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Discrimination and infertility treatment

It has been reported in the newspapers today that in many parts of the country smokers have been refused access to in-vitro-fertilisation treatment. This appears to be contrary to the national evidence-based guidelines for fertility treatment. Is this unfair?

It has been claimed that preventing access to IVF for smokers is unfair
because of the inconsistency in the rules that are applied to infertile
couples in different parts of the country (part of the so-called
postcode lottery). One of the reasons for the National Institute for
Clinical Excellence (NICE) guidelines that were released in 2004 was
the recognition that there was significant disparity in access to IVF
across the UK. This inequality does not seem consistent with the
general principles of a public health system. However 4 years later it
is clear that there remain major differences between trusts in the
rules that are applied to couples who apply for IVF. Local trusts have
discretion in the non-medical or ‘social’ criteria that they apply. So
some trusts, but not others limit or prohibit IVF to women who are
obese, who smoke, or if either partner have children from previous

Is smoking relevant to fertility treatment? The NICE guidelines state
that couples applying for IVF should be advised that smoking is likely
to reduce chances of successful pregnancies resulting from IVF, but
stop short of suggesting that IVF should be denied to smokers. A
national group of fertility doctors, the British Fertility Society,
have also recommended that smoking not be an exclusion criterion for
IVF. However there is reasonably good evidence that smoking affects
fertility and fertility treatment. The NICE guidelines cite a study
that found IVF success rates reduced by about a third in smokers. Other
studies suggested that non-smokers undergoing IVF were almost twice as
likely to achieve a live-birth as smokers.

IVF is in short supply in the UK. About one in seven couples in the UK
have trouble conceiving, but only 30,000 women per year undergo IVF,
and in many parts of the country women are only offered one cycle of
IVF. (NICE recommended that women be offered three cycles). The rates
of IVF in the UK are about 1/3 of those in countries in continental
Europe. When there is high demand for a scarce resource it is
justifiable to ration access to that resource. Rationing of medical
treatment is often on the grounds of need. So it is generally accepted
that childless couples should have greater priority for IVF than
couples who already have one or more children. But rationing can also
be on the basis of effect. IVF is less effective than in smokers than
in non-smokers. If there is only limited IVF funding, and this is made
available to women who smoke, a smaller number of live-births will

There is nothing inherently ethically problematic in restricting access
to IVF on the grounds of smoking, however there are a number of
limitations to this. Firstly, it seems entirely arbitrary that this
should apply only in some parts of the country and not others. If
smoking is a legitimate grounds for restricting a limited resource,
then this should be applied consistently across the health service.
Secondly, there are practical problems with using smoking to limit IVF.
It may be difficult to stop patients from concealing their smoking, and
difficult to police a no-smoking rule. Finally although the limited
availability of IVF might be used to justify social criteria that
exclude some individuals from accessing IVF, this might equally be used
to argue that there should be more funding available for fertility
treatment. Infertility causes significant distress to a large number of
individuals – both smokers and non-smokers. We need to decide as a
society how to weigh this benefit against other medical treatments, and
against other spending priorities.

1) Using some fairly rough figures, if 10,000 treatment cycles were provided to smokers as opposed to non-smokers, approximately 400 less live births would result. This is based upon an odds ratio for successful conception (smokers vs non-smokers) of 0.57, and a 14% live-birth rate per IVF cycle.


Smokers refused access to free IVF in a third of health trusts
Daily Mail 23/6/08

Hospitals deny IVF treatment to smokers
Guardian 22/6/08

Is access to fertility treatment fair?
BBC Health

NICE guideline on fertility

Social criteria for access to infertility treatment
, British fertility Society 08/2006

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