The Politics of Affordable IVF

May 13, 2011Carole No Comments »

Two infertility related news items caught my attention today.

The first was an ASRM Bulletin sent to all ASRM members to announce that Senator Kristen Gillibrant (D-NY) introduced legislation to  quote, “provide eligible taxpayers a tax credit of 50 percent of qualified infertility treatment expenses incurred during the taxable year. The FAMILY Act would apply to expenses related to in vitro fertilization and treatments to preserve fertility in advance of medical procedures which may impact fertility and would be capped at $13,360 per year.”  This fertility tax credit is based on an existing tax credit available to taxpayers who incur adoption expenses so perhaps there is hope for its passage.

In its message to members, ASRM encouraged members to call their two Senators in Washington to urge that they co-sponsor this legislation. I am sure that it might be even more effective if actual patients called their law makers to lobby for this tax credit. You can locate contact information for your Senators at http://www.senate.gov/ or connect via the US Capitol switchboard at 202-225-3121.

Perhaps a tax credit will be the most effective (=politically acceptable) means to provide financial relief to patients who are paying out-of-pocket for their fertility treatment costs.

The more straight forward approach of providing insurance for infertility care is getting little traction here or elsewhere. Even in Canada which has some provinces that have funded IVF coverage and have encouraging health care outcomes, most people seem to have a knee jerk reaction against using any public funds for covering infertility.

An example of this is the second news item that caught my eye.  Canadian columnist for the Globe and Mail, Andre Picar, tries and fails to make the case that “When the state funds IVF, the cost is too high for everyone“.  The province of Quebec started a program last August and completed their first 2,830 cycles in which the Quebec’s Provincial health insurance covered the cost of drugs and IVF for three ovarian stimulation cycles or six natural cycles. The cost for the anticipated 3500 cycles  to be completed in the first year is on target for 32 million or about $9000 per cycle. Thousands of women were on a waiting list for treatment for the first year.

Picar goes on to say that IVF is expensive (between $7000-$15,000 per cycle) and only 15-30 percent of cycles result in pregnancy. He concludes the IVF is a “high stakes gamble”because of these low rates. He does not explain where these pregnancy rate numbers come from. Are the pregnancy rates for natural or stimulated cycles because the cost and expected outcomes are wildly different between natural and stimulated IVF cycles. Natural cycles have a lower chance of success than stimulated cycles because you are bringing only one or two eggs to the party so even a 15% pregnancy rate in a natural cycle might not be unexpected since nature gives you roughly a 25% pregnancy rate per natural cycle in fertile people. Of course, without the cost of stimulation drugs, natural cycles are about one-third less expensive than regular IVF but if the pregnancy rate is that much lower, it may not be a great return on the tax payer investment. I would argue that in a good IVF program, younger women (under 35) should be able to expect a 50% or better pregnancy rate with stimulated cycles.

Frankly, if you wanted to get a “good return” on your government paid insurance investment, you could structure eligibility requirements to favor a higher pregnancy rate by excluding older women or women with especially poor prognosis, but that wouldn’t be very compassionate, now would it? Do we cut off medicare to old people who are most likely to need medical care. Ah, no, that’s the point of providing the health care coverage, because they need it.

Picar rightly points out that due to the high cost of treatment (particularly when it is self-pay!) patients opt for transferring more embryos, which ups the number of multiples, which increases health costs because of the increased risk of medical complications associated with the almost guaranteed premature birth anticipated with multiples. If a child (or multiple siblings) spend weeks in the NICU, medical bills in six figures and more are not unusual.  If the state spends $9000 on IVF to produce a singleton birth that stays out of the NICU, medical bills are minimal in comparison, saving the state funded health care system a lot of money. Remember in Quebec, the state pays for all the medical care, not just fertility -associated care. Longer-term health care costs can also be incurred in some of these kids due to developmental delays or congenital defects due to prematurity. All this argues forcibly for reducing the number of multiple births for both medical and cost savings reasons. In Quebec, the public funding of IVF that Picar disparages requires that women have a single embryo transfer as a condition of the public funding, so the creation of multiples- the expense driver- is effectively short circuited.

Public funding of IVF does drive down the multiple rate from IVF births.  The Ministry of Health data for the first year show that 51% of the cycles were single embryo transfers compared to the old rate of only 1.6%. Why not 100% single embryo transfers if recipients are required to transfer only one embryo to get the covered IVF? Well,  apparently there are a lot of exemptions to the one embryo transfer rule so even in the dreaded “socialized health care” system we are warned about in the US, there appears to be room for doctor-patient decision making. The best news is that along with the reduction in embryos transferred, the multiple rate plummeted from 27.2% to 3.8% of all pregnancies, meaning that almost all the pregnancies were low risk singleton pregnancies. Surely there will be cost savings to the health care system with this increase in healthier singleton pregnancies. Cost savings of $30 million were predicted in return for investing the $32 million in IVF.

Picar doesn’t provide any data on actual savings, yet he argues that these projected savings  are “bogus” because most of the multiples come from the use of stim drugs outside of IVF (stimulation cycles followed by intercourse or insemination, not IVF) which he points out can be prescribed by any physician. That is true and would actually support the idea that maybe the use of stim drugs without IVF should be more highly regulated(!!!) because he just presented data proving that using stim drugs with IVF is a very effective way to control the number of embryos  that have the potential to implant and thereby reducing the multiple rate from 27.2% to 3.8%.

Then he goes on to blame the patient and provider: “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?” Hello, you just said that the trade-off for public coverage in Quebec was to mandate single embryo transfer, with some exceptions,  meaning that the proven solution to the “self-inflicted problem” is already in place!

Picar complains that the  “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.” Asked and answered. Reducing the number of high risk Moms and high-risk multiples is exactly what is accomplished by providing financial relief for IVF thereby removing the incentive to transfer too many, and then the public funding further requires that the number of embryos transferred is more often 1, not 2 or more.

Picar raises the issue that money should be spent on infertility prevention instead of high tech fixes like IVF. I am a big fan of disease prevention but it won’t prevent all forms of infertility.  If infection with sexually transmitted diseases is avoided, some forms of infertility could be prevented. Here’s an idea- let’s not defund Planned Parenthood so people have access to birth control and STD protection information.  The  prevention of infertility is a great idea but many causes of infertility are unknown or not preventable and may have underlying genetic causes, so even if society were willing to fund prevention with a blank check, many people would still be infertile. Furthermore, for some patients, IVF is the ONLY infertility treatment that has any chance of working so it’s not like patients are choosing IVF over other less invasive, less expensive methods that could be just as effective for them. That just does not happen.

He goes on to cite the example of other provinces in Canada who modified their originally more generous IVF coverage by restricting IVF only to women with blocked tubes (Ontario) or moving away from coverage to a 40% tax credit option for IVF (Manitoba). I think that most patients would be grateful for any financial relief.

Then Picar becomes rather mean spirited saying that, quote,  “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.” As one commenter on his post pointed out, by all means, let’s decide what’s medically necessary. Since the vast majority of medical expenses in every person’s life (not just infertile people) are incurred in the last 6 months, maybe as a society we should decide that Granny has lived long enough, it’s no longer medically necessary to keep this declining person alive. One person’s medically necessary is another person’s medical “frill”. Is it a medical “frill” to treat a real medical condition that without treatment can cause depression and loss of quality of life equivalent to that experienced from a cancer diagnosis?  We all know that we can’t pay for everything all the time.  That’s certainly true but what we are willing to pay for with our tax dollars says a a lot about the kind of society we want to live in. You get to have an opinion too. Call your senator.

© 2011, Carole. All rights reserved.

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