Why Ontario must fund IVF now - By Dr. Mathias Gysler (Summer 2010)

WHY ONTARIO MUST FUND IVF NOW

By Dr. Mathias Gysler

(Summer 2010)

In Canada, 15% of couples will have difficulties conceiving. This number is more likely to increase as more couples delay childbearing in order to pursue professional aspirations. In the greater Toronto area, many women now have their first child after the age of thirty. Second marriages are increasingly common and the desire to have children in these new relationships is as important to couples as having their first children.

The World Health Organization has defined the right to have children as a basic human right and a health issue. All provinces in Canada accept infertility as a medical disorder, and therefore the diagnostic investigation and many aspects of the medical and surgical treatment of infertility are in fact covered by the different provincial insurance plans. So why is in vitro fertilization (IVF) not included? In most provinces IVF was simply never added as an insured service.
In Ontario, for example, many patients are not aware that in vitro fertilization was fully covered from 1983 until 1993, as long as the treatment was performed in a hospital setting (in fact, since the Ontario Health Insurance Plan covered the treatment, it was not permitted to deliver the service in a private clinic). The university hospitals in Ottawa, Toronto, Hamilton and London, as well as Toronto East General Hospital, developed IVF programs within their global budgets which served the population adequately. Other provinces chose not to invest. In 1993, during financially challenging times, the Government of Ontario restricted funding for in vitro fertilization, making it available only to patients with bilaterally blocked tubes. But even then, medical evidence showed clearly that IVF was equally effective for patients other than those with tubal obstruction. Restricting funded treatment to only one group of patients could not be justified by medical evidence but only on economic and political grounds. In Ontario this resulted in a two-tiered system of care, where private clinics began to open their doors, allowing a wider access for patients who could afford the treatment cost.

Today IVF (in vitro fertilization), ICSI (intracytoplasmic sperm injection), and cryopreservation (freezing) of egg cells, sperm cells and embryos at varying stages of development offer new and extended options to treat infertility. Success factors, success rates and outcomes are well understood and risks and potential complications documented. IVF has been shown to offer success rates in excess of 50% per cycle of treatment in selected patients and offers hope to those couples with severe male factor infertility, as well as those who desire to preserve their childbearing potential when undergoing cancer treatment. Both the Canadian Government and Canadian society have taken an active role in managing assisted reproductive technologies through regulatory bodies such as the Royal Commission on Reproductive Technologies and Assisted Human Reproduction Canada (AHRC), mandated to develop licensing and supervision standards and to provide guidance to the profession and society.

Now that assisted human reproduction and fertility treatments have matured to the extent that they are able to offer improved success rates, it is time for our society to follow the example of other developed countries in correctly funding such treatment. Great Britain, Sweden, Denmark, Belgium, Germany and France have all successfully developed and implemented funding solutions and regulations to the benefit of patients, their children and society.

In March 2010, Quebec announced its intention to fund IVF treatment. In the fall of 2009, Ontario received the report from the Ontario Expert Panel on Infertility and Adoption with its recommendation that Ontario fund in vitro fertilization. The Canadian Fertility and Andrology Society has publicly supported Québec’s decision and strongly advocates for both regulation and public funding of in vitro fertilization.

New analyses performed in Ontario have shown that by reducing the multiple births to 10%, regulated IVF will result in a net savings of $100 - $111 million each year. The details are as follows:

Ontario – Cost of IVF in first year = $72 M (1)

Benefits over the next 5 years:

The birth of a child for an additional 1,870 couples.
64% fewer multiple birth pregnancies: 60% fewer twins and 95% fewer triplets.
2831 fewer low birth weight multiples.

Cost savings:
Annual savings of at least $51–$70 million in perinatal hospitalization costs related to the birth of premature multiples.
Annual savings of about $30–$40 million in post natal health costs for the first year of care of surviving low birth weight multiples.
Annual savings of $91 - $131 million in long-term health and social services costs of caring for children with permanent disabilities as a result of pre-term birth.

Net savings = $100–$111 million each year.

Many an argument can be made for public funding of assisted reproduction. In a matter of such consequence, any decision-making process must first consider the patient and offspring, and the need to ensure the quality of care offered and the safety of all parties. Next, society and its values must be taken into account, and last but not least, financial considerations must weigh in.
Patients and their potential children would best be served by accredited clinics staffed by highly qualified professionals, following clear policies and procedures regarding both treatment protocols and patient selection, and providing full and accountable documentation and reporting throughout. Through a combination of provincial governance (College of Physician and Surgeons) and AHRC supervision, patients and society can be assured that clinical facilities and practices are held to a uniform standard of safety and accountability. Public funding for such health care would provide a framework for regulation and ease supervision.

With the implementation of licensing and accreditation processes, Canadian civic society would be empowered to provide input and influence the scope of practice and conduct of treatments through citizen involvement in such organizations as government-sponsored panels and dialogues, the AHRC, the provincial Colleges, professional organizations such as The Canadian Fertility and Andrology Society and the Society of Obstetricians and Gynecologists of Canada, and patient organizations such as IAAC.

A formal accreditation process through organizations such as Accreditation Canada, currently responsible for accrediting all public hospitals in Canada and many of the currently operating IVF clinics, could be invaluable in monitoring quality of care, safety, and performance standards in funded clinics.

The medical cost analysis of IVF has been calculated and released to the public many times over. But beyond financial calculations, the issue that Canadians, both citizens and government, must not overlook is the matter of safety. Unacceptably high rates of multiple pregnancies (twins and more) are the result of non-funded and thus inadequately supervised fertility treatment. Multiple pregnancies put mothers at risk and may adversely affect children at every stage of development from newborn onward. Under the current, non-funded status quo, many clinics have twinning rates in excess of 30% in successful treatment cycles. At a glance, this might look like an excellent result. But through emerging research and careful evaluation of results, it is now an accepted fact that 50% of these pregnancies will result in babies admitted to a neonatal intensive care unit, a birth experience for mother and child that is neither harmless nor uncomplicated. Prematurity remains a real and ongoing risk for twin or higher multiple birth children, and severe prematurity with serious consequences is much more common than previously thought. Since the cost of health care for these children alone would pay for the current number of IVF cycles performed, public funding is a clear logical choice. Transferring a single embryo as a mandate would avoid almost all of the current IVF-factor multiple pregnancies. The cost – a slight reduction in the pregnancy rate per cycle of IVF. In cycles where only one egg is retrieved, the most expensive and stressful incarnation of IVF treatment, pregnancy rates will likely remain the same through techniques such as embryo freezing and later transfer.

Another factor in the calculation of the financial benefit of funded IVF is the fiscal and professional contribution to be made to society by the individuals whose very existence is due to their parents’ accessing IVF treatment. It s difficult to see why a government that argues feverishly for the need to increase the national birthrate and the importance of young people to a society would not advocate as strongly for fertility treatments such as IVF that could well help to increase our numbers.

For those of us working hard to help couples fulfill their dreams of having children, it remains difficult to understand how Canada can continue to ignore the evidence, or that citizens continue to stand by our government’s failure to provide full coverage and support for infertility treatment when the simple means of IVF funding and supervision could save both money and lives. As citizens, should we not get involved, participate, and choose quality, safety and accessibility for all? Don’t we have a responsibility, more than that, an obligation, to live up to the expectations of the Canada Health Act and our proud tradition of universal access to healthcare?

Hearty congratulations are owed to Quebec and to those couples living there who will soon benefit from health coverage for IVF. The rest of us need to follow, whether it is out of compassion, concerns for safety, policy or simple financial sense. Fully funded and well supported services for patients with fertility problems are practical and just, and society will gain.

(1)As reported to Beverly Hanck by Health Economics Analyst, Lindy Forte, MSc in “A Cost versus Benefit Budget Impact Analysis for Ontario

About the Author
Dr. Mathias Gysler, MD, FRCSC, received his medical degree from the University of Western Ontario with fellowship training in Obstetrics and Gynecology at the University of Toronto in 1973. Following subspecialty training in reproductive endocrinology and infertility at the University of Southern California, he was a full-time staff member at the University of Toronto Obstetrics and Gynecology Department from 1980 to 1987.

Dr. Gysler became actively involved in IVF in 1983. He is the founding member and Medical Director of ISIS Regional Fertility Centre.

Currently the Chief of Staff at the Credit Valley Hospital in Mississauga, Dr. Gysler is very involved with the development of legislature regarding infertility in Canada.