The effect of clinical priority access criteria for access to infertility treatment was examined for women outside the body mass index (BMI) range of 18-32 kg/m 2 . Treatments and outcomes were analysed from 1280 cases referred from 1998 to May 2005. Sixteen percent of women had a BMI of >32 kg/m 2 . Overall, 38% of these women had a birth from conceiving a treatment-related pregnancy or spontaneous pregnancy, compared with 52% of women with BMI < 32 kg/m 2 . Weight loss allowed women in the BMI group >32<35 kg/m 2 to access treatment, but women in higher BMI groups were less successful.Keywords BMI, fertility, IVF, obesity, prioritisation.Please cite this paper as: Gillett W, Putt T, Farquhar C. Prioritising for fertility treatments-the effect of excluding women with a high body mass index.

Resources for funding of health services are limited and therefore decisions about who can have treatment need to be made. Until recently, decisions to commence fertility treatments were made by clinicians without the need to seek approval for funding. However, it is no longer possible to decide that a particular treatment option seems like a 'good idea' without considering its effectiveness and safety as well as the resource implications of providing that treatment. In many health systems, decisions about access to care have devolved into joint responsibilities between clinicians, policy makers and those who fund health care. With governments directing the available funding, the clinician's role has been to prioritise and rank patient need, while that of management has been to calculate how many patients can be treated.The report by Gillett et al. 1 describes the unique system that was introduced in New Zealand in the mid-1990s for ranking patients for elective, publicly funded procedures by the development of clinical priority access criteria (CPAC) for several procedures. A CPAC for patients with infertility seeking assisted reproduction techniques was introduced in NewZealand in 2000. 2 Prior to this time, access to publicly funded assisted reproduction technique was unequally distributed, and the CPAC model was designed to give preference to couples with infertility who were least likely to conceive without treatment. The majority of public funds were to be used for in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI) that are expensive treatments with low success rates compared with many medical and surgical interventions in other areas of health care. The cost of an IVF cycle in New Zealand is approximately $6000 and the cost of an ICSI cycle is approximately $8000. Following a completed IVF procedure where all embryos are used, between 25 and 50% of couples will 'take home a baby'. With these costs and outcomes in mind, the New Zealand Ministry of Health restricted access to publicly funded IVF and ICSI by using the CPAC approach. However, if a woman had a body mass index (BMI) of >32 kg/m 2 then, regardless of the CPAC score, she was required to lose weight first. The effect of obesity on reproductionWomen who are overweight are more likely to be infertile and have a lowered success rate with IVF and ICSI compared with women of normal weight. A study of 1880 women with infertility and 4023 control women showed that anovulatory infertility was three times more common in those with a BMI of >27 kg/m 2 . 3 Furthermore, being overweight also adversely affects the reproductive outcome of ovulation induction. In a cohort of 270 women, with polycystic ovary syndrome (PCOS) who received either clomiphene citrate or gonadotrophins for ovulation induction, almost 80% with a BMI of 18-24 kg/m 2 ovulated at 6 months compared with only 12% of women with a BMI ‡ 35 kg/m 2 . 4 Overweight women also require higher doses of clomiphene and gonadotrophins. 5 There is also evidence that women who are ex...

The in vitro production of immunoglobulins in response to stimulation with pokeweed mitogen (PWM) and fixed/killed Staphylococcus aureus Cowan 1 (SAC) was measured in conjunction with in vivo assays of plasma immunoglobulin levels to examine the quality and quantity of humoral immunity during human pregnancy and at parturition. Following stimulation with PWM, there is a significant enhancement of in vitro immunoglobulin-G (IgG) production during pregnancy. Following stimulation with PWM and SAC, there was a significant reduction in in vitro immunoglobulin-M (IgM) production immediately following parturition. There was a significant decrease in the plasma levels of IgG during pregnancy, although no change in the plasma levels of IgM were observed. The decrease in plasma immunoglobulin levels during pregnancy cannot be explained as the result of hemodilution and transplacental transfer. Altered humoral immunoregulation is the most likely means whereby an increase in immunoglobulin production during human pregnancy could occur. The possible effects of this on the outcome of pregnancy are discussed.

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Male and female partners of couples who conceived a child by donor insemination (DI) independently completed a questionnaire. Fifty-seven women and 53 men representing 58 couples taking part. Fifty-one were in a continuing relationship and seven were separated. A likert scale (0-7) of "happiness' before, during and after treatment and their perception of their partner's feelings were used as measures. These feelings were evaluated in relation to demographic and clinical factors. Fifty-one women and 49 men who were in a continuing relationship answered questions about their feelings about DI, compared to six and three, respectively, who had separated. Feelings about DI were consistently low before treatment began. For both continuing and separated couples there was an improvement of their feelings about having DI during treatment, and then again after treatment was complete. For the male partner, factors that were associated with greater unhappiness included difficulties with the relationship prior to treatment, waiting time for treatment and subsequent separation. The women, however, had more positive experiences with no measured factors adversely affecting their feelings about DI. The arrival of the DI child had a significant effect in improving the relation-ship. Our findings suggest that for many couples acceptance of the DI program was less than ideal and only improved with having the treatment and then conceiving. The data highlight the need for psychosocial assistance to be made available to couples prior to the commencement of treatment.