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Women's health

Inclusion and diversity in fertility nursing

Infertility affects people regardless of race, ethnicity, sexual orientation, gender, geographic location, religion, disability, educational background, and socioeconomic status.

Acknowledging and respecting our differences helps to empower society and facilitates everyone in that society to feel welcome, included, and valued, see: Inclusion health care and Diversity and inclusion.

Undergoing fertility treatment can often feel like an emotional and isolating experience, and nobody should have to face it feeling like they are in a minority. Fertility is, and has always been, a platform that can help create diversity in our society, see: Same-sex IVF – supporting diversity in our society.

All those working within the fertility sector, including non-clinical team members have a crucial part to play in tackling inequalities and evolving the care environment to help better serve our patients. 

The key areas here are:

The need to have supportive information and resources to specifically support the needs of the LGBTQI+ community when accessing and using fertility care services, including supporting trans people and surrogacy arrangements is explored here.

Surrogacy arrangements

Same sex male couples, trans, non-binary people and single men will often turn to surrogacy as a route to parenthood to create or grown their families. There are two options for surrogacy arrangements:

1. Straight (also known as traditional) surrogacy

Straight surrogacy is when the surrogate provides their own eggs to achieve the pregnancy. An intended parent will provide a semen sample which will be prepared and injected into the uterus (via Intrauterine Insemination, also known as 'artificial insemination') of a surrogate around the time of ovulation.

2. Host surrogacy (also known as gestational)

Host surrogacy is when eggs will be provided by a known or unknown donor and sperm is provided by an intended parent. Embryos are created by means of in-vitro fertilisation [IVF] and often same-sex male couples will both provide sperm samples to create embryos and will then decide which embryo to use first. The embryo will then be transferred into the uterus of the surrogate. 

When surrogacy takes place though a clinic, there are a number of tests and investigations that the surrogate and the IP will undergo and the surrogate (if using her own eggs), egg donor and Intended Parent/s (IP) will be screened and registered as gamete donors with the Human Fertilisation and Embryology Authority (HFEA).

When creating embryos for surrogacy through a clinic, there is a required quarantine timeframe for a minimum of three months before they can be used. Some transmissible infections have an incubation period which is why a quarantine period is required.

Surrogacy arrangements are based on altruism in the UK and surrogates cannot legally be paid to help create families, they can be reimbursed with reasonable expenses through the gestation and evidence of these payments needs to recorded. Surrogacy treatments are also not funded via the NHS so intended parents will need to fund the treatment themselves. 

One of the complex areas of surrogacy is to do with the law surrounding legal parenthood and parental responsibility. If a surrogate is single, they can nominate a non-biological intended parent to be the second legal parent – the surrogate will be the legal parent at birth. If a surrogate is married or in a civil partnership, then their partner will be the second legal parent at birth and the Intended parent/s can apply for a parental order to be the legal parents of the child when they are six weeks old. To apply for a parental order and become the legal parents of a child, the following criteria needs to be met:

  • that at least one of the IP’s has a genetic link to the child
  • that at least one IP is domiciled in the UK
  • the IP is over 18 years of age
  • the surrogate consents to the parental order application.

More information about surrogacy arrangements can be found in our publication Transition from Fertility to Maternity Care.

See also:

Too often those with learning disabilities or difficulties* face not only the challenge of infertility but the societal barriers related to their disabilities. Couples with learning disabilities should have the same rights as any other couple trying to conceive, this includes fertility treatment. This right does need to be balanced with the safety of any unborn child and the capacity to understand the decisions being made. 

(*Learning disabilities refers to a global impairment where intellect is usually measured as within the 2nd centile and the person needs significant support with adaptive behaviour skills (daily living), that has been present before 18. Learning difficulties is generally used to refer to specific learning needs, such as ADHD, dyslexia – where intellect may be normal, high, or low.) 

Informed consent is one of the pillars of Fertility within the UK. A concern often expressed with individuals with learning disabilities is their capacity to fully understand the risks and benefits of treatment however the principles of positive and individualised care requires all healthcare professionals to assess need on a case-by-case basis. Depending on the level of ability individuals can choose to pursue their desire of having a child/family, especially if well supported. 

It is also important to take due consideration for the safety and rights of the baby, which forms part of the overall assessment of suitability for fertility care to progress. A complex and critical safeguarding issue in fertility services is the welfare of the child/children which may result from treatment. The HFEA has extensive information on this issue and is clear that:

“No treatment services regulated by the HFEA (including intrauterine insemination - IUI) may be provided unless account has been taken of the welfare of any child who may be born as a result (including the need of that child for supportive parenting) and of any other child who may be affected by the birth.” HFEA Code of Practice, 9th Edition (Guidance note 8 - 2022)

Supported decision making tools should be considered when aiding enabling individuals with learning disabilities for them to articulate their values and choices, (NHS 2022) and NICE has also produced a Standards framework for shared-decision-making support tools, including patient decision aids (NICE, 2021).

See also:

Minority Ethnic groups, covers a wide range of people including black, Asian or mixed ethnicity groups and minority groups including Gypsy, Roma and traveller communities who may have different needs and experiences. Growing evidence suggest that here are significant differences in access to fertility care and success rates for minority ethnic groups.

HFEA, the regulatory body for fertility care across the UK, revealed statistics (HFEA 2021b) that demonstrate lower levels of access to, and success in fertility treatments, for people from ethnic minority backgrounds. In 2018, out of the 54,000 people who had fertility treatment, around 66 per cent were identified as white and 19 per cent identified as black, Asian or mixed ethnicity (BAME) this is an increase over the past five years, but the numbers are still low. This treatment ranged from IVF to donor insemination to donor eggs and surrogacy treatment. The report looked at how access to and outcomes of treatment differed by ethnic group.

Five categories were used during the report. Black, Asian, Mixed, Other and White. They are broad categories, but they were able to encompass a wide range of ethnicities. 

Some of the research found that:

  • Black patients had lower IVF birth rates, meaning their chances of a successful outcome were a lot lower than those from white or mixed backgrounds.
  • Black patients had a higher multiple birth rate, meaning that they experience a higher rate of ‘high risk’ pregnancies.
  • Asian and other ethnic group patients had treatment with eggs from a white egg donor. The number of donors from other ethnic backgrounds is very low.
  • Patients needing donor sperm from ethnic minority groups (excluding white minorities) were more likely to be using a donor sample that had been imported from overseas. This highlights the low number of sperm donors from other ethnic backgrounds in the UK.
  • Black patients also reported higher numbers of tubal factor infertility. Meaning they have blocked or damaged fallopian tubes making it much harder to become pregnant naturally. 

These findings show that there needs to be a lot more support in raising awareness for fertility treatment in black and ethnic minority groups. See: Ethnic diversity in fertility treatment 2018

What are the HFEAs plans moving forward?

The HFEA plans to speak with patients and fertility clinics to determine the possible differences in patient experience and will use this information to ensure greater equality across the fertility sector. Additionally:

  • Reviewing this data will also show if changes need to be made to its code of practice relating to information provision.
  • HFEA will consider if further specific information should be made more readily available on the website, including information on donor availability.
  • Although the HFEA is not directly involved in donor recruitment it has acknowledged the difficulties that are faced by some patients when trying to find a donor with a shared ethic background and will continue to monitor and report on the figures. This will continue to raise awareness relating to the lack of donors available.
  • HEFA is committed to working with GPs to ensure that data is shared to highlight that in some communities access to fertility care is starting at a later age.

The HFEA has said there are likely to be some complex socio-economical and cultural reasons for these differences. In a blog by Noni Martins, As an informed and evolved young Black woman, with exposure to information, even I blamed myself for our infertility, Nomi highlights some of these issues and where we can improve as professionals by raising awareness in black and ethnic minority groups. 

The HFEA have stated as part of their plan that they will work with organisations to better understand cultural and religious beliefs. 

What can clinics and individual health care practitioners do?

Fertility Clinics are being encouraged to review their own information in relation to statistics, and patients should be informed of their own success rates based on all factors, including ethnicity.

The RCN Fertility Nursing Forum believes that education is crucial, and clinics and GPs need to be providing resources that are clear and available at an earlier stage to make people aware of their fertility. There must also be information informing patients regarding the availability of funding so there is fair funding for all ethnic groups.

All clinics and professionals need to be mindful and make patients aware of the increased risk of multiple pregnancies in certain ethnic groups, as well as support the needs of all individuals in accessing and using fertility services.  

See also:

Consensus statement on RCN Education and Career Progression Framework for Fertility Nursing (2023). Publication code: 010 729 In 2021, the RCN Fertility Nursing Forum carried out an impact assessment on the RCN’s Education and Career Progression Framework for Fertility Nursing to establish its use and effectiveness and subsequently produced the Impact Assessment of the Education and Career Progression Framework for Fertility Nursing (009 927). To address the recommendations from the impact assessment, work was undertaken with key stakeholders in 2022 to discuss how the recommendations could be implemented more widely. This consensus statement aims to clarify the way forward.

Ultrasound Education for Fertility Nurses (In production, 2023)

Transition from Fertility to Maternity Care (2022) Pregnancy following fertility treatment can be an exciting, challenging and anxious time for expectant parents. This guidance is primarily to raise awareness of possible pathways of care for women and others (their partners/support networks) as they travel through fertility treatment and pregnancy, and how they can best be supported by the health care professionals they encounter along their journey.

An RCN Education and Career Progression Framework for Fertility Nursing (2021). Publication code: 009 926 This is a comprehensive framework highlighting recommended education and training pathways toward career development for fertility nursing. It can be used to facilitate a conversation and enable career development for all nurses and HCSWs in fertility services.

Impact Assessment of the Education and Career Progression Framework for Fertility Nursing (2021). Publication code: 009 927 This publication details the results of the impact assessment survey undertaken to assess the value and effectiveness of the framework, published in March 2018. This is a collaborative project between the RCN, the British Fertility Society and the Senior Infertility Nurse Group.

Fertility Preservation (2021). Publication code: 009 531 This publication provides information for nurses who are supporting and caring for those beginning treatment for potentially life-limiting diseases and where the treatment may adversely affect their ability to have children in the future. The guidance also encompasses those who may wish, for non-medical reasons, to defer having children until later in life, for example members of the armed forces, transgender people, or those considering gender reassignment surgery.

Fertility Provision for the UK (2020). Publication code: 009 494 This publication details the RCN’s position on the provision of fertility treatment in the UK.

Fertility care and emotional wellbeing (2020). Publication code: 007 770. This guidance has been developed as a resource for all health care professionals in all areas of fertility care and acknowledges the differences between emotional support and wellbeing, implications counselling and therapeutic counselling. The HFEA has supported the publication of this publication. 

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Page last updated - 02/08/2023

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