Analysis

Lack of evidence for interventions offered in UK fertility centres

BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i6295 (Published 28 November 2016) Cite this as: BMJ 2016;355:i6295

Re: Lack of evidence for interventions offered in UK fertility centres

Sir,

Non-evidence based fertility practices were important to highlight, but we disagree with the recommendation that NICE together with HFEA should provide fertility guidance on what is offered (1). HFEA have no legal jurisdiction in providing clinical guidance while NICE have seriously failed to provide evidence for first line treatment options (2). The original NICE guidelines stating IVF should be offered over intrauterine insemination (IUI) was controversial that an update review was initiated to take account of newer RCT leading to ask a specific question: 'What is the effectiveness of IUI in people with unexplained infertility, mild endometriosis or 'mild' male factor infertility?' (2). When the review occurred, the question was reworded to 'What is the evidence for IUI, with or without ovarian stimulation, compared with expectant management for people with unexplained infertility, mild endometriosis and mild male-factor infertility, and whether the 2013 recommendations should be updated?'. NICE continues to state in both reviews. 'The lack of high-quality evidence available’. The original recommendation was based on low dose clomid/ IUI yielding poor outcomes which NICE fail to qualify while omitting gonadotropin-stimulated cycles widely practiced yielding good IUI results. NICE therefore, fail to disclose the limitation of their recommendations (2) and more significantly have only earmarked the comparison of IUI with IVF for 2017, thereby NICE have issued definitive guidance before having considered the evidence.

It is not just the large number of non-evidenced based procedures on offer to the patients, the non-evidenced based NICE guidelines which persuade CCGs to pay prematurely for expensive and unnecessary IVF procedures remains contentious, and in the absence of a valid RCT comparing IUI with IVF is widely rejected (3). The 13-fold increased use of IVF procedures could not have been founded on evidenced based medicine (4), as would the unusually increased 2.9-fold classification of male factor infertility which would justify expensive ICSI procedures.

Fund holders have to pay a high price for unjustified IVF procedures while financial analysis show IUI is still a cost-effective treatment option. In one analysis, IVF was 43,375 Euro more expensive than IUI (5), with a possible annual cost saving of at least 20 million Euro in Europe is possible (6). Globally 74 million subfertile couples cannot access IVF procedures and IUI is their main option (4). For all these reasons clinicians and funding agencies should remain cautious of NICE fertility recommendation (2).

1. Spencer E, Mahtani K, Goldacre B, et al. Claims for fertility interventions: a systematic assessment of statements on UK fertility centre websites. BMJ Open 2016;6:e013940doi: 10.1136/bmjopen-2016-013940.
2. Fertility problems: assessment and treatment, NICE guidelines [CG156] Published date: February 2013 Last updated: August2016 https://www.nice.org.uk/guidance/cg156
3. Kim D, Child T, Farquhar Intrauterine insemination: a UK survey on the adherence to NICE clinical guidelines by fertility clinics. BMJ Open. 2015 May 15;5(5):e007588. doi: 10.1136/bmjopen-2015-007588.
4. Bahadur G, Homburg R, Muneer A, Racich P, Alangaden T, Al-Habib A, Okolo S. First line fertility treatment strategies regarding IUI and IVF require clinical evidence. Hum Reprod. 2016 Jun;31(6):1141-6. doi: 10.1093/humrep/dew075. Epub 2016 Apr 12.
5. Tjon-Kon-Fat RI, Bensdorp AJ, Bossuyt PM, Koks C, Oosterhuis GJ, Hoek A, Hompes P, Broekmans FJ, Verhoeve HR, de Bruin JP et al. Is IVF-served two different ways-more cost-effective than IUI with controlled ovarian hyperstimulation? Hum Reprod 2015; 30:2331–2339.
6. Haagen EC, Nelen WL, Adang EM, Grol RP, Hermens RP, Kremer JA. Guideline adherence is worth the effort: a cost-effectiveness analysis in intrauterine insemination care. Hum Reprod. 2013 Feb;28(2):357-66. doi: 10.1093/humrep/des408. Epub 2012 Nov 30.)

G. Bahadur, B Woodward, R. Homburg, A. Al-Habib, A Muneer
Reproductive Medicine Unit, North Middlesex University Hospital, Old Admin Block, Sterling Way, London N18 1QX; Homerton Fertility Centre, Homerton University Hospital, Homerton Row, London , E9 6SR; IVF Consultancy Services, Leicester, UK; University College London Hospital, 250 Euston Road, London NW1 2BU

Competing interests: No competing interests

08 December 2016
Gulam Bahadur
Consultant Clinical Andrologist
B. Woodward, R. Homburg, A. Al-Habib, A. Muneer
North Middlesex University Hospital
Sterling Way, London N18 1QX