Thursday, August 27, 2009

Who'll pay for IVF in Ontario (and elsewhere)?

Recently, an interesting proposal was made regarding a new service to be covered by OHIP, Ontario's public health insurance plan.

The Ontario government should provide funding for up to three cycles of in vitro fertilization for women under the age of 42, according to a report released Wednesday.

An expert panel on infertility and adoption, appointed by Ontario Premier Dalton McGuinty last summer, is also recommending replacing a "patchwork" of adoption services with a centralized adoption agency.

One in six couples will struggle with infertility and the greatest barrier to assisted reproduction services is the cost, with one cycle of IVF costing about $10,000, according to the panel.

The group said the high cost of fertility treatments is leading to decisions which result in an unacceptably high rate of multiple births in Ontario.

To increase chances of success, women and couples choose to have more than one embryo transferred, say the authors of the report. As a result, the rate of multiple births from assisted reproduction was 27.5 per cent in 2006, compared to rates below 10 per cent in other jurisdictions with controls on the number of embryos transferred, they say.


This plan is relatively controversial, given Ontario's own budgetary problems and concerns over strains on the healthcare system.

[The report] points to other jurisdictions that have used public funding as a mechanism to reduce multi-births and argues this saves money down the road by avoiding medical complications from twins and triplets.

But counting on those (imputed) savings requires a leap of faith. It may not fully account for the possibility that many other couples would line up for IVF at public expense – crowding out a strained health budget. In any case, if multiple implantations are medically unsound, they ought to be banned on medical grounds; it's not clear that the province should use its chequebook to discourage what it could otherwise accomplish through regulation and standards of practice.

Welcoming the report, Premier Dalton McGuinty expressed sympathy for families but warned that Ontario faces difficult economic times. That is a good place to start an informed public debate.


The question of government funding for fertility treatments has been a notable issue, triggering lawsuits against the provincial government.

In Quebec, high-profile TV personality Julie Snyder, the wife of Quebecor CEO Pierre-Karl Péladeau, urged the province to cover IVF treatments. She made a documentary about infertility and put pressure on politicians.

In April, Premier Jean Charest's government announced that it will fund three IVF cycles for couples, making Quebec the only province to do so.

Seang Lin Tan, a fertility expert at the McGill University Health Centre in Montreal, said one in eight Canadian couples struggles with infertility.

"What's frustrating, is that people who would be good candidates are routinely told they have to dig into their pockets," Prof. Attaran said. "I'm fortunate, law professors get paid decently. But that's not true for everyone."

After a year of trying to conceive, the couple paid $6,300 for one IVF treatment at an Ottawa fertility clinic. A further $6,500 in drugs was covered by private insurance.

A spokesperson for Ontario Health Minister David Caplan said he would not comment on the case.

OHIP paid for IVF in the past, but in a cost-cutting measure in 1994, Ontario withdrew funding except for women whose fallopian tubes are blocked. That applies to about 25 per cent of infertile patients, said Jeff Nisker, a professor of obstetrics, gynecology and oncology at the University of Western Ontario.


Just to the northeast, it should be noted that Québec has adopted a policy of subsidizing fertility treatments, first offering a refundable tax credit paying for 50% of the costs of the treatment up to a maximum of $C 10 000 and now preparing to fund the first three cycles of in vitro fertility treatments. This, it should be noted, is part of a historic policy on Québec's part of heavily subsidizing parents and their children.

Since 1997, the province has implemented a panoply of measures to support women who want to be good mothers without sacrificing their careers.

They include generous parental leave, affordable child care, tax incentives for child-bearing, and employment premiums for working parents.

They appear to have worked: Twelve years ago, the province's fertility rate stood at 1.51 children per woman. Today it stands at a 30-year high of 1.72 children per woman, significantly higher than the Canadian average of 1.58.

Premier Jean Charest calls his province "a paradise for families." He boasts that Quebec has succeeded in slowing its population decline, reducing child poverty and increasing the employment rate among women.

His government plans to go further, offering public funding to infertile couples who want in vitro fertilization.

Quebec's programs are expensive. The province will spend $6.5 billion to support families this year (45 per cent more than Ontario).

But its fertility rate is on par with those of the Scandinavian countries, the Netherlands and Britain.

Critics call Quebec's approach costly social engineering. But the majority of citizens support their government's family policies because they make life easier for parents and safeguard the province's francophone identify.

No other government in the country is following Quebec's example.


In covering this issue, many journalists have noted that in addition to Québec, countries like Belgium, Sweden, Australia, and Israel all pay the costs of at least several cycles of in vitro fertilization. I wonder if the number of countries providing fertility treatments will grow, perhaps driven by concerns over population issues as they effect national populations and national power. Certainly Australia and Israel have histories of wanting to boost their populations, motivated by concerns for these nation's continued survival.

At any rate, the question of assisted reproductive technologies and how they'll be used in different societies is sure to be a major issue, not least because of the continued increase in the age of women at their first child. The women might be blamed for their acting in non-traditional roles, and stigma surrounding male infertility will continue to some degree, but these technologies will continue to be used. In countries with any kind of health insurance program, the emotive question of whether or not aspiring parents will be supported in their desire to have children will continue to be asked.

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The Economist: The baby bonanza

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