Prioritising for fertility treatments—should a high BMI exclude treatment?

Abstract

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...

“I'm Just a Woman Having a Baby”: Negotiating and Resisting the Problematization of Pregnancy Fatness

“…In response health policy makers have introduced a raft of interventions intended to regulate and discipline fat pregnant bodies including the introduction of weight restrictions on access to publicly funded fertility treatment and low risk birthing facilitates; increased screening and medical management of fat pregnant and birthing people; and a narrowing in of population health programmes aimed at weight management to the new "priority area" of pregnant women, new mothers and their young children (see for example Farquhar and Gillett, 2006; Ministry of Health., 2012; Office of the Controller Auditor General, 2013). For example, in the Ministry of Health (2014) "Guidance for healthy weight gain during pregnancy" fat women are urged to lose weight prior to pregnancy, are encouraged to eat healthily (but not for "two"), undertake 30 min of exercise every day while pregnant, and to regularly weigh themselves and chart their gain according to advised pregnancy weight gains.…”

Female Obesity and Assisted Reproductive Technologies

“…That is the reason why there are strict upper BMI limits for access to IVF in some health-care settings. [61][62][63] The British Fertility Society suggests that infertility treatment should better be delayed until BMI is <35 kg/m 2 . 1,2,64 A woman's age is an important determinant, for younger women (<37 years), with good ovarian reserve (normal FSH), a reduction in BMI even to <30 kg/m 2 has been recommended.…”

Recent advances in understanding the relationship between long- and short-term weight change and fertility

“…Owing to the high prevalence of obesity among young women and the well-documented impacts of obesity on fertility, weight loss has been strongly promoted from the leading societies of reproductive medicine as one of the most effective means of increasing fertility in overweight or obese women 6 . In some countries, obese women are even denied access to or funding for infertility treatment in the absence of substantial weight loss 7 , 8 . Despite these strong statements, the actual impact of weight change on fertility is not entirely clear.…”