Abstract
Study question
What is the gap between guidance and practice of fertility preservation between countries and within countries with common clinical guidelines?
Summary answer
Substantial variation in provision of FP exists between countries and within individual countries with gaps between national and international guidelines and policies governing provision.
What is known already
A robust guideline on female FP was published by ESHRE in 2020, advising the application of FP in cancer and other conditions where treatment with cytotoxic agents or surgery will compromise reproductive function. Across Europe, in 13 countries (43.3%) FP is funded for all available FP procedures, in 13 countries (43.3%) no FP funding is available, and in 4 countries (13.3%) at least one FP option is funded. Variation in state provision of fertility care in different countries in Europe was highlighted in the ESHRE guidance. It did not specifically examine individual national policies or whether a national policy exists.
Study design, size, duration
Five clinicians performing FP in Europe were contacted to collect current FP provision data. Policies retrieved from the internet were not included as they could not be verified. Finally, FP funding policies for 135 Clinical Commissioning Groups (CCGs) in England, 14 Health Boards in Scotland, 7 Health Boards in Wales and 5 Trusts in Northern Ireland and 17 policies for regional heath services in Spain were included were included.
Participants/materials, setting, methods
Policies on FP for the UK and Spain were reviewed (n = 178), including policies from the 161 regions from the four nations of the UK and policies of 17 autonomous bodies in Spain. Information on funded procedures, type of conditions included for funding and duration of storage were extracted. The provision of FP was compared to the current European Society of Human Reproduction and Embryology (ESHRE) and National Institute for Health and Care Excellence (NICE) guidelines.
Main results and the role of chance
In England, 127/128 (99%) CCGs fund cryopreservation of oocytes, sperm and embryos. Cancer is the exclusive indication in 11%. Provision of FP for transgender individuals is specified in 28%, ovarian tissue cryopreservation is funded in 8% and storage funding varies from five to ten years.
In Scotland, a national policy is applied. All 14 health boards equitably fund cryopreservation of oocytes, sperm, embryos and ovarian and testicular tissue. Funding is provided for cancer, medical conditions which may impair fertility and transgender individuals. Storage funding is based on a five yearly review until age 43 in women and 60 in men. In Wales and Northern Ireland, cryopreservation of oocytes, sperm and embryos is funded for people undergoing medical or surgical treatment that is likely to make them infertile, provision for transgender individuals is not specified and ovarian tissue cryopreservation is not funded.
In Spain, all 17 Health Services fund cryopreservation of oocytes, sperm and embryos for patients whose fertility is at risk due to gonadotoxic treatments or other pathological processes. Ovarian tissue cryopreservation is funded in 94%, provision for transgender individuals is specified in 12%, and storage funding is available until the age of 50 in women and 55 in men.
Limitations, reasons for caution
Inability to retrieve fertility preservation policies for every country in Europe is a limitation, for which ongoing collaboration is sought. The variable nature of FP provision is likely to be multi-factorial; a lag in publication of guidelines and updated policies, ethical considerations and resource distribution may govern health policies.
Wider implications of the findings: The study highlights that provision of FP not only varies between countries but is also inconsistent within the same country. It is clear that there is a gap between ideal, evidence-based practice and actual provision. Variation in policies limits uniform access to care for patients.
Trial registration number
Not applicable.
Ovarian cryopreservation for fertility preservation: indications and outcomes