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Nurse assisting with egg retrieval procedure in theatre.Thinkstock

For Ontario couples struggling to start or enlarge their families, it is the kind of promise that would undoubtedly move their votes: Expanding the public funding of in vitro fertilization.

As the quintessential motherhood issue, paying for IVF makes for good politics. But does it make good policy?

The Liberal health minister who made the IVF pledge just before her government fell earlier this month didn't always think so. Or, at the very least, she didn't think it was a policy Ontario could afford.

Five years ago, Deb Matthews and her party declined to act on the advice of an independent panel that concluded the Ontario Health Insurance Plan should pay for three cycles of IVF for women 42 and younger. The panel was no collection of bureaucratic lightweights; it was stacked with medical and health-policy experts and led by David Johnston, now the Governor-General.

The panel's report, published in 2009, argued that paying for IVF could save money in the long-run, so long as the government adopted its full suite of recommendations, including making a reduction in the number of twins and triplets a condition of accreditation for fertility clinics.

But ordering the fertility industry to lower multiple-birth rates wouldn't work on its own, the panel argued. The province needed to pay for three rounds of IVF to keep desperate, cash-strapped couples from begging doctors to put all their eggs in one basket, so to speak. A cycle of IVF generally costs between $6,500 and $8,000, plus medications that range from $2,000 to $4,000.

For the health system, twins and triplets are expensive. Their mothers are likelier to go into preterm labour and require caesarean sections. The babies are likelier to be born prematurely and suffer ongoing health problems.

Preventing multiples is cheaper than caring for them, the panel concluded. It estimated the province could save between $400-million and $550-million over 10 years by reducing multiples born from assisted reproduction, plus $300-million to $460-million in care over the lifetimes of those children. (All these figures are in 2009 dollars.)

None of that convinced Ms. Matthews or then-premier Dalton McGuinty to follow the panel's advice. She told the Toronto Star in 2011 that she was unsure the cost savings would pan out. The report gathered dust.

Until now. Sort of.

In April, Ms. Matthews announced that Ontario would expand OHIP coverage to pay for one cycle of IVF for everyone, excluding the cost of drugs. (Ontario already covers IVF for women with blocked fallopian tubes.)

The NDP says its supports funding one cycle, too. The Progressive Conservatives don't oppose it per se, but it's not part of their plan.

The Liberals estimated the pledge would cost about $50-million per year and help an estimated 4,000 more women conceive. But beyond that, details were scarce.

How will the government enforce or encourage single-embryo transfer? Will there be an age limit for mothers-to-be? A weight limit? Will women qualify for another round of IVF after they give birth? The Liberals have promised to set up an advisory panel – another one – to hammer out these details.

But the one detail that is clear – that the Liberals plan to pay for only one cycle – is problematic, according to Art Leader, an Ottawa fertility doctor and a member of the old panel.

Although he's "delighted" to see the Liberals acknowledge that assisted reproduction should be covered by public health insurance, he is not sure funding a single cycle would cut down on the rate of multiple births. In that case, the savings evaporate.

If women fail to conceive after the first, government-funded round, "the second cycle would be at their cost and then they revert back to the same behaviour that's going on now and you don't do anything about the multiple pregnancy rate," Dr. Leader said. "It defers the problem and doesn't deal with the problem."

Quebec's experience is instructive here.

Its generous program, launched in 2010, covers three cycles, including frozen embryo transfers. (What does that mean? If a couple manages to produce more than one viable embryo in a cycle, one fresh embryo can be implanted and the rest frozen. If the fresh embryo doesn't lead to a baby, a frozen embryo or two can be thawed and implanted, leading to a second shot at pregnancy, all in one "cycle.") If a woman successfully gives birth after IVF, the clock resets and she gets another three chances.

All of this makes it easier for doctors in Quebec to convince would-be parents to agree to implant a single embryo. They know they'll get another shot. Building a family won't bankrupt them.

According to a study published last month in the journal Human Reproduction, Quebec's policy led to a dramatic decline in the multiple pregnancy rate, from 29.4 per cent in 2009, the year before full coverage of IVF was introduced, to 6.4 per cent in 2011.

That decreased the cost per live birth (including health costs in the first year of a baby's life) to $43,362, down from $49,517.

But at the same time, people flooded the program. The number of IVF cycles performed in Quebec increased 192 per cent in the first calendar year after the new policy kicked in and the cost per cycle rose, too, from $3,730 to $4,759.

So did publicly funded IVF actually save money? "The finding is that, yes, we did reduce the multiples and that led to a cost savings. But also the increase in [the] number of cycles kind of counteracted that savings," said François Bissonnette, director of the Canadian Assisted Reproductive Technologies Registry and one of the authors of the study.

Dr. Bissonnette said he expects that, in the long term, the savings will outweigh the costs. And, he points out, making more babies is generally a good investment for a society.

But the early lesson from Quebec's IVF experiment is that even if you succeed wildly in reducing multiple births, you won't necessarily succeed wildly in saving money.

There's no reason to think a half measure in Ontario would be any better.

Kelly Grant is a health reporter for The Globe.

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