Medicine Interview Hot Topics: Assisted Reproduction
Currently, NICE recommends that women under the age of 40 should be offered three cycles of IVF (funded by the NHS) if they meet the correct criteria (such as having been trying for a baby for a set amount of time or having had previous unsuccessful treatments). However, different Clinical Commissioning Groups may fund at different ages, leading to variation across the UK and what has been deemed a postcode lottery for fertility treatment.
Overview of Treatment Types
Intrauterine insemination or IVF with intracytoplasmic sperm injection (ICSI), or the use of donor sperm or eggs may also be offered.
IVF involves the removal of an egg from the ovaries and its subsequent fertilisation in a laboratory. The natural cycle is suppressed, before the egg supply is boosted through the use of medication. An ultrasound scan is then used to monitor the maturation of the eggs, which are removed when ready and fertilised in vitro. Finally, one or two fertilised embryos are replaced in the womb.
IUI is offered if the patient is unable to have vaginal sex (due to disability or a pyschosexual problem), if you have a specific condition that makes it impossible to conceive (like HIV preventing safe unprotected sex) or if you are in a same sex relationship and have failed to become pregnant after 6 cycles of IUI using donor sperm.
ICSI (essentially injecting a sperm into an egg) may be offered on the NHS if necessary - normally if the male sperm is generally of low quality (e.g. low motility), if the sperm sample that has been collected is of low quality (due to normal variation in sperm quality) or if previous IVF attempts have failed.
The success rate of IVF changes significantly based on the age of the patient - it is around 29% for women under 35, but only 9% for women aged 40-42.
The risks of IVF include multiple births, premature delivery and low birth weight, ovarian hyperstimulation syndrome (giving swollen and painful ovaries), along with the higher rate of miscarriage that is present for older women that become pregnant.
The Ethical Debate
Whether or not the NHS ought to offer IVF has always been hotly contested. Clearly for those couples that are infertile or have significantly reduced fertility, it is crucial - but for others it may seem an inefficient allocation of limited resources. We can divide the reasons for and against by the relevant pillar of medical ethics.
Patient Autonomy would seem to indicate that reproductive assistance being available on the NHS is correct - patients should have the right to choose whether they would like to start a family, and when. Looking at beneficence, then certainly giving patients the chance to start a family is beneficial to their psychological health. However, older women are far more likely to suffer problems during pregnancy, and their foetus is also more likely to have complications. In the interests of the greatest good for as many people as possible (Justice) we might say that offering treatment is a positive, as otherwise only the rich could afford it, creating an unfair landscape. However, by offering funding we take money that could be used elsewhere in the NHS.
Potential questions which may be asked at interview
- What do you know about assisted reproduction?
- What kind of help can couples with fertility issues receive from the NHS?
- Is it right that IVF be offered on the NHS?
- What are the arguments for and against IVF being offered on the NHS?
- Can you tell us what happens during the process of IVF?
- What type of patient is most likely to have a successful treatment?
- If IVF fails, are there further options that may be tried?
- Are there any risks associated with IVF?
How to answer questions on Assisted Reproduction
This topic requires you to have a knowledge of the different types of treatment, and who they might be suitable for, along with the risks of treatment. When you understand these areas you can formulate your response to the ethical question of whether assisted reproduction should be offered for free by the NHS. When answering an ethical question on the topic, make sure to give a balanced viewpoint that considers both the psychological wellbeing of the couple who want a family, and the need to direct NHS resources in a way that provides quality of life to as many citizens as possible.
How can you include the topic in your medicine interview
This topic can be referred to when discussing NHS funding, private vs public healthcare, and changes in healthcare (and what people expect to be provided for them) over the last forty years (it was first successfully performed in 1977, and ICSI first performed in 1991).