The Debate
According to the World Health Organization, infertility is a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.
In Canada, infertility affects the lives of 10 per cent to 15 per cent of reproductive-age couples, and results in considerable psychological distress, including diminished well-being, depression, low self-esteem, and feelings of sexual inadequacy and isolation.
Ontario’s Liberal government will fund one round of in-vitro fertilization for women starting in December, and is open to women before their 43rd birthday.
Should public funding be restricted to only those patients who meet criteria that determines the likelihood of success (age, weight, overall health)?
The Debaters
The Discussion
FOR: Canada needs strict eligibility criteria for publicly funded IVF programs
Dr. Jeff Roberts (Burnaby, B.C.) : Assisted Reproductive Technologies are the mainstay of medical fertility care, involving the manipulation of eggs and sperm in laboratories specially designed for the creation and culturing of human embryos. In vitro fertilization is the most commonly performed.
If we consider infertility a disease, then the goal is cure, which in this case is a healthy child. With the overall pregnancy rate with IVF in Canada approximately 30 per cent, one treatment cycle more often than not will NOT result in a baby. If society is not able to support effective fertility treatments and a reasonable probability of live birth for all patients, then the only way forward for funded IVF may be through the establishing of specific eligibility criteria.
A number of eligibility criteria have been proposed to help screen for better prognosis patients, including the specific cause for infertility, weight/body mass index (BMI), lifestyle factors such as smoking, and age. Certain diagnoses are associated with a higher likelihood of success. Patients who are obese have a lower likelihood of pregnancy, with a progressive reduction with a BMI above 30.
However, female age is by far the best predictor of outcome with natural conception and through fertility treatments. Pregnancy rates progressively decline through a woman’s 30s and then rapidly over the age of 40. This effect parallels the natural decline in egg numbers within the ovary (ovarian reserve) and their progressive loss of genetic competence.
The combination of a woman’s age and ovarian reserve testing provides fertility specialists with a sense of a patient’s chance of pregnancy with IVF. Ultimately, this problem can simply be addressed through egg donation, which is the most common method of conception through Canadian fertility clinics for women with severely diminished ovarian reserve. As a natural and unavoidable process, at what point in a woman’s life do we consider egg-related infertility a disease, and should society be responsible for addressing that problem?
By definition, disease is defined as an abnormal condition of an organ or system, as opposed to a physiologic process, which is a normal process.
If premature menopause is defined as the complete loss of ovarian function (no eggs) before the age of 40, then certainly reduced egg numbers and quality over age 40 cannot be considered abnormal. Germany, for one, has set an age restriction for their public fertility treatment funding program at age 40. At some point in a woman’s life, the efficacy of treatment becomes very low, and the risks outweigh any benefits.
The American Society of Reproductive Medicine defines futile treatment as the likelihood of live birth as less than 1 per cent. With increasing age, the cost of achieving a pregnancy with a woman’s own egg also gradually increases to a prohibitive amount. With a finite level of funding and resources in the medical system, setting of limits should be a requirement of any future public fertility treatment program.
Infertility is a complex disease with medical, social, psychological and financial implications.
To manage this condition, all aspects of the disease need to be taken into account and any public resources delegated appropriately and effectively – using strict eligbility considerations.
AGAINST: Strict eligibility criteria has no place in publicly funded IVF treatments
Dr. Neal Mahutte (Montreal, QC) : All provincial and territorial health plans currently cover the costs of the investigation of infertility, confirming that they recognize infertility as a legitimate medical condition, but very few offer coverage for fertility treatment.
Quebec has had comprehensive public funding for assisted reproduction since August 2010. In Quebec, the government introduced fertility coverage, as it might for any other medical condition. There were NO eligibility criteria – it was simply based on medical judgement, in exactly the same way that the rest of our health-care services are based on medical judgment.
Although this decision has been criticized and we anticipate fundamental change with the pending provincial vote on Bill 20, there are compelling reasons to justify Quebec’s initial position.
As health-care providers, we are not expected to judge our patients. Rather, we are expected to do our very best to help them. If an individual sprains an ankle or tears their anterior cruciate ligament playing football, we don’t refuse medical care because they were engaging in a dangerous activity. The sprain or the ACL tear won't kill them, but we value that person’s future quality of life, and society foots the bill.
Similarly, if there is a motorcycle accident involving someone not wearing a helmet and that individual then spends three months recovering in the intensive care unit or hospital, we don’t send them the bill for being reckless and irresponsible with taxpayer money.
We also don’t impose an age limit or weight limit on elective knee replacements or elective hip replacements, which – even though they are in fact elective – cost taxpayers a substantial amount and have significant risks for morbidity and mortality in older or obese patients.
As a society, we spend the vast majority of our health-care dollars supporting people in the final six months of their lives. We do this because we believe it is the right thing to do; we don't tell them that in order to be eligible for this health care, they need a “better” prognosis.
Furthermore, it can be argued that expenditures related to public funding of fertility care should not be seen as a cost, but rather as a societal investment. The children successfully conceived become future taxpayers and will make important contributions to society long after we are gone.
In Quebec, the government declined to introduce age or other eligibility criteria because it feared that such measures would be viewed as discrimination and would not stand up to a legal challenge in the courts. This same concern may also influence how the Ontario government decides to implement public funding later this year.
Although sensible arguments can be made in favour of eligibility criteria, our willingness to consider those arguments betrays a hidden bias that infertility is less worthy of public funding than other non-life-threatening medical conditions that have a profound influence on quality of life.
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