If Canada's obstetricians had their way, families using in vitro fertilization wouldn't have to foot the bill themselves.
The issue isn't cost, fairness or accessibility.
Rather, they point out that forcing potential parents to pay out of pocket nudges them toward unnecessary medical complications, something to be accounted for as provincial governments assess their IVF coverage. With Alberta and Ontario looking to set up programs, and Quebec having cut its program altogether, the heat is rising on this contentious question of who pays, and for what.
At the root of the controversy is a conflicting view of success: is it a patient becoming pregnant, or is it actually delivering a healthy baby without complications? And what complications are medically, financially and personally justifiable? The answers vary depending on whom you ask.
Most IVF procedures done in private clinics differ in a fundamental way from those performed in a publicly funded system: Many private clinics, often at the patient's own urging, implant multiple embryos to maximize the chance of the patient becoming pregnant. But multiple embryos can lead to a multiple pregnancy with twins or triplets, with multiple risks for both mother and babies.
Evidence shows that the risk of giving birth prematurely is much higher with a multiple pregnancy (about 6.7 per cent for singletons, 57 per cent for twins and 96 per cent for triplets). The rates of infant mortality, cerebral palsy, vision problems, growth restriction and a host of other medical problems are also higher. For the mother it can also lead to a greater risk of high blood pressure, bleeding or the need for a surgical delivery.
In contrast, in a publicly funded program, the government sets the rules, limiting implants to one embryo at a time, a process known as single embryo transfer or SET (which essentially eliminates the problem of multiple pregnancies).
The rate of multiple pregnancies has been rising steadily in Canada since the mid-1970s as Canadians, who delayed starting families into their late 30s and even their 40s, have increasingly turned to IVF. Twin pregnancies are up by more than 50 per cent while triplets and higher order pregnancies have risen by more than 300 per cent, due largely to fertility treatments. Canada's rate of multiple pregnancies due to fertility treatments is the highest in the world – tied only with the United States. This, despite the fact that most obstetricians agree implanting one embryo at a time during IVF is the best strategy for most patients.
Dr. Arthur Leader, professor of obstetrics at the University of Ottawa and past chair of the Canadian Foundation for Women's Health, sees clear-cut benefits in a publicly funded IVF program. "It's not only the right thing to do," he says, "it's the safe thing to do."
When Quebec implemented its now defunct publicly funded program in 2010, one of the requirements was that single embryo transfer should be the standard of care. The rate of multiple pregnancies dropped from 27 per cent to 5 per cent.
Studies show that the success rates between single and multiple embryo transfer are fairly similar. A review of 14 clinical trials done in 2013 by the Cochrane Collaboration found no significant difference in the success rates between single and double embryo transfer.
Yet as Dr. Clifford Librach, director of the Toronto-based Create Fertility Centre, says, the argument is not so black and white. He points out that studies look at cumulative success rates, which means they would look at the success of having two single embryo transfers versus one double embryo transfer.
"It's easy to say on a paper that I'll put three embryo transfers in a row, but the person actually has to go through that," he says.
Repeated procedures can exact a high emotional toll on a mother-to-be. It also costs more, a major consideration for patients who might only be able to afford one IVF treatment. And despite the higher risks, many patients actually want twins, Librach says. His patients' usual reaction: "Where do I sign up? I would love to have twins." He also adds that the most common outcome with twins is still two healthy babies.
Leader sees infertility as a medical problem that should be treated, and believes that a publicly funded program is still the best option when it comes to the health and safety of women. He points out that provincial health-care plans cover the cost of tests to diagnose infertility and care during pregnancy, but only pay for some parts of the treatment to help women conceive. "So what they're doing is, they leave the middle up to the patient and leave the treatment up to financial ability and not medical need," Leader explains.
What's more, Leader says, the high cost of IVF treatment leads some patients to believe they only have one shot at a procedure. Thus, they end up choosing multiple rather than single embryo transfer. "In an unfunded, unregulated system, that's what happens," he says.