New rules will redefine the lottery of NHS fertility treatment. It's bad news for the plump and middle-aged
When Barnaby and Nikki found that they could not have a child, they went to their doctor to ask for fertility treatment. They were told that they would have to go to the private sector because their health authority, North Hertfordshire, refuses to fund such help. So far they have spent pounds 13,000 with no success. Meanwhile, just down the M1 in the London borough of Hounslow, Alison and Chris were trying for a baby. There, the rules are different and their health authority paid for four cycles of fertility treatment. They now have twins. "It's extremely unfair," said Nikki, an art therapist. "You get discriminated against just because of where you live."

The "postcode lottery" of the way in which the National Health Service funds fertility treatment has long been notorious. One in seven couples seeks help but it depends on the whim of their local health authority whether they get it. There are no national rules about who should be eligible - in some regions women cannot receive treatment if they are over 35, in others they can get it up to the age of 43. In some areas couples must have been together for at least five years, in others three. A survey by the College of Health last year found that in the south and west of England fewer than four people in 100,000 were able to receive in vitro fertilisation on the NHS, compared with 27 people in every 100,000 in Scotland.

The Government is embarking on a radical overhaul of the system. Frank Dobson, Secretary of State for Health, has commissioned a study of all health authorities to find out what type of care is available around Britain. Then the Department of Health will for the first time issue national guidelines telling doctors whom they should treat and who should be given counselling instead. The aim is to identify the people who are, in Mr Dobson's words, the "deserving impotent". Age, fitness social habits and the type of relationship a couple have are all likely to be taken into account. Tessa Jowell, the health minister, says the new rules will target the pounds 50m allocated to infertility care by the NHS at couples with the best chance of success. "There will be a degree of redistribution, but the money that is there will be spent to better effect," she said. Critics say this is just a form of rationing. Is the Government just replacing a local lottery with a national one?

The guidelines produced by the Government's new National Institute for Clinical Excellence will be based on recommendations from the Royal College of Obstetricians and Gynaecologists. Its report, to be handed to ministers shortly, will point out that the chance of conception from IVF is very low if the woman is over 40. Women have a 16 per cent chance of becoming pregnant through IVF if they are between the ages of 25 and 35, dropping to 6 per cent at 40 and 1 per cent at the age of 45.

The Royal College will also highlight evidence that smokers, drinkers and women who are overweight are less likely to become pregnant through fertility treatment. It is likely to say that the "welfare of the child" - in other words the type of relationship which the couple have - should be taken into account when deciding who should be treated.

Professor Alan Templeton, who heads the review, says rationing is inevitable in a state-funded health care system. "There are very few treatments where there is not rationing in one form or another - that's the game in the NHS." He believes this means the cash available must be reallocated towards "effective treatment". "If women over 40 are to have treatment, they have to be aware that their chance of success is low," he said.

"Smoking and drinking affects the outcome of treatment so you may take the opportunity of saying to somebody, you do your bit and we will treat you." Tessa Jowell agrees that those are issues which will have to be considered but insists that it is not a form of social engineering. "If you want to have a baby, then all the clinical evidence is that smoking makes you less likely to conceive, and drinking and being overweight make it more difficult," she said. "Any guidelines will be based on clinical evidence, not nanny state-ism."

The new rules will mean that many couples who are not now treated will become eligible, but others in presently "generous" health authorities will lose out. Inevitably, most people will still go to the private sector. At present almost 80 per cent of couples who want in vitro fertilisation end up paying for it privately, at a cost of about pounds 2,000 a month. But ministers are concerned that many couples are being given false expectations about their chances of conceiving.

Across the board the chance of a woman becoming pregnant from IVF is less than 20 per cent, but many clinics give an unrealistic assessment of the likelihood of success. The Human Fertilisation and Embryology Authority, which regulates the sector, was forced to take action against one clinic recently which boasted, misleadingly, in advertising that it had a 70 per cent pregnancy rate.

The Royal College will recommend in its report that there should be an annual audit, taking into account the views of patients, of all the clinics. Professor Templeton says they must be forced to give more "frank information". The Government intends to issue instructions to the clinics to be more realistic.

"This is not denying people treatment that they want to pay for regardless," Tessa Jowell said. "My concern is that if they do that, then they do so in the light of a very clear understanding of the likelihood of success. We want to end the years of heartbreak with couples ploughing on with IVF, spending enormous amounts of money, when it may well have been the case that somebody could have told them at the beginning that they were not going to conceive. The public needs to be educated to understand just how difficult it is for infertile couples to get pregnant." In the end, whether there are regional or local guidelines on who may receive treatment, that basic fact is not going to change.