My Lords, I beg to move that the House do now again resolve itself into Committee on this Bill.

Moved accordingly, and, on Question, Motion agreed to.

House in Committee accordingly.

[The LORD SPEAKER in the Chair.]

moved Amendment No. 24:

I rise in strong support of this amendment, and am sorry that my noble friend Lady Jay is unfortunately unable to be here this afternoon. Forgive me if I appear to repeat some of the points already made so ably by the noble Baroness, Lady Finlay, but I want to describe in some detail what the experience of infertility implies to the Committee, and to put it on the record.

People who are infertile initially face a degree of anxiety which causes quite a lot of personal stress. Eventually, when they start to realise that they are seriously infertile, even before treatment, they have a feeling of disbelief. The anxiety rapidly becomes a serious form of sadness in a large number of cases. Depression is common in infertile couples, both in females and males. It is common, if not usual, for a happily married couple to have sexual problems once they realise that they are infertile. It is also quite common for males to be impotent and women to be anorgasmic and not enjoy intercourse. I have heard it repeatedly said by many patients in my own clinic when I was a practising doctor in this field, “I feel like an empty vessel”.

Males also feel that there is no point in having sex—one of the greatest gifts that God has given us—any more. There is naturally a huge incidence of marriage breakdown in infertile couples, and something akin to real physical pain. I do not want the Committee to underestimate that. The pain of infertility is as corrosive and serious as the pain of an osteoarthritic hip, for which treatment is easily available under the health service. A relationship breaking down is not good for anybody. The depression is sometimes so serious that even suicide has been contemplated and undergone by these people.

There is a biblical moment when Jacob is faced by his aggrieved and beautiful wife Rachel, and she says to him:

“Give me children, or else I die”.

That cry rings down the ages. It is true in this country and, incidentally, in the third world, where infertile women are often abandoned. When people suggest that there are already too many babies in the world, and that these technologies are therefore not necessary, they only need to look at the suffering of, for example, African women in this situation, or women in Asia where there is a serious population problem. One should not equate the notion of overpopulation with the lack of need to treat these patients effectively and with genuine compassion. It is interesting that Jacob replied to his wife, “Am I in God’s stead, that I can give you children?”, an angry response that rings true today.

Most noble Lords are in this House because of singular, great, personal achievements—they have contributed hugely to society in one way or another and feel very proud of those achievements. I feel quite proud of some of my achievements, but I must tell noble Lords that nothing in my life is remotely as important as the fact that I have produced three healthy children who contribute to our society. For nearly all of us in our society, promoting the next generation is the single most important thing we do. We do it as parents, we can do it as children or in many other ways, but it is something that is denied to these couples. Indeed, it is denied in a very subtle way. Women who are infertile sometimes cannot even bear to go into a room where there are pregnant women or children. They cannot attend a dinner party where the commonest conversation will be how people’s children are getting on at school or how the rest of the family is. Very often, they cannot tell their parents that they are infertile because they are ashamed, embarrassed or in pain about such a private grief. I promise noble Lords that I am not exaggerating.

One issue is that the National Institute for Clinical Excellence has in its wisdom, and I believe it was a wise decision, recommended that three treatments should be available to infertile couples under the health service. What has happened in practice has been well described already. Hardly any commissioning authorities will pay for more than one cycle, and many will not pay for any cycle at all. There is a postcode lottery in this form of treatment. Noble Lords should consider what that means. The implantation rate of the human embryo under ideal circumstances is about 18 per cent. That means that the rate for one treatment cycle under ideal circumstances, which is doing rather better than nature, is about 18 per cent. I do not suppose there are many people in this Chamber of child-bearing age but if you were, and you went home and had regular intercourse during your menstrual cycle, your chances of getting a pregnancy would be less than 18 per cent, much less in most cases. There is a cumulative need to repeat the cycles. What happens is that one cycle is given and then the treatment is refused. That is like treating a cancer and then withdrawing the drugs half way through the therapy. It makes no sense. It results in a huge waste of public money where it is undertaken in the health service; it results in these patients being put through the pain and the investigations and the results being ignored, even though they have been paid for.

There is another problem, which is the issue I referred to at Second Reading. As was so eloquently said by the noble Baroness, Lady Finlay, these patients are ripe for exploitation. The biggest single problem is that 90 per cent of patients go to a free-standing in vitro fertilisation clinic outside the health service. In the commercial sector, that means that they get in vitro fertilisation whether it is the most suitable treatment or not. There are hundreds of treatments for infertility. Infertility is not a disease; it is a symptom. If I have a pain my chest, I do not immediately ask for a bypass operation. I might have indigestion, high blood pressure, some cardiac impairment or bronchitis or I might have broken a rib, but once the infertile patient goes to a private clinic she gets a treatment that is not based on any solid medical evidence but is the treatment it can offer. That is why it is essential that these treatments are seen inside a comprehensive health service, the kind of health service that we are justifiably proud of in this country. Inevitably many patients who are given vitro fertilisation do not justify the treatment because if they were given much cheaper treatments they would become pregnant; indeed, some may get pregnant without any treatment whatever.

Exploitation is a real issue. The combination of desperation and high costs is corrosive not only to the patient but to medical practice. That is why the yardstick of having a really effective health service treatment is extremely important; indeed, in my view, if there had been proper health service provision in the beginning I doubt whether the 1990 Act would have been necessary because the health service could have very adequately regulated most of these clinical treatments, excluding the research. There are other problems.

The noble Baroness referred to a number of treatments which are totally non-evidence based that are offered to patients in the private sector. One is immune treatment for people who might undergo an early miscarriage or failure of implantation. People are being given treatment which most immunologists regard as being slightly dangerous, if not very dangerous; for example, gamma globulin treatment by injection or suppression of their immune system in a hopeless attempt to get these people pregnant. Of course some of them get pregnant, but no properly controlled studies have been done to justify that treatment, and certainly not to justify it in the private sector.

I have no problem with a private clinic offering treatment on a research basis, but if it is on a research basis then it is not reasonable for the patient to pay for that research. That should be done independently, and it concerns me that the Human Fertilisation and Embryology Authority has not been more rigorous in pursuing that line of thought in its code of conduct.

That is not the only treatment; the treatment of chromosome screening, which is widely offered at around £2,000 a time, has no scientific evidence, except in very rare circumstances, that it actually works. Indeed, the Cochrane review, which is the official review of these treatments, says that this should be seen merely as a research procedure. Why should patients pay £2,000 in the unwitting belief that this treatment will help them in some way when there is no evidence that it will? I will not go on with other unproven treatments because I do not want to bore the Committee at great length.

I must refer to two other issues. One of the real concerns that has already been raised is the issue of fertility tourism. That is not a good situation. It is very concerning that some clinics in the private sector clearly have arrangements with overseas consultants or clinics where they send patients when the treatment is not allowed under the HFEA. That should be written into the code of conduct. If we have this kind of approach from the commissioner of infertility treatment that would be a start to better regulation in this area.

Finally, the noble Baroness, Lady Finlay, raised the issue of multiple embryos and the ideal solution of transferring single embryos. That is a very unlikely possibility unless this treatment becomes available in the health service. Unless that happens, it will not take place. At the moment there are large numbers of multiple births, which clearly have a massive drain on the public services. To keep a premature baby in an incubator costs roughly £1,000 a day, and a triplet pregnancy invariably means that you have three babies in incubators perhaps for a month or more. It does not take much mathematical expertise to work out the cost to the health service. Therefore, it is very important that the public sector is stimulated, and I hope that the Government will consider this amendment, which could be improved—on Report we can add bits to it—in all seriousness.

I ask the noble Baroness, Lady Finlay, for clarification, bearing in mind the very moving comments of the noble Lord, Lord Winston. If it is true that there is only one treatment per woman at the moment, could the specialist service commissioner allocate three treatments to everybody who undertook one treatment—in other words, if the first treatment did not bring fruition, they would be allowed up to three treatments? If that happened, surely two other women would be denied treatment in the first place. Is that the sort of wisdom of Solomon in which the specialist service commissioner would have to get involved?

Secondly, on the point made by the noble Lord, Lord Winston, about the sort of things going on in private clinics, could the specialist service commissioner regulate, license, or, if you like, monitor, services for in vitro fertilisation in private clinics?

Despite having sometimes had to resist the temptation to throw a cushion at the noble Lord, Lord Winston, when he appears on my television screen, for his sheer ebullience and over-enthusiasm, that was one of the finest speeches about infertility that I have ever heard. I hope that all patients countrywide will have access to what he said, because it truly encapsulated the sort of patients I saw in general practice and family planning clinics when I was practising. The sheer despair of those patients has to be experienced. It destroys marriages; it destroys families sometimes. The fact that it spreads beyond the couple needs to be emphasised. I thank him for that speech and I thank the noble Baroness, Lady Finlay, for tabling the amendment, which we of course support. It is obvious that this provision has to be made.

But—and the Committee would expect me to say “but”—the noble Lord, Lord Winston, mentioned overpopulation. The world is heading for disaster if we do not do something about population growth during the next decade. I appreciate that that is nothing to do with this problem. By denying infertile couples treatment in this country, we are not denying people who have too many babies worldwide the opportunity to limit their family size. We must do both. Even in this country, contraceptive services are not the best. Long-acting, reversible contraceptives are in very short supply, and many primary care trusts are not able to offer those methods for their patients. We must attend to that at the same time as we attend to the needs of infertile couples.

Sexual health provision has been much talked about. I have just been to a presentation by the Healthcare Commission, which reports that sexual health provision in this country still needs to be greatly improved. I seem to remember the noble Lord, Lord Winston, saying some time ago that he did not feel that pelvic inflammatory disease was a huge contributor to infertility. He shakes his head, so perhaps he did not say that.

We know that sexual health services are essential. A report in the Times today—a newspaper that I do not normally read—says that almost half the young people surveyed did not know where to find their sexual health clinic. We really must do something about that, because a whole generation of young people out there are heading for infertility problems when they get into their 30s and 40s. We must ensure that more emphasis is placed on prevention so that they do not hit those problems in later life.

Finally, we have still barely touched on sex and relationship education in this country. Again, in the survey reported today, most of those over 17 who were spoken to said that they have never had any proper relationship education their schooling. What are we doing with our young people? We are bombarding them with sexual images and making it the norm to have sexual intercourse with whomever and whenever. Yet we are not giving them the education, the facilities and the knowledge to prevent them getting into trouble: having unnecessary pregnancies and contracting unnecessary genito-urinary disease. I therefore urge the Government, who I hope will support and take on board the noble Baroness’s amendment today, to bear in mind that there is a good deal of work to be done on these other fronts, too.

I think we all agree with the noble Baroness, Lady Tonge, that we have been hugely privileged this afternoon to hear two such well informed and deeply moving speeches. On behalf of the HFEA, I shall add very briefly to what they said. The HFEA commissioned an expert report on multiple births. It revealed what clinicians in the field know: the risks, the sadness and the costs of multiple births. No less importantly, it also revealed that most women with good, skilled clinical help have just as good a chance of achieving a child through a single embryo transfer as they do through the transfer of two or more embryos. The HFEA, which is committed to the policy of single embryo transfer where appropriate—and it is appropriate for most women—has a huge task persuading women who want babies that this is so and a huge task persuading a lot of the private clinics in the field, for all sorts of obvious reasons. One of the greatest barriers is the reason for this amendment: the fact that it is so difficult to get fertility treatment on the NHS, which is so patchy in some parts of the country that it seems impossible. If the NICE guidelines of three cycles were available to every woman seeking fertility treatment across the country, this would do a huge amount to help women to see that it is in their best interest to have a single embryo transfer rather than to have two or more embryos transferred. We should support the amendment very strongly indeed.

I was a member of the Joint Committee that considered the draft Bill. We supported the essence of the amendment, the purpose of which, as I understand it, is to make IVF treatment available throughout the NHS in this country. If that happened, my understanding is that the trust using the facilities that are commissioned would be supposed to follow the NICE guidelines. The NICE guidelines are not absolutely mandatory, as I understand the present position, but they are certainly supposed to be what lawyers refer to as a persuasive authority. It would therefore be rather strange if the NICE guidelines were to be departed from in the provision of this service. So although the amendment does not directly mention the point, the inference that can be drawn from it is that if it is made effectual, the NICE guidelines will come into operation when these treatments are given and will I hope be followed. That means three cycles and a single implantation.

I support the amendment. The issue is quite simple: is infertility a medical condition? If it is, should treatment be available in the NHS? The noble Lord, Lord Winston, very clearly stated why it is a medical condition and why it should be treated as such. The issue is then: if it is available, how should it be made available in the NHS? One route is clearly the commissioning route whereby the commissioners are asked to ensure that this service is available in their areas. The second is that the NICE guidelines are followed. The All-Party Group on Infertility also recommended that these services should be available in the NHS. I come from a part of the United Kingdom where for years we have been fortunate enough to have these services available under the NHS. It is not costly, therefore, to patients who seek them.

On properly conducted research—this is extremely important—the evidence suggests that, in terms of successful outcomes and reduction of complications, the best treatment for patients with infertility is in vitro fertilisation. Yesterday we were talking about over stimulation and hyperstimulation of ovaries. This is more likely with some of the treatments that do not involve in vitro fertilisation, such as clomiphene and gonadatrophin treatment, which produce severe degrees of hyperstimulation of the ovaries, not the mild kind that occurs in about 30 per cent of patients.

On the evidence, in vitro fertilisation is the best treatment. Infertility is a medical condition and the question is, therefore, why the treatment should not be available under the NHS. If it is a cost issue, many other treatments have cost issues and the costs will have to be managed, but the principle needs to be accepted that these treatments should be available in the NHS. I support the amendment.

I digress slightly and turn to the issue of multiple pregnancies. I declare an interest as a father of twins. For years I studied multiple pregnancies and their outcomes, which was very interesting. It is correct that higher order births above two have severe degrees of complications and the outcomes are poor. In the case of dizygotic twins—I must not be accused of bamboozling science again—the incidence of non-identical twins occurs in different proportions in different races. In the United Kingdom it is one in 100 pregnancies; in Nigeria it is one in 25; in Japan it is one in 200. The outcomes for dizygotic twins are not dissimilar to singleton pregnancies. But the outcomes for monozygotic twins—which occur with the same incidence in every race and we do not understand why—are the same.

The problem with infertility treatment is the incidence of higher order multiple births of three, four and more. Furthermore, the incidence of monozygotic identical twins is slightly higher with infertility treatment than in naturally occurring births. If there are more than three or four, it is higher still. There are issues about putting in more than one or two embryos but that has to be matched with the successful outcomes of pregnancies. I support the amendment.

I support the amendment of the noble Baroness, Lady Finlay, for two reasons. Many of us who have worked in this field know that much of the drive for regulation and the fears about ethics come from the fact that 80 or 90 per cent of the work is private, with all the dangers that attach to it, in a field which has proved very lucrative. If much more of the work were carried out in the NHS we would have fewer fears about ethics, it would become mainstream and fears about breaking the law would be reduced, it would be less competitive and there would be less of a drive to use multiple embryos in order to produce a greater success rate. In other words, this treatment should be mainstreamed so that it ceases to need the kind of attention that this House has to give it over so many days.

Nevertheless, there will be the problems which attach naturally to the NHS of speed and demand on resources. One can sympathise with a hospital that has to balance the need for cancer treatment against the need for infertility treatment. It would be wrong to believe that reproductive tourism would be reduced either way because one of the consequences of our membership of the European Union is that everyone has the same right to move around Europe freely in search of medical services and there is the right to freedom of movement of goods and services. In other words, British people will always be able to go abroad to seek a treatment that they cannot get here. Conversely, I imagine that people in Europe would be able to come here and seek our NHS treatment, were it to be widespread. This is perhaps a difficult solution, but nevertheless in the long term it would mean that one could have much greater confidence in this area of the law.

I, too, support my noble friend Lady Finlay. I passionately believe that this area should be regulated inside the National Health Service. I thought the noble Lord, Lord Winston, made a very compelling case to us today and at Second Reading when he spoke about those who operate outside the NHS. He described some of their suspect practices and gave the impression that charlatans were operating, with some very bogus therapies being produced that were not helping patients who presented themselves. For those reasons, regulation within the National Health Service is a far better way for us to proceed than that which unravelled after the 1990 legislation.

I was struck when listening to my noble friend Lord Patel talk about the issues around twins. I hope that the Minister will accept his plea for more research to be done into those unknown causes. I know from our private conversations that my noble friend knows a huge amount about the subject. I hope that the House will listen carefully to him. My noble friend Lady Finlay quoted Dr Charles Kingsland earlier but she does not know, although my noble friend Lord Patel does, that 17 years ago, when the 1990 legislation was going through both Houses, my own wife miscarried a twin and Dr Kingsland was the doctor on duty that night. I have followed this issue carefully and it is one that we should spend more time trying to understand and diagnose.

We should also look more closely at the issue of prematurity. I recently chaired a meeting that was addressed by one of the leading authorities in the field, Professor Brind, who produced evidence that where people have had a pregnancy end prematurely, there is subsequently a higher risk of prematurity leading to the very issues that the noble Lord, Lord Winston, described and the additional costs that arise from dealing with very early birth, some of which can bring disabilities with them. There are long-term issues there that we need to discuss.

I say to the noble Baroness, Lady Tonge, that there is no difference between us about people having the right to decide about the number of children they have, but it is worth pointing out that in OECD countries the population has been falling. If it were not for the very welcome arrival of Polish people and others in our country, our population would have been falling too.

The issue, surely, is one of poverty. My late mother came from the west of Ireland and, as everyone knows, in the 19th century before the Irish famine the population was 8 million but it fell to 4 million, and the reason was acute poverty: 3 million emigrated and 1 million died. It is my passionate belief that, throughout the developing world, if we attack poverty we will see a normal reduction in family size.

I agree with many of the noble Baroness’s other remarks and I hope that the Government will take these issues seriously.

I rather hesitate to intervene in support of the amendment in view of the expertise so brilliantly expressed by my noble friends, both professional and political. I speak from my own experience as a former GP, as well as on behalf of my colleagues and the British Medical Association, to back my noble friend in his reasoning that infertility is a pathological condition. It is not merely a problem that some people have, which is their own responsibility to look after. It is a serious failing of the National Health Service that infertile couples have to turn to the private sector, with all the problems my noble friend has described. The amendment is overdue and we should support it.

That was another extraordinary debate. I am proud to be able to participate in it.

As the noble Lord, Lord Winston, and the noble Baroness, Lady Finlay, passionately pointed out, infertility affects thousands of people across the country. Approximately 27,000 people receive infertility treatment every year, both privately and in the NHS. The Government recognise the pain, distress and stress caused by fertility problems. As a mother of three, I recognise that the pain for those who are infertile must sometimes be intolerable.

I listened with care to the speech on sexual health by the noble Baroness, Lady Tonge. It is an important issue, but it is for another time.

The Government are committed to improving the provision of IVF services. We began that process when we commissioned the NICE fertility guidance some seven years ago. The guidance was published in 2004, and recommended among other things up to three cycles of IVF for eligible couples. At that time, we recognised, as did NICE, that the guideline could not be implemented in full overnight, and we asked the NHS to begin by offering at least one cycle of IVF to eligible couples. Most PCTs now provide this, but we recognise that there remain considerable variations in access criteria from locality to locality. I should explain that NICE technical appraisals are mandatory, but that NICE guidelines are not. The fertility guide provided by NICE in 2004 was a guideline.

The noble Baroness, Lady Finlay, was right to point out both the problems and the examples of good practice in certain parts of the country—although I recognise that they are too few. She was right also to mention multiple births. The noble and right reverend Lord, Lord Harries, told us of the deliberations in the HFEA. I understand that the HFEA has today called for a professionally led, co-ordinated national strategy to reduce the number of multiple births following fertility treatment. The Government will consider the part that they can play in that strategy, including through the expert working group on primary care trusts that we are in the process of setting up. I shall speak about that again shortly.

To help address the regional variations, we are funding a project run by the leading fertility patient support organisation, Infertility Network UK, to work with the NHS to identify and disseminate good practice in the provision of fertility services, and to develop standardised criteria for access to IVF, such as whether to treat people who have children from previous relationships.

We are also in the process of setting up an expert working group whose remit will be to identify the barriers, which have been graphically described, to the full implementation by the NHS of the NICE fertility guidelines and to provide advice, support and information to help overcome them. We of course need better commissioning. The group will comprise of NHS commissioners and the leading fertility patient support organisation.

This is the best way to improve access to NHS IVF services, as it aims to improve services while retaining local decision-making to meet the needs of local populations. The crux of our discussion today and of many debates in this Chamber about the health service is the discrepancy between our national policies and the way in which they are implemented on the ground. The best way forward is to listen to the expert group. We will ask it to consider the spirit of the amendment of the noble Baroness, and to consider recommending that PCTs should identify local IVF needs, explain their local decision-making and report to SHAs annually on the process and outcome, with the SHA making the report public. Naturally, I would facilitate meetings between the noble Baroness, the noble Baroness, Lady Jay, and the expert working group to ensure that their clear, passionate views were taken into account. I hope that, on that basis, the noble Baroness will feel able to withdraw her amendment.

I am very grateful to the Minister for her reply and for being so instructive about the instructions to go to the strategic health authorities on commissioning. I still have some concerns, however. I reassure the House that the NICE guidance is not on IVF alone but on fertility assessment and treatment for people with fertility problems, and deals with the full spectrum from the beginning of infertility. I assure the Committee—and the noble Baroness, Lady Tonge, knows this—that this includes screening for chlamydia and other sexually transmitted diseases right at the outset. It is very comprehensive guidance, which is why it is such a good guide to commissioning.

I remind the House that when there are multiple pregnancies and babies are born prematurely, we have a huge problem, as we have a shortage of neonatal cots in special care baby units in this country already. We have this terrible spectre of babies being transported around the country. The speech given by the noble Lord, Lord Winston, was absolutely wonderful and his words—or the words from the Bible—will ring in everybody’s ears: “Give me children or I am as good as dead”. So many people feel like that. I have colleagues who have undergone or are undergoing infertility treatment at the moment who are barely coping with the activities of daily living because it is so dominating their lives.

I hope I am not misleading the Committee, but I understood that the cost of the NHS providing that sort of treatment is somewhere in the region of £3,500 for a cycle. If you compare that to a day of a neonate in the—but I think that the noble Lord, Lord Winston, wishes to intervene and correct me, which I shall appreciate.

I did not really want to interrupt the noble Baroness, but I seriously believe that the cost of the NHS treatment has been considerably inflated. It is fair to say that many trusts charge an arbitrary sum for IVF treatment and that if it was effectively costed out it could be provided at a much lower cost. Moreover, if we were more cautious with the expensive drugs that we use, as we have been advocating, the cost could be further reduced. That is one reason why it is very important to keep a research arm within the public sector, so I hope that that can be incorporated. I think that £3,500 is a considerable overestimate.

I am very grateful to the noble Lord, Lord Winston, for correcting me on that, but those were the figures that had been supplied to me.

In summing up, I stress the remarks just made on research. If these contracts are within the NHS, we can begin to look at translational research for ways to make infertility treatments even more cost effective, which is not going to be done in the private sector as it would work completely against its profit motive. In that way, we lock ourselves into poor standards that are replicated rather than locking ourselves into assessing outcomes against standards, benchmarking services and, one hopes, coming up with what may become a really very cheap way of coping—and I use “cheap” in the best sense of the word. It would be a cost-effective way of coping.

I hope that speeches such as that of the noble and learned Lord, Lord Mackay, have answered the concerns of the noble Baroness, Lady O’Cathain, in that this would not mean spreading provision more thinly. These services are available, or they can be if things are organised a little more efficiently and the contracts are in the NHS.

I shall go away and reread all the comments and contributions today. I am most grateful to noble Lords for all their contributions. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

I beg to move that the House do now resume.

Moved accordingly, and, on Question, Motion agreed to.

House resumed.