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When the state funds IVF, the cost is too high for everyone

It's been nine months since Quebec became the first jurisdiction in North America to fully fund in vitro fertilization.

The first state-funded test tube babies will soon be born, so it's as good a time as any to take stock of a plan that was supposed to bring joy (and children) to wannabe parents and save the health system money to boot.

Since last August, when the province launched the much-anticipated program for infertile couples, 2,830 cycles have been performed, according to new data from the Quebec Ministry of Health and Social Services.

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An IVF cycle typically consists of ovarian stimulation to produce eggs (using drug treatments), retrieval of eggs, insemination and growing the embryo in the lab, implanting the embryo(s) at the optimal time in the menstrual cycle, and then waiting to see if pregnancy occurs. Quebec's health insurance covers the cost of drugs and medical treatments for three medically-induced cycles or six natural cycles.

The province is on track to meet its target of 3,500 cycles performed in the first year - at a cost of $32-million - which is not surprising given there was a waiting list of thousands of women before the official announcement.

There are those who argue that infertility is a medical condition and motherhood/parenthood is a social good so IVF should be funded as an essential medical treatment, and not limited to those who can afford it. But public funding for IVF has been justified principally using economic arguments, such as the reduced cost of caring for premature babies.

IVF is expensive - between $7,000 and $15,000 per cycle - which is comparable to the cost of heart surgery and some cancer treatments. Bear in mind too that only between 15 and 30 per cent of cycles result in pregnancy, depending on a woman's age and other factors. Those numbers tell us that IVF is a high-stakes gamble.

Because of the high cost of treatment, couples and clinicians have typically opted to implant numerous embryos, hoping at least one will survive.

While it is possible to selectively abort fetuses, IVF can result in "multiples" - anything from twins to the infamous "Octomom" octoplets. Multiples tend to be born prematurely and have a high rate of health problems, which can result in tremendous medical costs and life-long expenses, such as special education.

In Quebec, the trade-off for public funding is that women are implanted with one embryo at a time.

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The new Ministry of Health data show that 51 per cent of cycles now involve a single embryo transfer, up dramatically from 1.6 per cent before public funding. It's not 100 per cent because there are a number of exceptions to the one-embryo rule and the reality is that many parents (most of whom have struggled for years and spent a lot of money trying to have children) want twins.

Still, the early numbers show only 3.8 per cent of pregnancies in the IVF program are now multiples, down sharply from 27.2 per cent.

Based on those numbers, the IVF program will be hailed as a tremendous success.

The data seem to give credence to projections that the program would be cost-effective: It was estimated that investing $32-million in IVF would result in $30-million in savings in medical and social services costs. Those costs soar when low birth weight babies (which preemies often are) are born with conditions like cerebral palsy.

But, let's face it, that's a bit of a bogus argument. First of all, most multiple births are due to ovarian stimulation - and any physician can prescribe those drugs. Further, multiples are a self-inflicted problem - the direct result of a decision by clinicians to implant multiple embryos. Is that ethical? Should the practice be regulated - regardless of whether there is public funding?

There is an unusual situation here in that private fertility clinics can make a tidy profit helping women get pregnant while the public system has to bear the costs when expensive neonatal care is required for high-risk moms and high-risk multiples.

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In other words, state funding is offsetting costs created by the industry itself. That is hardly a "savings." And as the number of subsidized cycles increases - to 7,000 and $80-million in 2014 - the real (and imagined) savings diminish.

In fact, a new study from the Institut de recherche et d'informations socio-économiques concludes that the big winner in the public funding of IVF treatment "is the private sector, not women."

The author of the IRIS brief, Julie Depelteau, notes that little or nothing is being spent on preventing and treating infertility but a lot of money is going into an expensive technological fix - in vitro fertilization with the state assuming all the costs and the risks.

There is a lot of pressure - from consumer groups who get their funding from companies that make fertility drugs it, should be noted - for other provinces to follow Quebec's lead and fund IVF. That pressure will grow now with the publication of numbers showing a sharp drop in multiples.

So far, though, other provinces have been cautious. Ontario covered IVF back in the 1990s but now pays only in specific cases, such as when a woman has blocked fallopian tubes. Manitoba, for its part, offers a 40 per cent tax credit to those who purchase IVF treatments, which can result in tax savings of up to $8,000 a year.

As we undertake reforms of medicare to make it more cost-effective and fair, a distinction needs to be made between medically necessary services that should be covered by public insurance and other "frills" (for lack of a better word) that should be covered out-of-pocket, by private insurance or some other means.

Infertility can be a medical condition but helping women get pregnant with high-tech methods like IVF is not a medically necessary service that should be covered by medicare.

This is not to suggest that funding in vitro fertilization is not a legitimate social program that the state might choose to support for other reasons - compassion, a desire to increase the birth rate, an attempt to reduce multiple births, etc.

Let's just be clear about the distinction between what is medically necessary and what is socially desirable.

IVF offers tremendous benefits in the form of little bundles of joy and future taxpayers, but it comes at a cost, one that we may (or may not) wish to share collectively. But let's dispense with the fiction about "savings."

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