Bromley CCG Assisted Conception Funding Form Checklist for Eligibility Criteria for NHS funding of Assisted Conception

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1 Bromley CCG Assisted Conception Funding Form Checklist for Eligibility Criteria for NHS funding of Assisted Conception This form is for the use of administrators of Assisted Conception Units to notify Bromley CCG about couples who meet the criteria for NHS funded assisted conception. Please complete this checklist and send (as a word document) to Bromley CCG: BROCCG.fertilityfundingrequests@nhs.net We will then confirm funding in reply to forms indicating no exclusions. Patients must not be offered IVF / ICSI until eligibility and funding has been confirmed by Bromley CCG. This form is for IVF / ICSI only and does not apply to core investigations, diagnostics, and conservative treatment which are routinely available on the NHS along the appropriate primary and secondary care pathways. The eligibility criteria for NHS funding of IVF / ICSI are included in the South East London Treatment Access Policy which is publicly available at For couples who do not meet the criteria the following levels of appeal are available: Stage one: An informal process of communication between the ACU and Bromley CCG should be attempted in the first instance to resolve the problem. Communication should maintain the pseudonymity of the couple and avoid patient identifiable information being shared at this stage of appeal. Stage two: If the matter has not been resolved to the satisfaction of the couple and the NHS consultant wishes to pursue NHS funding on their behalf they must submit an Individual Funding Request (IFR) to the Bromley CCG IFR Team at BROCCG.ifr@nhs.net The IFR Panel can only approve funding against the TAP in cases where it has been demonstrated there are exceptional clinical circumstances. The patient s signature must be on the IFR form to demonstrate their consent to allow Bromley CCG to access and share their personal information with other health professionals as part of the decision making process. Information about the IFR process is available at Stage three: The IFR process is not an appropriate route for couples who disagree with the TAP. If there are no exceptional clinical circumstances but the couple wish to share their concerns about the policy they can contact the CCG directly at or follow NHS complaints procedures. REFERER DECLARATION ON PATIENT CONSENT 1. I confirm this Bromley CCG Eligibility Criteria Form, and the latest South East London Treatment Access Policy, has been discussed in full with both partners. 2. I confirm the couple are aware that Bromley CCG will be accessing the NHS Portal to confirm they are currently registered with a Bromley GP practice. Bromley CCG will record Trust ID number, NHS number of both partners, and date of birth of the partner seeking to become pregnant on their database. This information will only be used to answer queries from the ACU about this application, and to validate billing. However, no other patient identifiable information will be held by the CCG. 3. I confirm the couple understand they have the right to withdraw their consent at any point, however this might affect their application as Bromley CCG will not be able to carry out certain checks and processes without accessing the patient information highlighted above. 4. I confirm the couple have read and understood the above points and they are happy to provide consent for their information to be used as part of this application by Bromley CCG to carry out its duties as part of the funding request process. YES NO [Please indicate] Date: Applicant (GP / Trust Clinician) is requested to record patients consent within patient s individual health records.

2 REFERRER DETAILS Name of Referrer: Referring Hospital: NHS Consultant: Tel No: GP Practice Code: Date of Consultant decision to refer: Date form sent to CCG: PATIENT DETAILS PARTNER SEEKING TO BECOME PREGNANT PARTNER Initials: Trust reference: NHS Number: NHS Number: Date of birth: BRIEF DESCRIPTION OF DIAGNOSIS OF INFERTILITY (e.g. diagnosis or unexplained) Criterion ALL eligibility criteria MUST be met Yes / No Eligibility 1. NICE Clinical Practice Has the couple gone through the primary and secondary care sub-fertility pathways appropriate to them before IVF is considered? 2. Couples should be living together and in a stable relationship Are the couple living at the same address (for at least 6 months)?

3 3. Duration of infertility Do the couple have unexplained infertility of > 3 years duration? This means that the couple has tried all lifestyle changes, and surgical or medical treatments appropriate to their situation and they have not conceived during that time. OR Taking into consideration both age and waiting list times, do the couple have unexplained infertility of > 2 years duration? (Contact CCG) OR Does the couple have a diagnosis of male or female factor problems? 4. Age of female applicant who is to receive treatment at time of cycle starting Will the partner who is to receive treatment be aged between 23 and 39 years old (up to 39 years and 364 days) at the time of treatment. (Ovarian stimulation should therefore have been completed before the woman s 40th birthday.) Or If under 23, has medical investigations confirmed that conception is impossible without fertility treatment? (Contact CCG) 5. Number of cycles / Previous infertility treatment The female partner should not have had any previous NHS funded attempts at IVF or ICSI and not more than three NHS funded attempts at IUI. For a definition of a full cycle of treatment see end of form. Have the couple had any previous NHS funded attempts of IVF ICSI? 6. Women in same sex couples

4 Infertility needs to be demonstrated in the partner who is seeking to become pregnant. Has the partner seeking to become pregnant undergone at least three privately funded unsuccessful attempts of IUI? (NHS funding is not available for insemination facilities (IUI with donor sperm) for fertile women who are single or part of a same sex partnership). 7. Childlessness Fertility treatment will only be offered to couples where the following two criteria are met: a) where there are no living children in the current relationship b) where neither partner has children from previous relationships Does either partner have any living child from their current relationship or from any previous relationship? 8. Sterilisation Has either partner been sterilised? 9. BMI Does the female receiving treatment have a BMI over 19 and under 30 before receiving any treatment? 10. Smoking Couples must be smoke free prior to and during treatment. Couples must continue to meet the eligibility criteria for NHS funding of a second cycle of treatment. Are both applicants non-smokers for at least three months before commencement of the treatment? 11. Informed choice of NHS provider Bromley CCG holds contracts with Guy s and King s ACUs. The CCG will consider requests for funding at other NHS providers on a case by case basis. The CCG does not fund treatment carried out by private providers. No = encourage to

5 Has the couple looked at relevant provider websites for outcome details and visited preferred provider unit? do so before referral 12. HFEA Code of Ethics Is there any reason to think this couple will not conform to the HFEA Code of Ethics? This includes consideration of welfare of the child which may be born. STATEMENT TO BE SIGNED BY THE REFERRER I confirm that all the above access criteria have been met and this couple is therefore eligible for NHS funded IVF treatment. Referrer s signature: Designation: *Definition of one full cycle of IVF treatment (NICE guidance, DoH gateway ref Embryos not transferred during a stimulated invitro fertilisation treatment cycle may be suitable for freezing. If two or more embryos are frozen then they should be transferred before the next stimulated treatment cycle because this will minimise ovulation induction and egg collection, both of which carry risks for the woman and use more resources. The full cycle of IVF is therefore regarded as the fresh cycle plus the transfer of frozen embryos where this is possible. Bromley CCG will fund 2 frozen embryos per patient for 2 years. This will include the cost of freezing and storage. For unsuccessful patients, i.e. those not resulting in a live birth, the CCG will also fund the transfer of frozen embryo. The age of female applicant at the time the embryos are frozen is required to be within the age limits set out in the policy. This does not apply to the age of transfer.