Following publication of the NICE Guideline Fertility: Assessment and treatment of people with fertility problems, the major challenge in the United Kingdom is to ensure that its recommendations are implemented. The Guideline will not, in itself, address current inequalities in the availability and delivery of care. It may go some way towards guiding those responsible for commissioning services to ensure that all infertile couples now have access to evidence-based care including in vitro fertilisation, where appropriate. It should be possible to develop clinical standards from the Guideline and audit referral, investigation and treatment practice against them. In addition, assessment of patient satisfaction is increasingly seen as an important method of ascertaining the quality of service provision.

At a national level, the opportunity should be taken to strengthen the case for a National Service Framework, although the difficulties should not be under-estimated. Politically, infertility is not seen as a big health problem, compared with cancer, heart disease or stroke, even though it can have a major disruptive effect on the lives of young productive individuals, men and women. However, a lesson can be learned from the Sexual Health Strategy, which, despite Department of Health support, is in danger of foundering for lack of a National Service Framework. An important message to get across is that implementation of the recommendations may be cost neutral or even cost saving, by preventing inappropriate referral, unnecessary or duplicated investigations and ineffective treatment. There is also likely to be a major saving by reducing multiple births arising from fertility treatment.

It is not just triplet and high order births that are the issue. Twins, although less problematic clinically than triplets, occur in 20–25% of births after assisted reproduction and fare significantly worse than singletons. The NICE Guideline agrees with the Human Fertilisation Embryology Authority (HFEA) Code of Practice, as well as previous British Fertility Society (BFS) and the Royal College of Obstetrics and Gynaecology (RCOG) recommendations in stipulating that no more than two embryos should normally be replaced; but this will not prevent twins. Only elective single embryo replacement will do this, and already Scandinavia is moving in this direction. In one Helsinki clinic, single embryo transfers are carried out more than 60% of the time, while in Sweden increasingly, informed patients will not accept even two embryos.

A further recommendation in the Fertility Guideline is that intrauterine insemination treatment should be carried out, in the first instance, without gonadotrophin stimulation. This has been greeted with scepticism, and more research is clearly needed to determine whether successive cycles of intrauterine insemination without stimulation can achieve the same outcome as fewer cycles with stimulation. In regard to the cost savings that might be anticipated with a reduction in multiple births, experience from new strategies in Belgium may prove invaluable. Specialists have agreed an arrangement with the Belgian Government, whereby, in return for limiting the risks of multiple birth (by reducing gonadotrophin use and embryos replaced), more individuals will have access to fully funded treatment. The cost savings will easily pay for the proposed increase in funded service provision.

There are many more challenges facing fertility specialists, not least a better understanding of the underlying causes of infertility. Surgical treatment of mild endometriosis is apparently effective, with improvement in pregnancy rates, but the same cannot be said of medical treatment. Can this discrepancy be accepted or is further research and more clinical trials needed? Surgical treatment of varicoele does not improve fertility, but is varicocele nonetheless a cause of infertility, and if so how? Ten years of studies comparing recombinant with urinary derived gonadotrophins have indicated no clear benefit of one over the other, but the pharmaceutical interests driving much of the work may have distracted attention from the effects of ovarian stimulation on the endometrium, and hence, implantation. Surely, more work is needed to examine the luteal phase effects of ovarian stimulation, including excess oestrogen production and premature progesterone release.

Any attempts at embryo manipulation with the intention of improving pregnancy rates must first be shown to be safe and then clinically effective. Assisted hatching is frequently carried out, but with uncertainty as to appropriate patient selection, clinical benefits or long term risks. Aneuploidy screening is believed to be beneficial, but the first randomised study carried out by the Brussels Free University team has shown no improvement in pregnancy rates. The availability of new technology (frequently paid for by patients) does not in itself justify its use in clinical practice until safety and efficacy have been assessed. Appropriately conducted clinical trials are more likely to be feasible, and achieve greater credibility and widespread applicability, if they are carried out on a multicentre basis and independent of any manufacturing interest. Encouragingly, there is a developing network of Fertility Centres in the United Kingdom, equipped to address the bigger questions in clinical and embryological practice.

It is also important not to lose sight of preventive measures in relation to infertility. There is a need for a greater understanding of the limits that a woman's age places on the outcome of currently available treatments. To some extent, this is a public health issue which requires more information and education. Meantime, the prevalence of chlamydial infection in young people in our society continues to increase. Fortunately, this has not yet translated into a measurable increase in pelvic infection, including its sequelae—infertility and ectopic pregnancy. However, the undoubted association between lower tract infection with Chlamydia trachomatis and tubal disease underlines the need for better understanding of the factors that place those young people with asymptomatic chlamydial infection at risk of developing pelvic inflammatory disease. A possible association between genital tract infection in men and subsequent infertility is increasingly recognised. Further studies exploring the possibilities of prevention are warranted, bearing in mind that male infertility is the biggest single cause of infertility.

Finally, we need to preserve the reproductive research base that has developed in the UK. The HFEA is in the process of granting the first research licences to clone human embryos, with the express purpose of producing stem cells. This is possible because of the HFE Act, which has unquestionably contributed to a public and political climate in which the relevant research can be pursued. Although the regulation of clinical treatment has from time to time raised difficulties, it has, on balance, probably done more good than harm. The production of embryonic stem cells and the preservation of gametogenesis are just two areas of activity with perhaps the most potential to help future generations. The proposed review of the HFEA Act and indeed the HFEA itself (included in the current scrutiny of health regulatory bodies), may provide opportunities for those opposed to the kind of work that brought about the birth of Louise Brown a generation ago. It is therefore important to take nothing for granted, and to keep focus on the legislation that best ensures the provision of safe and effective clinical treatment and sound reproductive research.