Of couples trying for a baby, about eight in 10 will get pregnant within a year. The one in six who will experience problems can find themselves alone. Ireland is the only state in the European Union not to offer publicly funded IVF. This leaves those struggling to conceive navigating the private fertility industry, spending years and potentially tens of thousands of euros on treatments. It’s no wonder fertility is big business here.
Not all of those wanting fertility treatment are heterosexual couples, of course. Many LGBTQ+ couples who want children, and single women wanting to get pregnant or freeze eggs for later use, need it too. But successive governments haven’t kept pace with these social and demographic realities. Funnelled into the commercial fertility sector, those wanting to have a baby are left to make decisions on the dizzying array of sometimes gruelling treatments that may help, and “add-ons” that may not.
In October 2017, the cabinet approved the Assisted Human Reproduction (AHR) Bill, a piece of draft legislation that laid out regulations for AHR and the need for the establishment of a regulatory body. In 2019, the government committed to publicly funding infertility services. Then minister for health Simon Harris said he expected publicly funded IVF to be available in 2021. It still hasn't happened.
If you need help to have a baby in Ireland or you want to proactively preserve your fertility for a later date, you need money. This makes Ireland an outlier. In most other countries in the EU, fertility treatment is either whole or part funded or reimbursed by the public health system. Some 12 countries offer up to six funded cycles of intrauterine insemination (IUI), according to the European fertility atlas, a comparative map that grades countries on legal access to fertility treatments, as well as their funding and reimbursement. The index was published last in December by the charity Fertility Europe, along with the European Parliamentary Forum for Sexual and Reproductive Rights.
Three countries offer up to six fully funded cycles of IVF or intracytoplasmic sperm injection (ICSI), where an embryologist injects a single sperm into the egg to assist fertilisation, and 35 partially fund it. France has become one of the latest countries to give lesbian and single women the same rights to fertility treatment as heterosexual couples. Those rights include reimbursement for four IVF treatments and six IUIs.
As early as 2008, the European Parliament called on member states to 'ensure the right of couples to universal access to fertility treatment'. Irish citizens are still waiting
Indeed Ireland ranks 40th out of 43 nations for access to fertility treatment, according to the atlas. Only Belarus, Ukraine and Turkey rank lower than us. Countries such as Belgium and the Netherlands are the gold standard, according to the atlas, scoring 86 per cent on the scale. In Belgium, public funding or partial funding is given for up to six IUIs and six IVF/ICSI treatments including insemination with donor sperm for heterosexual couples, single women and female couples. Treatment with egg donation is also funded for those groups and for male couples. France, Portugal, Finland, Norway, the UK and Spain all score between 70 and 80 per cent on this monitor. Ireland's score is just 27.
As early as 2008, the European Parliament called on member states to "ensure the right of couples to universal access to fertility treatment". Irish citizens are still waiting.
“Fertility specialists can help you to become pregnant. These treatments are available privately only. This means they are not provided by the public health service,” the HSE website states. So if you are struggling to have a baby, that’s on you. If you are struggling to conceive and don’t have money, or don’t have enough of it, your opportunities to have a child are less. Your chances to have a family will be limited by your funds. If you need fertility treatment, you better have substantial savings.
"As somebody involved in the provison of reproductive healthcare, this angers and frustrates me," says Dr Sorca O'Brien, Aspire Fellow in Fertility at the National Maternity Hospital and the not-for-profit Merrion Fertility Clinic. The WHO's recognition of infertility as a "medical disease" and a "disability" holds little currency here. "The creation of families in Ireland continues to be a luxury for those who can afford it or a financial burden for those who incur debt," says O'Brien.
Many coming through the door of fertility clinics aren't infertile but are experiencing a delay in getting pregnant, says Mary McAuliffe, head of clinical services at the Waterstone Clinic, which has five branches around Ireland. Would-be parents will be acutely aware of time. With each passing year, the chances of conceiving reduce. Aged 30, a fertile woman trying for a baby has a 20 per cent chance of natural conception each month. By the age of 40, this dips to five per cent, says McAuliffe. A delay in having your first child may not leave enough time for you to have the others you might wish for.
The investigations and options for those struggling are many and in private healthcare, each has a price. Those attending a fertility clinic can expect initial exploratory blood tests, semen analysis and scans. For a couple, this will cost about €400 in total. Where a woman isn’t ovulating, a €200 ovulation induction can be “a low-risk and cost-effective approach”, says McAuliffe. Where there is no obvious issue, IUI is an option. “That means giving them low dosage of follicle-stimulating hormone and subcutaneous injections that they take themselves every day. We would scan the woman once or twice in the cycle. The guy would give a sperm sample into the lab to be washed and prepared and loaded up high into the female partner on her most fertile day.” It’s not how many will have hoped to conceive. This procedure, which costs €900 a cycle, is also used by single women and same-sex couples using donor sperm.
A third of fertility treatments at the Waterstone Clinic are related to male factor infertility where ICSI is a common course. The cost is €5,500. Where a woman has blocked fallopian tubes, reduced ovarian reserve or is over the age of 39, IVF is the likely option. The cost of one round of IVF in Irish clinics can range from €4,000 to €6,500. At the not-for-profit Merrion Fertility clinic, the cost is €4,500. At the Waterstone Clinic it’s €5,000. “That’s your nurse consultation, your prescription, all of your scans, egg collection, sedation, embryo transfer and lab work. If you have [additionally] embryos after, you have them for freezing and storage and there is a charge attached to that as well,” says McAuliffe. Embryo freezing at the clinic is €1,595 for three years and €25 a month thereafter.
But producing a baby from IVF isn’t a certainty. Age is the biggest determinant of its success. “If you are under 35, your chance of taking home a baby from an IVF cycle at our clinics is 56 per cent, but if you are over 42, your chance of taking home a baby from IVF is 15 per cent,” says McAuliffe. “From [age] 35 to 37, it would be 44 per cent. Once you go over the age of 35, it drops off year on year. It becomes quite difficult to get pregnant naturally or through treatment once you are over the age of 43.”
Fertility clinics, like any other private healthcare provider, are free to set their own costs. Some clinics may quote a cost for the treatment only, such as IVF or ICSI for example, and not include the freezing and storage of leftover embryos and or administration costs. Blood tests and scans also add to the bill. Medication is covered by the drugs payment scheme up to a maximum of €114 a month.
With an estimated 50 per cent of those with fertility challenges needing IVF and many couples requiring more than one cycle to get pregnant, costs quickly rack up. Some people have no option but to travel to private clinics abroad where treatment costs less. The price of IVF in Poland, Latvia and Greece can be between a half to a third of the cost in Ireland, but this doesn't include flights, accommodation and time off work. Online fertility forums are full of stories of those who have taken out bank or credit union loans, or borrowed from family. Those without funds hit a roadblock.
Other clinics eschew IVF for what they call a "restorative" approach to fertility. "If a couple can't get pregnant, there has to be a reason," says Dr Phil Boyle, of NeoFertility. His patients use an app to track the basics of a woman's menstrual cycle, cervical mucus and ovulation. "We restore as good a cycle as we can and then we allow up to 12 cycles for fertilisation to follow. The couple make love at the appropriate time once we've restored the ideal environment. The baby is more the fruit of your love than your labour." An initial consultation costs €250, and those proceeding to the programme pay €1,750. IVF is expensive, and isn't right for everyone, he says. "When it's high stress, high pressure, high intensity, conception rates are lower. There has to be a pleasant context around it." Success rates quoted by some IVF clinics can be tricky to interpret too, says Boyle. "A lot of clinics quote clinical pregnancy per embryo transfer, but that's not what a couple really needs to know. They want to know, 'will I have a baby at the end of this?'" Whether you use IVF, a restorative approach or try naturally, age is a big determinant.
The cost of housing in Ireland is one factor in why we are having children later. Spending our peak reproductive years saving for a house means by the time some of us get around to trying for children, we are less fertile. The average deposit needed to buy a home is now €52,500 for a first-time buyer, according to figures from the Banking and Payments Federation Ireland. The median age of all joint buyers without children is 36. It's a chicken-and-egg scenario. Many don't want to start a family before owning a home.
Private fertility treatment, if needed, will cost money. "We know female fertility declines with age and, all too often, if patients can eventually afford treatment it is too late and their chance of success is at least half what it would have been if they had received assistance five years earlier. This breaks my heart," wrote Prof Mary Wingfield, clinical director of the not-for-profit Merrion Fertility Clinic in this paper. That was in 2015.
The cost of housing aside, there are other demographic realities at play too. The world where people have children when younger and only as part of a heterosexual couple doesn’t exist any more. Contraception, a longer time spent in education and greater workforce participation by women are all happy realities. Women are marrying later too, if at all. Same-sex marriage was legalised in 2015. The Gender Recognition Act the same year means individuals over the age of 18 can self-declare their own gender identity. In short, people are having children later, those wanting to have children are not all heterosexual or in a couple, and both groups may need State help.
If, as a country, Ireland is not too exercised about assisting fertility, it’s probably because we generally never had to worry about it. For three decades in the 1960s, 1970s and 1980s, Ireland topped the EU leaderboard when it came to the total live births per woman, peaking at 3.85 live births per woman in 1970. This was the heyday of the marriage bar when working women were forced to leave certain jobs on marriage. Times have changed.
The funding of fertility treatment by our European counterparts points to demographic realities those countries have grasped much quicker than us
In 2019, the average age of mothers at maternity in Ireland was 33.1 years, according to CSO figures. The number of births to mothers aged 40 and over, now at 8 per cent, is increasing too. Indeed women across the EU are having fewer children while they are young, and more children later, according to Eurostat figures. Like our neighbours in Denmark, Germany, the Netherlands, Sweden and Norway, the average age of women at the birth of their first child is above the EU average. The average number of children born to a woman in Ireland has dropped to 1.75. This is below the replacement rate of 2.1. The funding of fertility treatment by our European counterparts points to demographic realities those countries have grasped much quicker than us.
When it comes to reproduction, women have always been acutely aware of the maths. Those who would like children and have money can be proactive. “We’ve seen an increase in women coming in for assessments, and looking to build their family alone, perhaps doing IUI and using donor sperm,” says McAuliffe of the Waterstone Clinic. “They are not waiting for something that may or may not happen in the future.” Others are looking to preserve their fertility. “Having a baby on their own right now might not be what their life plan is, so they will look towards freezing their eggs for a time in the future.”
The earlier a woman freezes her eggs, the more eggs of better quality she is likely to produce and so the greater her chances of having a baby from them, says McAuliffe. “I would think a sensible cut-off would be age 37, but the earlier they do it, the better their chances of success. It’s all about getting them frozen young and getting plenty of them frozen.” But this too comes at a significant cost.
A female fertility check at McAuliffe’s clinic is €275 and includes a hormone blood test, a pelvic ultrasound scan to see how the ovaries are functioning and a consultation with a doctor. The tests can indicate how many quality eggs a woman is likely to get from a cycle of egg freezing. An egg freezing cycle there costs €3,000. Some women may need two cycles which costs €5,500. Egg storage at the clinic costs €25 per month, paid by monthly direct debit. This tallies with the Sims Clinic where one egg freezing cycle is also €3,000. At Thérapie Fertility, the cost of an egg freezing cycle is €1,995 with egg storage costing €18 a month.
Educating citizens about their fertility and encouraging them to take personal agency of it has never been a national strongpoint
If the woman meets a partner in the future and they fail to have a baby naturally, there will be the option to try fertilising her younger eggs with his sperm or donor sperm. All of this is a big expense for a single woman, some of whose peak reproductive years will co-occur with establishing her career and saving for a first home. If she lived in Belgium for example, all of this treatment would be State funded.
Educating citizens about their fertility and encouraging them to take personal agency of it has never been a national strongpoint. The European fertility atlas awards points to best practice in countries such as the UK and Armenia, who have a state-organised and sponsored fertility education programme that teaches young people about fertility care and challenges. As Ireland doesn't have a programme, commercial clinics are filling the gap.
Dr John Kennedy of Thérapie Fertility says: "Women should be fertility aware. They should take ownership and they should take agency." The Thérapie brand may be familiar to Irish women as a provider of laser hair removal, lip fillers and fat freezing treatments. Targeting this same cohort with fertility treatments is a "synergy", says Kennedy. "This isn't about encouraging anyone to have fertility treatment, it's about encouraging women to have choices and options and to get information," he says. "The longer you leave it before having a family, the more likely you are statistically to run into problems."
The clinic offers treatments to all cohorts, though he says the biggest is heterosexual couples. It is also experiencing growth from those in same-sex relationships and members of the trans community. “They may be transitioning and looking to freeze eggs or sperm,” says Kennedy. “It’s giving these people some place to go and someone to talk to when traditionally, they would have felt somewhat marginalised.”
The UK fertility market is worth £320 million (€375 million) per year and is experiencing accelerating growth, a 2018 report by the UK's Human Fertilisation and Embryology Authority (HFEA) estimated. There is no equivalent data here, but fertility clinics have never been busier, they say. The pandemic has been a factor; people have had time to slow down and think about their long-term goals, and they have also had time to save.
Thérapie Fertility positions itself as “affordable”, though it is “still private healthcare”, says Kennedy. Pricing structures in some longer established clinics don’t reflect modern efficiencies, he claims. “Freezing embryos, growing embryos to day-five blastocyst stage, putting embryos in a time-lapse incubator which takes photos of them so you don’t have to take them out to grade them under a microscope every day – the majority of clinics would still have some of these as add-ons,” he says.
The up-selling of additional tests and services offered part way through a treatment can also be problematic. Patients can be faced with a bamboozling list of extras, such as assisted hatching, endometrial scratch, Chicago bloods, immunology testing, immunoglobulins and tests for "natural killer cells", among other things. Not all treatment add-ons are bad. Some can increase chances of pregnancy and reduce miscarriage. It's just hard for patients to get an unbiased view of what is best for them. "We are lacking a degree of regulation in Ireland," says McAuliffe. She refers to the UK regulator's consumer-friendly website where the HFEA labels treatments green , amber or red based on their evidence of success. "When you are offered something, it is really difficult to say 'no, thank you' because you are frightened in case it will take from your chances," says McAuliffe. The UK regulator is trying to secure powers to fine clinics that mislead patients over the efficacy of their treatments. In Ireland, fertility clinics are regulated by the Health Products Regulatory Authority (HPRA) but patients won't find treatment guidance there.
“Endometrial scratch, immunology testing – we don’t do it,” says Kennedy. “If we don’t think it increases your chances of having a baby, we don’t offer it,” he says. “The line, ‘it won’t do any harm, it might do some good’, can be used to justify almost anything. There are extraordinarily vulnerable women and couples and you cannot have a conversation about a potential add-on without that woman feeling under enormous pressure to adopt it.”
The Assisted Human Reproduction Bill has still not been signed into law – and without that, there can't be better industry regulation or consumer protection
The evidence for such treatments is “dubious to say the least”, says O’Brien of Merrion Fertility. Testing for natural killer cells is expensive, as are the resulting treatments, which are not without their side effects. “We have no information for the long term health consequences of those who receive them.”
Fertility is all about timing and while the clock ticks for would-be parents, urgency amongst policymakers is missing. The publicly funded model of fertility care promised in 2019 will come in stages: the first is patients seeing their GP. If the GP deems it necessary, patients are referred to one of six regional fertility hubs. The hubs will treat “females under 36 who have failed to conceive over 12 months, females over 36 who have failed to conceive over six months” and those where there is a known cause of infertility such as endometriosis or previous failed fertility treatment. The HSE says the regional fertility hubs have been “approved and funded to provide blood tests, semen analysis, assessment of tubal patency, hysteroscopy, laparoscopy, fertility-related surgeries, ovulation induction and follicle tracking”. The department estimates “50 to 70 per cent of patients presenting with infertility issues can be managed at this level of intervention”. Critics fear this approach will stall those wanting to be parents in a holding pattern of “wait-and-see” testing, when more aggressive intervention such as IVF could yield better results.
The Department of Health says four of these hubs at Cork University Maternity Hospital, Dublin's Rotunda, Holles Street and The Coombe hospitals are "currently operational". Hubs in Galway and Nenagh, Co Tipperary, will be complete by the end of 2022, it says.
The HSE says the “target” maximum hub wait time is six months, with older patients prioritised. The hubs don’t provide IVF, sperm donation or surrogacy services so single women, female couples and male couples are excluded.
The hubs are a postive step and will help some couples but not all, says O’Brien. “Unfortunately 50 per cent of patients will find their fertility issues cannot be addressed in these hubs. For some, IVF or ICSI should be the indicated treatment from the start. There is a real risk that some could end up caught in a cycle of inappropriate treatment.”
In the context of Covid and an ongoing recruitment crisis, having six hubs up and running by 2022 seems an “impossible achievement”, she says. “Patients simply don’t have time to wait. For some it is already too late.”
Meanwhile, the Assisted Human Reproduction Bill has still not been signed into law – and without that, there can’t be better industry regulation or consumer protection, and publicly funded IVF will not take place. It also means there is currently no specific Irish legislation to regulate surrogacy and many LGBTQ+ parent families remain largely unrecognised under Irish law. The department is continuing to engage intensively with the Attorney General on the matter, it says.
For those wanting to be parents, time is ticking. Monthly ovulation cycles, diarised rounds of treatment, the “two-week wait” to see if an embryo has stuck, and then the nine months of hoping for that baby. For a country at times in its history obsessed with pregnancy and babies, our lack of protection and practical support for those who can’t have them continues.