Quebec Stops Multiple Births by Funding IVF by Dr. Annie Janvier, Pediatrician-Neonatalogist and Clinical Ethicist (Fall 2011)

QUÉBEC STOPS MULTIPLE BIRTHS BY FUNDING IVF
by Dr. Annie Janvier, Pediatrician-Neonatalogist and Clinical Ethicist

A normal pregnancy lasts 40 weeks and baby is said to be born prematurely when he is born before 37 weeks of gestation. As a pediatrician working in the neonatal intensive care unit of the Sainte-Justine mother-child Hospital, in Montreal, I deal every day with the medical complications affecting babies born prematurely. In Canada, almost 8% of all babies are born prematurely. Some factors increase the risk of preterm birth, for example multiple births (twins and triplets) and mothers who are pregnant when they are 35. The neonatal intensive care unit is the most cost-efficient intensive care: many babies survive the intensive care and do well.

The medical problems plaguing some of these babies later in life – such as cerebral palsy, hyperactivity, learning problems, behavioural difficulties, deafness, visual impairment, intestinal problems, chronic respiratory difficulties, etc. – are generally due to premature birth. The vast majority of preterm babies survive and do well, but some die and others survive with disabilities. Prematurity is a lottery and it is hard to know which ticket women draw when they get pregnant (about one in ten will deliver a preterm baby). Because prematurity is not rare, neonatal intensive care still costs a lot of money. Also, because some babies survive with disabilities, these costs continue for their entire life.

Many mothers wonder what they could have done to avoid a preterm birth. Most of the time, the answer is that nothing could have been done. Unfortunately, this is not always the case. Twins and triplets are more likely to be born preterm. They take more space in the uterus and come out sooner: 50% of twins need to be admitted to the neonatal intensive care unit, and 95% of triplets. When nature made the mistake of creating twins and triplets, we blame nature. Unfortunately, assisted reproductive technologies (ART) also create twins and triplets. Every time more than one embryo is implanted through IVF, there is a risk of twins (and sometimes triplets or higher order multiples) being born. Also, every time a woman takes ovulation induction drugs, she is also at risk of having twins or triplets. Before Quebec reimbursed and regulated IVF, a substantial number of premature babies were the result of the multiple pregnancies associated with non-regulated assisted reproduction technologies (ART) whereby more than one embryo was implanted. The consequence of this practice was an epidemic of twins and triplets. This epidemic is still going on in the rest of Canada.

In 2006, I submitted a memoir to the government of Québec, on behalf of the APQ and SNQ (Association des pédiatres du Québec et Association des néonatologistes du Québec), at a time when health authorities began worrying about the increased rates of multiple births. Our recommendations were that the Québec government imitate other countries, such as Sweden and Belgium, which had successfully reduced their rates of multiples by instituting single embryo transfer in most IVF cases. At that time, in Quebec, 30% of all IVF births were multiple pregnancies. In Sweden, for example, only 5% were multiple births. We wanted Quebec to go below 10%. We also recommended that drugs for ovulation induction be strictly controlled.

The proven benefits of single embryo transfer

Along with several of my colleagues from McGill University, I had the opportunity to conduct a systematic research on what the benefits of mandatory SET would bring. We reviewed the records of the Royal Victoria Hospital’s neonatal intensive care unit, in Montreal, from July 2005 to July 2007. We found that 82 babies (17%) admitted to the NICU during the study period were multiples resulting from assisted reproduction technologies, and that 75 infants from this group were IVF twins or triplets. In our study entitled “The Epidemic of Multiple Gestations and NICU Use: The Cost of Irresponsibility”, which appeared in the April 2011 issue of The Journal of Pediatrics, we examined the medical and financial consequences of these IVF-related multiple births.1 The vast majority of these admissions could have been avoided if only one baby had been born. We were able to extrapolate that every year, across Canada, 840 fewer babies would be admitted to neonatal intensive care units, 40 deaths and 46 brain injuries would be avoided, as well as 42,400 days of NICU hospitalization, if single embryo transfer during IVF were implemented. We also determined that a mandatory single embryo transfer policy –similar to that in Sweden- would save the Canadian health system $40 million per year, considering that caring for an infant in a NICU costs about $1,000 a day. At 30%, Canada currently has one of the highest rates of multiple births subsequent to IVF in the world.

Why public funding is necessary to reduce multiple births

In all the jurisdictions where a single embryo transfer (SET) policy has been implemented, it has been tied to public funding of ART. I have been asked the following question many times: if the solution to the social and human costs of multiple births is a policy of single embryo transfer, why not simply pass legislation enforcing SET (except in specific cases)?
The short answer is: because it won’t work. For many couples struggling with infertility, the desire to conceive is so great that they often focus on achieving pregnancy and are willing to take risks, as they are told implanting more than one embryo usually increases success rates of being pregnant. Couples paying for infertility treatments invest a lot of money for these treatments. They are financially and emotionally vulnerable. Couples hope to go through the procedure preferably only once; therefore having twins allows them to have their family complete after one cycle only. Or increases their chances to have a baby. A study showed that implanting two embryos once gave the same results as implanting one embryo twice (for two possible pregnancies). Vulnerable infertile couples prefer having one pregnancy. Because infertility in Canada is mostly treated in the private sector, couples will choose which clinic has the highest success rate. Clinics that will implant more than one embryo will have higher success rates: not implanting one embryo, in the private sector, is also beneficial to fertility clinics. When IVF is in the private sector, there is a perverse incentive to implant more than one embryo and have more morbidities for women carrying multiple births, and more morbidities and mortalities for babies born.

When patients pay for their fertility treatments, they are financial hostages to the system and are ready to take risks they may not take if they weren’t. Were single embryo transfers to become mandatory while patients still had to fork out substantial sums for treatments, this would only foster what has become a lucrative sector: reproductive tourism. Women and couples would just seek IVF elsewhere – most likely the United States or Eastern Europe – and some women would become pregnant with multiples. Of course, they would not deliver in those countries. They would come back home to have their babies, because it is home and because care is free in Canada. Thus, it is the Canadian health system which would pay for these high-risk pregnancies and high-risk babies.
On the other hand, if IVF is publicly funded along with the freezing of extra embryos, patients are willing to accept SET, especially as the rate of success of both SET and treatment cycles using thawed embryos has gone up markedly over the past few years. This has been demonstrated in every country that has funded and regulated IVF. As already stated, a study published in Human Reproduction in 2005 has shown that two implantations of a single embryo now produces the same number of children as one implantation of two embryos. When women are pregnant twice with one baby, the pregnancy is more likely to be low risk and the babies more likely to be born full term. Implanting one embryo twice saves financial and emotional costs compared to implanting two embryos once. Mainly because there are fewer preterm and low-birth weight babies born.2

A matter of public health policy

Surprisingly, a parallel may be drawn between the public funding of abortions and that of ART. Both raise strong religious and ethical debates. In both cases, ethical and humane considerations are involved. At the core of these governmental decisions is a public health concern. Ethical or religious principles aside, abortion legislation was passed largely to prevent the severe health problems, sometimes leading to death, which women were suffering because they went to charlatans or tried to put an end to unwanted pregnancies themselves. Wherever governments fund IVF, while enforcing a single embryo transfer policy, an important objective is to reduce complications for women and children. Prevention is the key word here.

The public health aspect is undoubtedly what has motivated the government of Québec, where ART have been covered by the health care system, medications and freezing of embryos included, since August 5, 2010. The objective of reducing multiple pregnancies has been met: before the program was implemented, the rate of multiple pregnancies in Québec was 27.8%, and the latest figures now place it at 5.2%. In December 2010, the Canadian Fertility and Andrology Society held a press conference to disclose the results of the Québec IVF-funding program three months on. At that time, the rate of multiple pregnancies had fallen to a mere 3.8%, and there were no triplet pregnancies to report. This meant that Québec is the place which has achieved the lowest post-IVF multiple pregnancy rate in the world, in the shortest time.

Myths and misconceptions about fertility treatments

This is the news which I fully expected to make front page headlines the morning after the CFAS press conference. However, there was not a word about this remarkable success, but negative reports on the rise in demand (something to be expected) and the capping of doctors’ fees, sometimes confused with the maximum number of cycles set by the government for the first year. I wrote letters to newspapers to set the record straight, to no avail.

For some reason, the media has been reluctant to publish “positive” news concerning the public funding of IVF. Is it because bad news sells more copies? I am at a loss to find the answer, but maybe it lies in the fact there are many myths and misconceptions about assisted reproduction technologies.

Myth Number 1: Our society cannot afford to fund IVF
Much has been said and written about what the Québec IVF-funding program will cost taxpayers. That it is a luxury. The exact figures will not be available for a while, but it is only logical that the program will pay for itself. This has been shown in every country that has funded and regulated IVF. Clearly, if we are producing less multiples, there will be fewer premature infants in neonatology units, which means lower costs. Heads of neonatology departments may not see their budget increase, but globally the healthcare system will be saving. I am personally convinced that, given the high cost to society of premature babies presenting severe disabilities (estimated at a minimum of $800 000 over their lifetime), the Québec IVF-funding program will in fact save money.

Myth Number 2: ART is used by older women who waited too long to try to conceive
I have heard such comments as “IVF is used by 60-year-old women who want twins”. In reality, the average age of women seeking IVF in Canada is 32. Women generally consult an infertility clinic after they have tried to conceive for one year.

Myth Number 3: Infertility is nature’s way of saying that a person is not meant to have children, therefore public funds should not be allocated to ART.
Whenever I venture to say that infertility is not different from the inability to have sexual relations, I am told that it is not the same thing at all. I disagree, and so does the World Health Organization which has declared infertility a disease. The ability to reproduce is considered a basic human need, much as the need for love, shelter, food and clothing. Society considers it acceptable to supply Viagra and penile pumps free of charge to men up to 75 years of age, but would do nothing for a 30-year-old woman who discovers she cannot conceive naturally? Infertility is always caused by a medical problem. If one were consistent with the “nature’s call” argument, I guess one would have to say that cancer is nature’s way of saying that it is time to die, and we would forego C-sections or not treat diabetics. In medicine, most of what we do is to try to counteract nature’s mishaps.

Here is a list of procedures and treatments reimbursed in Canada by the Universal Health System:
- Abortions
- Tubal ligations
- Vaso-vasectomies
- Primary investigation for infertility (not all exams)
- Laparotomies (endometriosis)
- Repermeabilisation of fallopian tubes
- Pre-implantation genetic diagnosis (but not IVF following PGD)
- Impotence treatment for geriatric men
- Investigation and treatment for hair loss

On the other hand, the following are not reimbursed (except in Québec):
- Assisted reproduction treatments
- Most drugs used for ovulation induction
- Intra-uterine insemination (IUI), intracytoplasmic sperm injection (ICSI), IVF
- Many infertility treatments

Myth Number 4: People should try adopting rather than undergo fertility treatments.
I have met many IVF patients who would have preferred to adopt, but gave up because the obstacles were too great. International adoption is complicated. It is very costly, requirements are very strict and the wait is so long that many people become discouraged. Trying to adopt locally is not easier, in Québec at least. The body regulating adoption, the Direction de protection de la jeunesse, has a policy of favouring biological mothers. It is rare for children to be ‘adoptable’. They are usually placed in foster care first (banque mixte). The chance of foster parents adopting a child is about one in four. Losing a child after a year is not what parents have in mind when they want a family.

Myth No 5: Success is defined by the pregnancy rate
A clinic’s success should be defined as the rate of term healthy live births. However, some clinics define success as a pregnancy which reaches 20 weeks. A public register indicating the term live birth rate and following children to ensure they are healthy would be helpful.

Conclusion
In societies where patients pay for IVF, there is a perverse economic incentive to end up with high-risk pregnancies which translate into more complications for women and more impaired children. In addition to drastically reducing the rate of multiple pregnancies and putting an end to the inequality in access to care, public funding of ART coupled with single embryo transfer increases efficiency since women consult earlier.

Avoidable multiple pregnancies are responsible for more deaths and disabilities than mad cow disease, the West Nile virus and bird and swine flu altogether. They are wasting our precious health care resources. Yet, apart from Quebec, ARTs are not regulated in Canada and implanting more than one embryo is the norm. This is a public health emergency that has been ignored for too long.

References:

1 Janvier, A., Spelke B., Barrington K. The Epidemic of Multiple Gestations and Neonatal Intensive Care Unit Use: The Cost of Irresponsibility. The Journal of Pediatrics, April 2011.

2Pandian, Z., Templeton, A., Serour, G., Bhattacharva, S. Number of embryos for transfer after IVF and ICSI: a Cochrane review. Human Reproduction, October 2005.

About the author
Annie Janvier is a neonatologist and clinical ethicist at the University of Montreal, Quebec, Canada (CHU Sainte-Justine). She is the co-director for the clinical ethics masters program at the University of Montreal. She has written many scientific articles in the fields of bioethics and neonatology. She is a member of the Quebec government consultation committee examining IVF regulation and reimbursement.