Ontario’s premature IVF announcement

On Thursday April 10, 2014 Ontario made the long awaited announcement that it was going to boost its coverage of IVF. I say long awaited because the Expert Panel on Infertility and Adoption recommended that it do so in its 2009 report.

What Ontario announced was that it will now cover the procedural costs of one IVF round for all infertile Ontario residents. An advisory panel will determine how much each ‘couple’ will receive as well as who is eligible. Other than that, little information has been provided. It is not known at this time if the funding will be through the provincial medical plan, through a tax credit, or other vehicle. It is also not clear if the province will require a single-embryo transfer in exchange for the funding in order to reduce the risk of multiple births.

Due to the lack of details, it is not clear what the policy rationale for this proposal is. In addition, given the lack of decisions made regarding the implementation, the proposal appears to be ill thought out and the announcement made prematurely. That is, it was an announcement for announcement sake. That is the kind of policy that I hate.

The overall live birth rate per IVF cycle started is 24% in Canada (note that the success rate for natural conception is 25% in fertile couples). So if the oft quoted figure of 4,000 couples that will benefit from this policy is true (assuming this is an annual figure, but again not clear), then we expect it to lead to 960 live births per annum. The Ontario government expects to pay out $50M annually, meaning, ceteris paribus, that each live birth will cost Ontario taxpayers $52,083.

Normally, we expect to see some tradeoffs on the part of infertile couples like was done in Quebec. In exchange for partial funding, the ‘couple’ must agree to transfer only one embryo. This quid pro quo reduces the costs associated with multiple births, thereby saving the province the cost of high risk multiple births. This was what was done in Quebec. Quebec funds three rounds of IVF in exchange for a single embryo transfer and its multiple birth rate dropped from 27.2% to 3.8% within the first three months of the programs implementation. The costs saved from lower multiple births exactly offset the cost of the program, meaning a zero sum game for Quebec taxpayers..

However, the industry itself has already been moving towards more single embryo transfers on its own, even without cost sharing, due to the medical risks. Canadian fertility clinics reported a decrease in the multiple birth rate from 32% in 2009 to 18.4% in 2012 (note the natural rate of multiple births is about 2%); however, how much of that drop is due solely to Quebec vs. adherence to the recommendation by the Canadian Assisted Reproductive Technologies Register (CARTR) of a single embryo transfer for women under the age of 35 is not reported.

So it is not clear if Ontario’s motivation for this policy is to reduce multiple births, but if it is it needs to mandate single embryo transfers (it also needs to better regulate the industry, but that is a whole other kettle of fish). But if it is, then why is it funding just one round of IVF treatment? The pregnancy rate from one round is low (equal to that of the natural rate among fertile couples). Most couples will need a second round and even third round (either a fresh round or transferring frozen embryos from a previous fresh round), and without regulation related to the number of embryo’s transferred in these subsequent rounds, the risk of multiple pregnancy rises with each round as each round increases the incentive to transfer more and more embryos to achieve a successful pregnancy. The recommendation from the Expert Panel on Infertility and Adoption was to fund 3 rounds, with the live birth rate from 3 rounds being 70% for women under 35 and about 60% for those between 35-40.

The policy is also not consistent with evidence related to achieving a successful pregnancy from IVF. Evidence shows that the highest success rate from IVF occurs in rounds where the frozen embryo’s are transferred and where the uterine lining has been ‘scratched’ in the cycle before the transfer. If Ontario wants to increase the live birth rate, thereby reducing the cost of each live birth, then it needs to focus on matching its policy to evidence on success rates.

How the funding will be delivered is also important. If the goal is to make fertility treatments for affordable to those who might not already be able to afford them, then a tax credit does not meet this test. A tax credit requires the participants to pay the costs out of their pocket and then seek partial reimbursement at tax time. They need to have the money on hand first and foremost and be able to carry that expense until they are able to obtain the tax refund, which can be more than a year and half from the time they incur those expenses. Given that the average cost of a single cycle of IVF is $10,000, including medications, this is no small sum to incur.

Which leads to the other cost problem. The Ontario policy will only cover the cost of the procedure and not the cost of medications. Typically, the procedure runs around $5,000 and the required medications amounting to around an additional $5,000. Most private health plans exclude fertility medication from coverage, the exception being many public sector workers for whom these expenses are covered (again, a whole other kettle of fish).

So it is not clear that the policy will help increase access to IVF treatments or whether it will subsidize the costs for those that are already willing and able to pay for the treatment.

While many are passing judgement on this policy as not being needed, saying there are more important costs to cover in Ontario, I will not jump on that band wagon. Infertility is recognized by the medical community as a disease of the reproductive system. This disease affects between 1/6 and 1/8 couples of child bearing age and most infertility is an exogenous condition. Our medical system happily treats, at taxpayers cost, diseases and conditions that are brought on by the behavior of the individual, such as smoking, drinking, obesity, and so on as well as the costs associated with tubal ligation and vasectomies that arguments such as these against IVF funding are repugnant. That said, Ontario’s policy needs much more thought and clarity before it can be assessed as being a good idea or a poorly thought out policy with good intentions.