Quebec Funding - From Dream to Reality - by Veronique Robert (Winter 2011)
Printer-friendly versionQUEBEC FUNDING – FROM DREAM TO REALITY
Véronique Robert
Winter 2011
These interviews were conducted between September 22nd and October 15th, 2010.
WHAT DOCTORS ARE THINKING
A QUEBEC SPECIALIST REPORTS (Interview with Dr. Louise Lapensée)
Dr. Louise Lapensée is an experienced obstetrician-gynecologist and fertility specialist at both the Hôpital Saint-Luc and OVO Fertility Clinic in Montreal. In the previous issue of CREATING FAMILIES she spoke of her enthusiasm for the new Quebec program. Two months after its implementation, she reports on how it is evolving.
Are things going the way you had predicted?
Indeed! Everyone at OVO is working longer hours, the waiting rooms are full, as expected, and the staff is understandably tired. However, things are going very well medically speaking. Pregnancy rates are as high as before – 30% for first transfers. As the program came into force recently, results are available for first transfers only. This 30% rate for first transfers means that the 75% cumulative success rate I was anticipating for women who produce several embryos – most women are in that situation – is realistic. The new single embryo transfer policy is not lowering chances for success, in part because the survival rate for frozen embryos is now excellent. Furthermore, we have had no multiple pregnancies, as opposed to 20% before.
How long is the waiting list and how are patients reacting?
We are very efficient. A patient registering now will begin receiving treatment four months from now. This is not bad, considering the high demand. Of course, several patients with previous IVF experience find waiting lists difficult to accept, as they did not exist before public funding. Some of them choose to seek treatment out of province, notably in Ottawa. But most people are very pleased and feel lucky, especially when they realize that just about everything is covered by the program.
Are some patients reluctant with respect to the single embryo policy?
This has not been a problem, generally speaking. We have had to argue with a few couples who had undergone IVF before and were used to having more than one embryo transferred. But we are being strict, all the more so that the success rate with the single embryo transfer is very good. So good, in fact, that we have extended the policy from women aged 37 to women up to 40. A whole culture change is needed, not only in patients, but in physicians as well.
There have been reports that demand has “exploded”. Does that worry you?
It means the program was necessary, and my colleagues and myself are just as enthusiastic about it. It is highly motivating to offer services which are obviously needed. What worries us a bit more are the quotas established by the government. We do not know what will happen once these quotas are met and that creates uncertainty. Otherwise, I am so relieved I don’t have to talk to patients about money anymore!
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NAVIGATING THE NEW IVF PROGRAM AT THE MUHC REPRODUCTIVE CENTRE (Interview with Dr. Janet Takefman)
Dr. Janet Takefman is Director of Psychological Services at the MUHC Reproductive Centre – formerly the McGill Reproductive Centre – and assistant professor in the Department of Obstetrics and Gynecology at McGill University.
How would you describe the transition to the publicly-funded IVF program?
Smoother than we thought it would be! We had feared there would be panic about waiting lists. Instead, there is a sense of relief among the staff, because the situation is manageable. We have now [end of September] provided treatment to most of the patients registered with us before the program was implemented, and we have initiated treatment for hundreds of patients registered under the new program. There are also two types of patients we are offering treatment to; those who had IVF before and thus are familiar with the process and those who have no prior experience and thus require more teaching and education. For the latter group we are now booking in December. One cannot be too precise, but a woman calling today will probably begin treatment anywhere between three and six months from now. The demand should level off even more once we hire extra staff, which will further stabilize the situation and eliminate the waiting list altogether.
The government set a limit of 3,500 cycles for the first year. Does this mean you had to establish a quota?
MUHC has a quota of 1,700 cycles and we will meet our quota for the year.
Have you set an age limit for IVF?
It has not changed. It is 45 for women with their own gametes and 50 in the case of an egg donation. Older women are not being penalized under the new program. The law provides for physicians to exercise their judgment in several cases, therefore a doctor may decide a woman needs to be treated urgently. This, also, has always been the case.
Do you find you have less time to spend with patients?
I am a psychologist, so the time I devote to individual patients has not changed. I don’t know about doctors but, generally speaking, the patients I see do not seem angry or frustrated.
What is the general feeling among patients?
Most of them feel like they won the lottery. We now see people who would not have sought treatment before because they could not afford it. Our new patients come from all walks of life and diverse ethnical backgrounds. Our waiting rooms look like the United Nations.
Do some patients have difficulty with the single embryo transfer?
Surprisingly not. When it is explained to them that the government will pay for all transfers – a woman must use all of her frozen embryos before moving on to another IVF cycle – and when they are given the statistics about the problems associated with multiple births, they agree that this is a sound policy. Patients with previous IVF experience may be somewhat more reticent, but, in certain cases, transferring two embryos in older patients remains a possibility.
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TREATING MALE PATIENTS UNDER THE NEW PROGRAM
Peter T. K. Chan MD, CM, MSc, FRCS(C) is the Director of Male Reproductive Medicine at the McGill University Health Center.
Treatment of male-factor infertility is covered by the new Quebec program. Has the demand increased as much as for female patients?
It certainly has, and we are seeing many patients who would not have sought treatment before because they couldn’t afford it, all the more so that the cost of treating male-factor infertility must be added to the cost of IVF. Our staff is doing a fantastic job at managing waiting lists, and the situation could have been a lot worse. A patient registering now will begin receiving treatment about two months from now, and will probably be evaluated before that, which is not bad at all. If he requires surgery, the wait would be somewhat longer, maybe six months.
This increase in volume is a good thing, because people tend to be less aware of male-factor infertility than of female-factor infertility, so they might seek IVF treatment without having solved a major problem. We now know that male-factor is present in about 50% of infertility cases.
Which is the most common condition in infertile males?
The majority of men who consult have a very low number of sperm or no sperm at all, therefore the only option available to them is intra-cytoplasmic sperm injection, or ICSI, whereby a single sperm is injected directly into the egg. Men who have no sperm in their semen will require a sperm retrieval surgery, and the success rate ranges from 50 to 100% depending on the underlying cause. There are many other treatments available for men aimed at improving sperm quality, so that other options such as intra-uterine insemination or natural pregnancy may be possible. Virtually all of these treatments are covered by the Quebec provincial health care program.
Are you able to give priority to some patients?
As we have always done, we will treat urgently, for instance, a man diagnosed with poor sperm quality just before his partner is due to begin her IVF cycle.
Are there age limitations for men as there are for women?
An increasing number of studies show that the older the father, the higher the risks for various conditions including schizophrenia, autism or Down Syndrome, which is why the American Society for Reproductive Medicine suggests that donors should not be over 40 years old. As men age, their testosterone level gradually declines. This condition is sometimes called “andropause”. However, unlike menopause in women, physiological changes in andropause are much more gradual, and men do continue to produce usable sperm even in their 60’s, 70’s or beyond, so we do not have to set age limits. Keep in mind that men always prefer to use their own sperm if possible.
How do patients feel about the new Quebec program? Are they worried about the quality of services?
Most patients are happy so far, even those who could afford treatment before and now have to wait longer than they expected. We are all working harder, but to this day we have been able to maintain the same quality standards with our existing staff. However, extra nurses, doctors and embryologists will certainly be needed if the demand keeps rising.
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THE OPINION OF AN ONTARIO SPECIALIST (Interview with Dr. Arthur Leader)
Dr. Arthur Leader is a prominent specialist in reproductive medicine and Professor of Obstetrics, Gynecology and Medicine at the University of Ottawa. He is a founding partner of the Ottawa Fertility Centre, past President of the Canadian Fertility and Andrology Society and an advisor to provincial and federal governments on issues relating to assisted human reproduction. As a strong advocate of access to assisted human reproduction for infertile Canadians, he has requested public coverage of assisted reproduction treatments for Ontario patients.
How did you react to Quebec’s announcement that it would fund three IVF cycles?
Quebec is setting an example for the whole country. They believe in the value of family and have demonstrated compassion for the suffering of the infertile. The new program complements subsidized daycare and parental leave. Quebec’s comprehensive program covers medications while protecting women’s safety and regulating ethical conduct. This policy is superior to anything offered in North America. IAAC can be proud of their efforts in this regard. Quebec patients also benefited from the support of two influential personalities, Céline Dion and Julie Snyder.
Would you welcome this program in your province?
Of course, and so would the infertile community in Ontario. Today, only one third of infertile couples can afford to receive treatment. Unfortunately, the family is not important in Ontario where no political party promotes IVF funding. The situation is similar in the rest of English Canada – The Edmonton Journal called Quebec’s funding of IVF “Puppies for yuppies”. Provinces more favourable to funding assisted reproduction have an important francophone population – Quebec, Manitoba and New Brunswick. In English Canada there is greater stigma attached to infertility. In Quebec it is accepted as a disease, as defined by the World Health Organization.
Could Ontario afford to fund IVF?
Yes, the logic is the same: if funding is associated with a single embryo transfer policy, one can reduce the number of multiple births, which are very costly for the health system. The program would be even easier to implement in Ontario – we have 15 fertility centres, as opposed to five in Quebec.
Do you think that Quebec will accept having residents from Western Quebec treated for free at the Ottawa Fertility Centre?
I hope so, and so do the patients. Similar arrangements exist for high-risk obstetrics and women’s cancer, for example. One third of my practice is from Quebec because infertility services are only available in Ottawa or Montreal. Having to travel four hours to Montreal for treatment puts Outaouais women at risk.
Some wonder how the Quebec health system will be able to accommodate more mother-child care, given the current shortage of obstetrician-gynecologists.=
I think it is a matter of how care is organized. Family doctors and midwives can care for singletons. What would happen if the program were not implemented and women were to seek IVF on their own and perhaps one-third become pregnant with multiples? Wouldn’t that put an even greater burden on specialists? We have had couples come back from Eastern Europe expecting quadruplets. The existing system has to provide for these high-risk pregnancies when they are born here. The new IVF program addresses this situation.
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WHAT PATIENTS IN QUEBEC ARE THINKING
MONTREAL
Catherine Williams, a patient at OVO Fertility Clinic, pregnant following a government-funded IVF
I was so lucky! Not only were my husband and I good candidates for IVF, but our timing was perfect. As it happens, my doctor thought that IVF was the next step for us after four failed IUIs. Money was a problem, but this was 2009 and government-funded IVF was in the air. So we crossed our fingers. What a relief when we learned that Bill 26 had been passed! We broke into a dance! After 10 years of hardship, our life project could finally resume its course. We were happy not only because treatments were going to be free, but mostly because we would at last have a chance at starting our family.
Last summer, our doctor suggested we initiate the protocol, which did not involve too much and would only cost $35. If the law didn’t pass, we could always put an end to the process. Funding was instated on August 5th. On the 18th, I had one embryo transferred – two top-quality extra embryos have been frozen for later use. On August 30th, a blood test confirmed that I was pregnant. We will be going South in January – I will have a good excuse for looking plump on the beach!
I am tired of hearing negative comments about IVF funding. When infertility happens to you, that’s not how you see things. When you meet someone and decide that you both want children, you take for granted that it’s going to work. You don’t ask, “What are we going to do if we have difficulty conceiving?”
GATINEAU
Céline Martin, patient, leader of the IAAC’s Souhait-enfant support group with her husband Alexandre St-Pierre
I have endometriosis and three IUIs have been unsuccessful. What compounds my problem is that I am premenopausal although I am only 32. That is why my doctor is telling me that I need to hurry. I may attempt another IUI, but for me IVF is probably the way to go.
If IVF were not so expensive, I would gladly continue being treated at the Ottawa Fertility Centre, which is so conveniently located for me and where I have a wonderful physician, Dr. Leader. Of course, I think it is great that assisted reproduction treatments are now publicly funded in Quebec. But for people like me who live in an area without facilities near by – the Ottawa Fertility Centre is not in Quebec – the good news comes with a downside.
Since the IVF-funding program was implemented, there have been discussions about permitting Western Quebec residents to receive free treatments in Ottawa. I was clinging to the hope that this would happen because travelling to Montreal would add an extra layer of stress to treatment procedures which are burdensome to begin with. Unfortunately, I don’t think this will happen, at least not quickly enough for me. I should begin treatment now, all the more so that my hormonal balance is finally back to normal, I believe thanks to acupuncture – I see an acupuncturist who has helped many women become pregnant. So I am resigned to the idea that I must go to Montreal for treatment. What other choice do I have?
QUEBEC CITY
Nancy Fournier, patient and leader of a recently formed IAAC support group
I am 33 years old and I was diagnosed with polycystic ovarian syndrome in my early twenties. I underwent one unsuccessful IUI and I plan to do two other attempts before I try IVF. How fortunate that IVF is now funded, because otherwise it is unlikely that I could afford it. If the law had not been passed, I would have had to discuss the matter with my partner – and borrow money from the bank.
Free access to IVF is all the more crucial in my case that adoption is not an option for us: adopting a child is very complicated in Quebec. International adoption is out of the question as well for my partner and myself because it is very expensive and because we do not meet the criteria. The new Quebec program may turn out to be a lifesaver for us!
WHAT PATIENTS ACROSS CANADA ARE THINKING
TORONTO
HOORAY FOR IVF FUNDING
by Danielle Alderman, patient and former Patient’s Perspective writer for CREATING FAMILIES
After nearly six years of trying to conceive, more money and science than one could shake a stick at, we finally did it. We got pregnant. Indeed a dream come true, but not one that could make the outstanding balances on our credit lines disappear.
Somewhere between twenty and twenty-five thousand dollars out of pocket were spread out over six years – not something that we could absorb easily. Knowing how many other organizations, associations and groups were looking for money from the government, plus hearing about constant cutbacks and strains on the system, I never really believed that funded IVF would actually come to be. Of course, I knew the arguments from “our” side and logically it made sense to me. But, as we know, our logic and the government don’t always see eye to eye. Imagine my surprise when I heard that I was wrong – funded IVF would soon become a reality for Quebec residents.
I was certainly a little disappointed that this is not something I’ll ever partake in as my IVF days are over. But I was filled with joy at the thought that so many families will no longer feel the financial burden that comes with IVF along with the emotional challenges of trying to conceive through ART.
When it was my money being spent, I won’t lie, I never had less than two embryos transferred (four transfers, two embryos each time). To have only one transferred wasn’t something I was willing to accept, tolerate or allow. My money, my body, my dreams – meant my call. As usual, hindsight is 20/20 and back then I didn’t fully understand the potential hazards of risking multiples. I was far too invested on too many levels and too desperate to make a rational decision.
I likely would have been pretty ticked had I been forced into single embryo transfer, but that’s simply because I was given the choice. Having said that, if I had not been given a choice and it wasn’t my money, I would have played by the rules.
As for rules… without a doubt, serious regulations must be established to keep patients and their babies safe. Never mind who’s paying the bills. And yes, one of those rules should be single embryo transfer.
OTTAWA
FREE HEALTH CARE FOR CANADIANS… JUST MORE FREE FOR OTHERS
by Cara Strong, patient and leader of a new IAAC support group in Ottawa
Jealousy is a feeling my husband and I are becoming more and more aware of and one, if you are reading this, you are probably familiar with. My husband and I are part of the one in six couples suffering from infertility in Ontario. August 5th, 2010 was a bittersweet day for us as residents of Quebec were granted three free IVF cycles. As much as I was happy to see a step forward for others like myself, I was confronted with the green-eyed monster rearing its ugly horns again.
Infertility is a disease, not a choice, and Quebec is recognizing that now. What could get Ontario to come on board? It concerns me that the Ontario government would prefer to pay for my medical expenses if I have pregnancy complications or if my children are born with medical issues. Why not help eliminate these costs by regulating the IVF process and helping couples in my situation? The costs for government-funded IVF versus potential medical fees resulting from multiple births is a question Ontario needs to seriously consider and one that Quebec is now addressing with its single embryo transfer policy.
Does Quebec’s financial assistance outweigh the restriction of single embryo transfer? In my case I will require an egg donor, a process that carries with it a little over 50% chance for a live birth, but nearly 70% success with multiple embryos. All things considered, would the risks associated with multiples stop us from trying to increase our chances to start a family sooner? No. Would it if we didn’t have to save for three years and now re-mortgage our home? Yes.
So what options are left for families in Ontario? Sure, we could move to Quebec. But we have spent years working to create a home here in Ontario. One that is close to our friends, family and jobs. And we’re ready to start our own family. No more “relax, it will happen eventually”; no more “be patient.” The time it would take to change jobs, move and actually receive treatment in Quebec doesn’t make sense if we hope for kids in the near future. If Ontario does step up to the plate it will be too late for us. Our ducks are in a row… We’re doing this now.
VANCOUVER
Sue Dumais, patient, leader of an IAAC support group and contributor to CREATING FAMILIES
Do I think British Columbia will adopt a policy similar to Quebec’s IVF-funding program? Absolutely! Can the BC government afford to do it? They can't afford NOT TO adopt such a program. When you look at the long term savings from reducing the rate of multiple births, I can't understand why they haven't seen the light and taken action already. It makes no sense that assisted reproduction treatments are not covered. After all, this is not cosmetic surgery. Couples need to have ART to conceive due to medical conditions or circumstances beyond their control.
I teach yoga for fertility and I asked my class what they thought about the Quebec program. The consensus was that they aren't jealous, but they are certainly hopeful that BC will follow suit. They would like to see more public awareness raised to convince the government it is in everyone's best interest to fund IVF. There is a general understanding of why the Quebec program specifies single embryo transfer. Everyone seems to agree that this is fair. As most of my clients do not want multiples, this makes sense to them.
WINNIPEG
Paula Chorney, former patient, Board Member of the Manitoba Chapter of IAAC
I myself became a mother thanks to IVF and I would certainly welcome such a program in Manitoba. Since our population is considerably smaller than that of Quebec, it would not be as costly. The Fertility Tax Credit which came into effect in Manitoba on October 1, 2010 is an important first step. Unfortunately, I don't think Manitoba is planning on expanding on that Tax Credit at the moment. But I hope that the example set by Quebec will encourage the Manitoba government to go one step further.
I facilitate the support groups held every two weeks for the IAAC Manitoba Chapter. A recurrent topic at meetings is that many of our members cannot afford treatment. Many couples delay treatment or forego it due to lack of money. We have spoken about the new Quebec policy in our support group. One of the comments people made was, "We should move to Quebec!"
FREDERICTON, NEW BRUNSWICK
Mélanise Daigle, patient, member of an IAAC support group
I was both very happy for the people in Quebec when I heard the news, and sad that not all Canadians can benefit by publicly funded treatments. I remember hearing former Premier Shawn Graham say that New Brunswick needs to increase its population – give me 8 000$ for IVF and I will give you children!
I have undergone two IVF cycles, without success. I am now 33 and I would go through another cycle if it were free. I am somewhat hopeful that IVF may be funded one day in New Brunswick because I had the chance to speak with the Conservative candidate in my riding of Oromocto, Jody Carr. I was sitting in a park where he was introducing himself to people. I asked him about the promise his party had made to fund IVF and I told him a belonged to a support group for infertile people. To my surprise, he asked whether he could attend one meeting to learn about the issue, and he showed up and listened. What is encouraging is that he said that all of his party’s promises had been budgeted for.
So I haven’t lost hope for IVF-funding in New Brunswick, but time is running short for me. My husband and I are now considering moving to Quebec.