Françoise Baylis reviews some of the proposed changes to public funding of IVF in Quebec and explains why these changes will not increase the multiple pregnancy rate.
In August 2010, the province of Quebec began public funding of IVF. Insured services included the transfer of one or two embryos in women 36 years of age or under, and the transfer of up to 3 embryos (including no more than two blastocyst stage embryos) in women 37 years of age or over. Predictably, these regulations resulted in a dramatic reduction in the number of multiple pregnancies in the province (from 27.2% in 2009 to 5.2% in 2013).
Four years later, the Quebec government is now looking to radically revamp its IVF program (see here and here). On November 28, 2014, the government tabled Bill 20, An Act to enact the Act to promote access to family medicine and specialized medicine services and to amend various legislative provisions relating to assisted procreation. Bill 20 replaces public funding of IVF under the provincial health insurance plan with a sliding scale of tax credits. At one end of the spectrum, families earning less than $50,000 a year will be eligible for an 80% tax credit. At the other end of the spectrum, families earning more than $120,000 a year will be eligible for a 20% tax credit. Bill 20 also limits the number of embryos that may be transferred into a woman per cycle. Single embryo transfer will be mandated for women under 37, while women between the ages of 37-42 will be eligible for double embryo transfer.
In response to the government’s decision to amend public funding of IVF, Dr. Bissonette (President of the Quebec Fertility and Andrology Society) and Dr. Mahutte (President of the Canadian Fertility and Andrology Society) issued a press release on November 28 condemning this decision. Therein, they celebrate Quebec’s success in dramatically reducing the rate of multiple pregnancies and denounce the government’s decision to continue funding artificial insemination, which is responsible for the highest number of multiple pregnancies. It is clear from this press release (and a subsequent press release issued on November 30 by Dr. Mahutte) that the physicians who provide IVF are not happy to lose the government investment of $70 million a year. What is less clear is whether the press releases are also a call on the Quebec government to stop funding artificial insemination.
Women who get pregnant without using technology typically have one baby at a time. Women who use technology such as fertility drugs or IVF are at increased risk of getting pregnant with twins, triplets or more. While this may seem like good news for women who might not otherwise get pregnant, multiple pregnancies are bad news. The pregnant woman is at increased risk for a number of medical complications including pre-eclampsia, pregnancy-induced hypertension, and toxemia. The pregnancy is at increased risk of ending in a miscarriage. And, the potential offspring are at increased risk of being born premature (< 37 weeks) with all of the negative health consequences that entails.
So, what is the current best evidence on the number of embryos physicians should transfer per IVF cycle? According to guidelines issued in April 2010, by the Joint Society of Obstetricians and Gynaecologists of Canada –Canadian Fertility and Andrology Society Clinical Practice Guidelines Committee, best available evidence supports the increased use of single embryo transfer in good-prognosis patients in order to avoid multiple pregnancies. Good prognosis patients are women 35 or under (and sometimes 36 and 37), in their first or second attempt at IVF with at least two good quality (preferably blastocyst stage) embryos. In select cases, where the chance of pregnancy is poor, the Committee allows that it is reasonable to proceed with double embryo transfer to increase the chance of a live birth. In reaching beyond the evidence, the Committee’s closing statement is that public funding of IVF should be provided to promote the uptake of single embryo transfer.
For years I have argued that the laudable goal of promoting single embryo transfer to reduce the multiple birth rate and to promote the health of pregnant women and newborns does not depend on public funding. Rather, it depends on the practice of evidence based medicine. Evidence based medicine is about “integrating individual clinical expertise and the best external evidence,” regardless of who pays.
Contrary to this view, many of those who argued in support of public funding for IVF in the 2000’s insisted that public funding would reduce the number of multiple pregnancies, which in turn would reduce the number of multiple births. This in turn would reduce the number of admissions to the neonatal intensive care unit, which in turn would reduce costs to the health care system. As yet, the predicted cost-savings have not been documented. It is undeniably true, however, that there has been a dramatic reduction in the number of multiple pregnancies in Quebec over the last four years. This is an impressive achievement, something about which Quebec physicians can rightly be proud.
It is misleading to suggest, however, (even indirectly) that this achievement is reason enough to maintain public funding of IVF. The reduction in multiple pregnancies is not the result of public funding, but rather the result of legal limits on the number of embryos that can be transferred per cycle. Such limits were in the original 2010 regulations introducing IVF funding, and revised limits are in the 2014 regulations amending IVF funding. As such, whether IVF is funded through the Quebec health insurance program (2010 regulations) or through tax credits (2014 regulations), the number of multiple pregnancies will remain low.
Kudos to Quebec IVF docs for reducing the number of multiple pregnancies.
For more on this issue listen to Françoise Baylis on CBC The 180 with Jim Brown “Should the healthcare system pay for In Vitro Fertilization treatments?”