Time to fund IVF: Ontario infertility panel

David Johnston David Johnston
(Aug. 26, 2009)    The Expert Panel on Infertility and Adoption today called on the province of Ontario to finance fertility treatments.

The Ontario Health Insurance Plan ought to pay for three cycles of in vitro fertilization (IVF) for Ontarians under 42 seeking the treatment, the panel said. Included should be the cost of intracytoplasmic sperm injection, freezing and storing embryos, and up to two frozen embryo transfers per egg retrieval.

Each year Ontario clinics and fertility centres provide about 5,000 cycles of IVF and over 22,000 cycles of intra-uterine insemination. In 2006, there were over 1,500 babies born in Ontario from IVF.

Now in Ontario, one in eight couples is struggling with infertility; would-be parents have lobbied the province to pay for expensive IVF treatments.

In its report "Raising Expectations" the panel found that the single greatest barrier to assisted reproduction services is the high cost—about $10,000 for an IVF cycle. Most procedures are not covered by health insurance.

Many couples who have to pay for IVF have more than one embryo implanted, to increase the chances of a live birth. The result is an unacceptably high rate of multiple births from assisted reproduction—about 300 children were conceived through IVF in 2008 in Ontario, and of those, 27.5% were multiple births. This compares unfavourably with rates under 10% in other jurisdictions which control the number of embryos transferred.

David Johnston, Chair of the Expert Panel and president of the University of Waterloo, said the province can't afford not to finance IVF. Multiples are 17 times more likely to be born pre-term, to require a caesarian delivery and to need expensive care at birth and throughout their lives. In not covering assisted reproduction services Ontario now spends hundreds of thousands of dollars a year dealing with the consequences.

"By reducing those number of births, we more than capture the amount of money that we're proposing be invested in public support," Johnston said.

The panel recommended requiring that all IVF clinics and fertility centres be accredited within five years in order to provide assisted reproduction services in Ontario. To keep their licence, clinics would have to lower their multiple birth rate to 15% within five years and to 10% within ten.

Clinics and fertility centers don't currently need accreditation. People don't know where to go for the best care, said the panel's report.

Other barriers to assisted reproduction: some live too far from the small number of clinics, while others—such as single people and same-sex couples—face social and legal barriers. The stigma associated with infertility keeps many Ontarians from seeking help.

The government should provide fertility education so people can make informed family building choices, and act to reduce social and legal barriers to assisted reproduction so Ontarians who could benefit from services are able to do so.

Further recommendations:
-- Fund the freezing and storage of eggs, sperm and embryos for fertility preservation.
-- Set up a province-wide donor sperm, egg and embryo bank and surrogate database.
-- Review the process for establishing parentage to accommodate assisted reproduction services, and then implement the Uniform Law Conference of Canada's recommendations on declaring parentage.

Other jurisdictions have more progressive approaches to infertility treatment. Quebec began a program in April 2009 to pay for three cycles of IVF. Countries funding IVF include Australia, Belgium, Denmark, Finland, Netherlands and Sweden. By paying for procedures like IVF, countries have been able to reduce the risk of people having twins or triplets, while containing health costs.

To limit multiple births, controlling the number of embryos implanted is preferred practice in countries such as Australia, Belgium, Finland and Sweden. These have lowered their multiple birth rate to 11% or less with public support, the panel found.

In Ontario the number of private IVF clinics proliferated after the province withdrew most of its public funding for IVF in 1994 over questions about how effective the procedures actually were. Now there are 28 infertility clinics or doctors in Ontario offering assisted reproduction services, according to the list Fertility Clinics in Canada.

For the panel's approach to adoption in Ontario, see Ontario's adoption system needs fixing (Aug. 26, 2009).

Ontario appointed the 11-member panel in July 2008 to find ways to make fertility treatment and adoption more accessible and affordable. See Ontario convenes expert panel on infertility and adoption (July 11, 2008).

In August 2009 the panel issued its report "Raising Expectations" (PDF) with recommendations for the provincial government to consider.

On the panel were reproductive endocrinologists, specialists in counselling, family medicine, complementary therapies and adoption; lawyers and business executives; people who have experienced infertility or used assisted reproduction; and adoptive parents. Their study included an online survey, in-person or telephone interviews, a literature review, comparison of programs in other jurisdictions, and review of presentations from experts.

Even for those who can afford IVF, the process can be financially devastating. The average cost of a single cycle of IVF is $10,000 including medications—almost 14% of the median family income in Ontario.

Currently in Ontario, publicly-funded assisted reproduction services include IUI for all women and up to three cycles of IVF for women whose two fallopian tubes are completely blocked or absent (not as the result of voluntary sterilization). Complete blockage of the fallopian tubes accounts for only 20% of the need for IVF treatments. Even for these insured patients, the costs of treatment can still be out of reach. Despite the fact that infertility is a medical condition, most assisted reproduction services—including ancillary services such as sperm washing for IUI and ICSI for male factor infertility—are NOT covered by our universal health insurance plan.

As a result, Ontarians who need to use assisted reproduction to build their families face high costs: up to $6,000 (not including medications, lost work time or travel costs for people in communities that do not have a clinic) for each cycle of IVF. These costs put assisted reproduction—particularly IVF—out of the reach of most Ontarians.

For many Ontarians, there is no public funding for assisted reproduction services. This means that in 2009, for every cycle of IVF, people must pay about $6,000 for treatment alone—around $8,000 if ICSI is also required. Even for patients whose treatment is covered under OHIP, costs range from $1,500 to $5,000 per cycle (depending on whether they go to a public or private clinic). Ontarians who need IUI, a funded service, must still pay hundreds of dollars for sperm washing and administrative fees. These amounts do not include all of the other costs necessary for treatment—medications (which may cost just as much as IVF itself), travel, accommodation and time off of work—which add thousands more to the cost.

"Raising Expectations" (PDF) - Report of the Expert Panel on Infertility and Adoption

News Release - Expert Panel Releases Report on Infertility and Adoption in Ontario

Canadian Press - Panel recommends Ontario pay for in-vitro treatments, overhaul adoption system

Globe and Mail - Report calls on Ontario to foot fertility bill

Toronto Star - Panel recommends Ontario pay for in vitro treatments

Family Helper - Fertility Clinics in Canada
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