delays during investigations of 2–5 years before referral for ART. 

Between May 2016 and May 2018, the prospective observational study compared participants going through the conventional NHS pathway (n=191) with participants going through a one‑stop pathway (n=28; 20 at the one-stop clinic at St Albans City Hospital, and eight at the new one-stop clinic in Oxford). Data were taken from participants’ NHS notes at the two tertiary care fertility units. The cost to the NHS of participants going through the two pathways was calculated.5

Participants also filled in a validated fertility-related QoL questionnaire (FertiQoL).19

Duration and cost

Preliminary data showed that participants attending a one‑stop clinic underwent fewer days of investigation (1014 [standard deviation {SD}=280.4] vs. 1297.5 [SD=687.5]; p=0.0331) and cost the NHS less money (£460 [SD £280] vs. £941 [SD £495]; p<0.001) compared with those on the conventional pathway.5

The one-stop clinic showed statistically significant reductions in the time from:5

  • first GP referral to referral for secondary care by approximately 243 days
  • first GP referral to referral for ART by approximately 470 days
  • first NHS referral in secondary care (NHS fertility clinic) to referral for ART by around 250 days.

The mean cost of investigations via the one-stop pathway was £460 compared with £941 via the conventional pathway—a cost saving of approximately £480 per couple.5

If the 900 couples who request fertility investigations in the Oxfordshire CCG in a year were referred to the one-stop clinic, it could save around £432,900 a year (900×£481).

Oxfordshire CCG only offers one NHS-funded cycle for couples with a female partner who has not reached her 35th birthday by the start of treatment, and only if neither partner has children from a previous relationship.19

Oxfordshire CCG funded more than 90 IVF/ICSI cycles in 2015/16, and each cycle cost between £3000 and £4000 (information obtained from Oxfordshire CCG via a Freedom of Information request). If the CCG used the money saved from implementing the one-stop pathway, it could fund many more cycles each year, enabling more couples to access treatment. 

Box 4 summarises recommendations for introducing a one-stop service for infertility investigation and treatment.

Box 4: Recommendations
  • Introducing a one-stop fertility clinic will lead to cost savings in fertility investigations in primary and secondary care and free up clinicians’ time
  • Savings could be ring-fenced by CCGs and used to maintain or increase the number of NHS-funded ART cycles they provide to couples—this may promote better practice, and provide an alternative to UK citizens seeking ART abroad, which is associated with multiple pregnancies and higher pregnancy-related costs, morbidity, and mortality, thereby improving patient and child safety, as well as saving the NHS money further down the line
  • One-stop fertility clinics reduce delays for people who present with infertility to access ART, which improves their chances of a successful pregnancy
  • Further research is needed to investigate the effect of fertility investigations and treatment on patients’ QoL, but the early impact on QoL observed in the one-stop pathway suggests that psychological support should be offered to patients early in the investigative process
  • There is a need for a national database to collect information on multiple pregnancies—whether they are conceived through ART, whether couples received treatment in the UK or abroad, and any complications that arise—to allow the impact on the NHS and social services provision in the UK to be determined
  • NICE guidelines should be updated and adopt newer more efficient investigative tests
  • Better public health awareness of reproductive health should be promoted—a number of patients first present to the GP with difficulty trying to conceive after more than 2 years, and if they had presented earlier, they would have been referred for ART.

ART=assisted reproductive technology; QoL=quality of life

Quality of life

One-stop participants were found to have a lower QoL than conventional pathway participants.5 This early impact on participants’ QoL was surprising, and the reason for it is not clear, but it may signify that couples do not feel in control of their plans or that a new diagnosis initially puts a strain on their relationship. 

It is possible that couples adapt better to their diagnosis over time and/or receive support; thus, their QoL improves gradually. 

NICE recommends psychological support for couples trying to conceive.1 The findings of this study indicate that the impact on QoL may occur earlier in the investigative process; patients may, therefore, benefit from earlier expert psychological support in the one-stop pathway. Further research is needed to investigate the precise explanation for this finding.

Conclusion

Difficulty conceiving affects one in seven UK couples, and puts significant pressure on limited NHS resources.1 There is no single solution that will resolve the problem of funding for fertility investigation and treatment for individuals requiring help to achieve a pregnancy. However, a one-stop clinic may be part of the solution in reducing costs and decreasing the duration of investigation and treatment of patients having difficulty conceiving. One-stop fertility clinics would enable cost savings to be ‘ring-fenced’ to maintain or even increase the number of NHS-funded ART cycles that CCGs currently offer. This may discourage patients from going abroad for fertility treatment and returning with high-risk, costly multiple pregnancies. However, further research is required to fully understand the factors affecting QoL of patients undergoing investigation and treatment for infertility via a one-stop clinic. 

Conflicts of interest

Dr Batwala has received funding from Merck Serono Ltd to attend continuing professional development conferences in 2018 and 2019.

References

  1. NICE. Fertility problems: assessment and treatment. Clinical Guideline 156. NICE, 2013 (last updated 2017). Available at: www.nice.org.uk/cg156
  2. Human Fertilisation & Embryology Authority. Fertility treatment 2018: trends and figures. London: HFEA, 2020. Available at: www.hfea.gov.uk/about-us/publications/research-and-data/fertility-treatment-2018-trends-and-figures/
  3. NICE. NICE calls for an end to postcode lottery of IVF treatmentwww.nice.org.uk/news/article/nice-calls-for-an-end-to-postcode-lottery-of-ivf-treatment (accessed 2 April 2020).
  4. Hrehorcak M, Nargund G. “One-stop” fertility assessment using advanced ultrasound technology. Facts Views Vis Obgyn 2011; 3 (1): 8–12.
  5. Batwala M. An observational prospective study on NHS expenditure and patient quality of life with duration of fertility investigation in conventional pathways and comparison with one-stop fertility clinic pathways  [thesis currently in submission for the degree of Master of Sciences]. Oxford: University of Oxford, 2019.
  6. NICE. Clinical knowledge summary: infertilitycks.nice.org.uk/infertility (accessed 2 April 2020).
  7. Royal College of Obstetricians and Gynaecologists. Clinical guideline no 4. The management of infertility in tertiary care. BJU Int 2001; 87: 213–217.
  8. Fields E, Chard J, James D, Treasure T. Fertility (update): summary of NICE guidance. BMJ 2013; 346: f650.
  9. Handyside A. Preimplantation genetic diagnosis after 20 years. Reprod Biomed Online 2010; 21 (3): 280–282.
  10. van Loendersloot L, van Wely M, Limpens J et al. Predictive factors in in vitro fertilization (IVF): a systematic review and meta-analysis. Hum Reprod Update 2010; 16 (6): 577–589. 
  11. Dhillon R, McLernon D, Smith P et al. Predicting the chance of live birth for women undergoing IVF: a novel pretreatment counselling tool. Hum Reprod 2016; 31 (1): 84–92.
  12. Karabulut A, Özkan S, Oğuz N. Predictors of fertility quality of life (FertiQoL) in infertile women: analysis of confounding factors. Eur J Obstet Gynecol Reprod Biol 2013; 170 (1): 193–197.
  13. NHS. Availability—IVF. www.nhs.uk/conditions/ivf/availability (accessed 2 April 2020).
  14. Human Fertilisation & Embryology Authority. Pilot national fertility patient survey. London: HFEA, 2018. Available at: www.hfea.gov.uk/media/2702/pilot-national-fertility-patient-survey-2018.pdf
  15. Ismail L, Mittal M, Kalu E. IVF twins: buy one get one free? J Fam Plan Reprod Health Care 2012; 38: 252–257.
  16. Fertility Fairness. Number of CCGs offering 3 IVF cycles has halved since 2013www.fertilityfairness.co.uk/number-of-ccgs-offering-3-ivf-cycles-has-halved-since-2013/ (accessed 2 April 2020).
  17. Ledger W, Anumba D, Marlow M et al. The costs to the NHS of multiple births after IVF treatment in the UK. BJOG 2006; 113 (1): 21–25.
  18. Cardiff University. Fertility quality of life tool—more about FertiQoLsites.cardiff.ac.uk/fertiqol/background/ (accessed 2 April 2020).
  19. NHS Oxfordshire Clinical Commissioning Group. Thames Valley Priorities Committee Commissioning Policy Statement. Policy No. 11i (TVPC 11g):assisted reproduction services for infertile patients.www.oxfordshireccg.nhs.uk/professional-resources/documents/commissioning-statements/011i-TVPC-11g-Assisted-Reproduction-Services.pdf (accessed 2 April 2020).

This supplement has been commissioned and funded by Merck Serono Ltd and developed in partnership with Guidelines in Practice.  Merck Serono Ltd suggested the topic and author, and it describes information from a Joint Working project between Merck Serono Ltd and the Oxford Fertility Unit analysing different fertility treatment pathways. Merck Serono Ltd carried out full medical approval on all materials to ensure compliance with regulations. 

The sponsorship fee included an honorarium for the author. The views and opinions of the author are not necessarily those of Merck Serono Ltd, or of Guidelines in Practice, its publisher, advisers, or advertisers. No part of this publication may be reproduced in any form without the permission of the publisher.

UI-NONF-00042

Date of preparation: September 2020