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Cassandra’s prophecy: response on behalf of the Royal College of Obstetricians and Gynaecologists
Reproductive BioMedicine Online (2013) 27, 575– 576
www.sciencedirect.com www.rbmonline.com
LETTER Cassandra’s prophecy: response on behalf of the Royal College of Obstetricians and Gynaecologists
To the Editor Thank you for asking the Royal College of Obstetricians and Gynaecologists (RCOG) to respond to the article by Jane Everywoman on her experience of fertility treatment (Everywoman, 2013). The RCOG is a professional body of doctors specialising in women’s health. Almost all senior doctors in gynaecology and obstetrics in the UK are members of the College, as are many doctors working in sexual health and in general practice, and there are several thousand international members. The key role of the RCOG is to set professional standards by training doctors in the specialty, publishing guidance for medical practice, and providing continuing medical education. The RCOG also has an active consumer group with patient representatives in all College activities (RCOG, 2013a). Everywoman’s story contains, sadly, themes that are familiar to gynaecologists working in fertility services: lack of awareness and information concerning biological ageing, inappropriate reassurance, delayed referral, and misleading ‘success stories’ in the media. How can the RCOG improve this situation for Everywoman? Firstly, by establishing the facts concerning fertility and biological ageing, through the research which is carried out by its members both in clinics and laboratories. This important work is supported by research grants, but unfortunately reproductive research is not prioritised by the larger grantgiving bodies. In 2011 the RCOG organised a study group of experts from the fields of gynaecology, obstetrics, public health, and epidemiology to pool their knowledge during a three-day workshop. This resulted in publication of an authoritative book on reproductive ageing (Bewley et al., 2009), an educational meeting at the RCOG, and coverage in the press that was informed and generally accurate (RCOG, 2009). Secondly, by reviewing this research and distilling the facts into practical guidance for clinical practice. The RCOG first issued national guidelines on the investigation and management of infertility in 1998. These addressed the issues for primary care (GPs), secondary care in general hospitals, and specialist units. These evidence-based guidelines were amalgamated and updated for the UK’s National Health
Service (NHS) by the National Institute for Health and Care Excellence (NICE) in 2004 and most recently updated in February 2013 (NICE, 2013a). This report is freely available online and there is a complementary version of the guidance for people affected by fertility problems (NICE, 2013b). A notable change in the newest guidance is the recommendation to extend the age range for provision of NHS fertility treatment (up to a woman’s 42nd birthday in certain circumstances). A major driver for this was the improvement in IVF success rates over the last decade, so that the ‘cutoff’ live birth rate of 10% used for the offer of NHS treatment is now reached at 42 rather than 40. However, a success rate of 10% is scarcely encouraging to couples suffering infertility, and the message must still be to avoid postponement of childbearing if possible, and to minimise delays in tests and treatment. The guideline recommends early referral for women over 35 who are trying to conceive (after 6 months) so that investigations can be carried out promptly; this should identify couples who need assisted conception before it becomes too late for effective treatment. Thirdly, by educating health professionals, especially doctors training in gynaecology (RCOG, 2013b). Their training includes communication skills, which are vital in the care of infertile couples, and for women experiencing miscarriage. Unfortunately trainees do not routinely get exposure to assisted conception services, which are highly specialised, and the quality of investigation and advice in general gynaecology clinics has sometimes been poor. Again the message nowadays is appropriate referral to specialist centres. The RCOG provides ongoing education for senior doctors, including established consultants who need to keep their knowledge up-to-date (RCOG, 2013c). This training is now compulsory for all doctors, as they need to be ‘revalidated’ regularly in order to practice (Department of Health, 2012; RCOG, 2013d). Recent journals and courses have included updates on assisted conception and miscarriage, which should improve the care given to Everywoman. Fourthly, by providing information for women. The RCOG translates its medical guidance into information for women and lay people, which is freely available online (RCOG, 2013e). The RCOG consumer network hosts public lectures, and influences the ‘hot topics’ for research and educational material. There is potential for greater influence here, as support groups and chatrooms are often the first source of information for patients. Links could be made to websites such as Infertility Network UK to ensure that couples have
1472-6483/$ - see front matter ª 2013, Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.rbmo.2013.09.003
576 access to reliable information. At present the search engines are dominated by commercial IVF services. An important source of information for women is contact with health professionals. Opportunities arise during routine attendance for cervical cytology, usually undertaken by GPs and practice nurses, and also during provision of contraceptive and sexual health services (‘Family Planning’ clinics have a broader remit than prevention of pregnancy). The RCOG may be able to influence this through its close association with the Faculty of Sexual and Reproductive Health. Everywoman’s article refers to the influence of the media. There are optimistic accounts in the popular press of celebrity pregnancies (possibly achieved by assisted conception with donor eggs). The RCOG press office can encourage responsible reporting by the media. The RCOG handles numerous media enquiries and can raise its profile by responding to news items with reliable and authoritative statements from national experts. In summary, we advocate Better education of health professionals Prompt access to specialised fertility services and better provision of care Access to accurate information to support women in planning their families
References Bewley, S., Ledger, W., Nikolaou, D., 2009. Reproductive Ageing. Royal College of Obstetricians and Gynaecologists Press, London, pp. 353–356.
Letter Department of Health, 2012. Policy paper: Announcement of medical revalidation in the UK.. Everywoman, J., 2013. Cassandra’s prophecy: why we need to tell the women of the future about age-related fertility decline and ‘delayed’ childbearing. Reprod. Biomed. Online 27, 4–10. NICE, 2013a. Fertility: assessment and treatment for people with fertility problems. Clinical guidelines, CG156. . NICE, 2013b. Assessment and treatment for people with fertility problems. Information for the public. . RCOG, 2009. Reproductive ageing. . RCOG, 2013a. Women’s voices at the RCOG. . RCOG, 2013b. Education and exams. . RCOG, 2013c. . RCOG, 2013d. Revalidation. . RCOG, 2013e. Patient information. .
Melanie Davies FRCOG On behalf of The Royal College of Obstetricians and Gynaecologists, 27 Sussex Place, Regent’s Park, London NW1 4RG, United Kingdom
www.sciencedirect.com www.rbmonline.com
LETTER Cassandra’s prophecy: response on behalf of the Royal College of Obstetricians and Gynaecologists
To the Editor Thank you for asking the Royal College of Obstetricians and Gynaecologists (RCOG) to respond to the article by Jane Everywoman on her experience of fertility treatment (Everywoman, 2013). The RCOG is a professional body of doctors specialising in women’s health. Almost all senior doctors in gynaecology and obstetrics in the UK are members of the College, as are many doctors working in sexual health and in general practice, and there are several thousand international members. The key role of the RCOG is to set professional standards by training doctors in the specialty, publishing guidance for medical practice, and providing continuing medical education. The RCOG also has an active consumer group with patient representatives in all College activities (RCOG, 2013a). Everywoman’s story contains, sadly, themes that are familiar to gynaecologists working in fertility services: lack of awareness and information concerning biological ageing, inappropriate reassurance, delayed referral, and misleading ‘success stories’ in the media. How can the RCOG improve this situation for Everywoman? Firstly, by establishing the facts concerning fertility and biological ageing, through the research which is carried out by its members both in clinics and laboratories. This important work is supported by research grants, but unfortunately reproductive research is not prioritised by the larger grantgiving bodies. In 2011 the RCOG organised a study group of experts from the fields of gynaecology, obstetrics, public health, and epidemiology to pool their knowledge during a three-day workshop. This resulted in publication of an authoritative book on reproductive ageing (Bewley et al., 2009), an educational meeting at the RCOG, and coverage in the press that was informed and generally accurate (RCOG, 2009). Secondly, by reviewing this research and distilling the facts into practical guidance for clinical practice. The RCOG first issued national guidelines on the investigation and management of infertility in 1998. These addressed the issues for primary care (GPs), secondary care in general hospitals, and specialist units. These evidence-based guidelines were amalgamated and updated for the UK’s National Health
Service (NHS) by the National Institute for Health and Care Excellence (NICE) in 2004 and most recently updated in February 2013 (NICE, 2013a). This report is freely available online and there is a complementary version of the guidance for people affected by fertility problems (NICE, 2013b). A notable change in the newest guidance is the recommendation to extend the age range for provision of NHS fertility treatment (up to a woman’s 42nd birthday in certain circumstances). A major driver for this was the improvement in IVF success rates over the last decade, so that the ‘cutoff’ live birth rate of 10% used for the offer of NHS treatment is now reached at 42 rather than 40. However, a success rate of 10% is scarcely encouraging to couples suffering infertility, and the message must still be to avoid postponement of childbearing if possible, and to minimise delays in tests and treatment. The guideline recommends early referral for women over 35 who are trying to conceive (after 6 months) so that investigations can be carried out promptly; this should identify couples who need assisted conception before it becomes too late for effective treatment. Thirdly, by educating health professionals, especially doctors training in gynaecology (RCOG, 2013b). Their training includes communication skills, which are vital in the care of infertile couples, and for women experiencing miscarriage. Unfortunately trainees do not routinely get exposure to assisted conception services, which are highly specialised, and the quality of investigation and advice in general gynaecology clinics has sometimes been poor. Again the message nowadays is appropriate referral to specialist centres. The RCOG provides ongoing education for senior doctors, including established consultants who need to keep their knowledge up-to-date (RCOG, 2013c). This training is now compulsory for all doctors, as they need to be ‘revalidated’ regularly in order to practice (Department of Health, 2012; RCOG, 2013d). Recent journals and courses have included updates on assisted conception and miscarriage, which should improve the care given to Everywoman. Fourthly, by providing information for women. The RCOG translates its medical guidance into information for women and lay people, which is freely available online (RCOG, 2013e). The RCOG consumer network hosts public lectures, and influences the ‘hot topics’ for research and educational material. There is potential for greater influence here, as support groups and chatrooms are often the first source of information for patients. Links could be made to websites such as Infertility Network UK to ensure that couples have
1472-6483/$ - see front matter ª 2013, Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.rbmo.2013.09.003
576 access to reliable information. At present the search engines are dominated by commercial IVF services. An important source of information for women is contact with health professionals. Opportunities arise during routine attendance for cervical cytology, usually undertaken by GPs and practice nurses, and also during provision of contraceptive and sexual health services (‘Family Planning’ clinics have a broader remit than prevention of pregnancy). The RCOG may be able to influence this through its close association with the Faculty of Sexual and Reproductive Health. Everywoman’s article refers to the influence of the media. There are optimistic accounts in the popular press of celebrity pregnancies (possibly achieved by assisted conception with donor eggs). The RCOG press office can encourage responsible reporting by the media. The RCOG handles numerous media enquiries and can raise its profile by responding to news items with reliable and authoritative statements from national experts. In summary, we advocate Better education of health professionals Prompt access to specialised fertility services and better provision of care Access to accurate information to support women in planning their families
References Bewley, S., Ledger, W., Nikolaou, D., 2009. Reproductive Ageing. Royal College of Obstetricians and Gynaecologists Press, London, pp. 353–356.
Letter Department of Health, 2012. Policy paper: Announcement of medical revalidation in the UK.
Melanie Davies FRCOG On behalf of The Royal College of Obstetricians and Gynaecologists, 27 Sussex Place, Regent’s Park, London NW1 4RG, United Kingdom