Women who get pregnant without using technology typically have one baby at a time. Women who use technology such as fertility drugs or in vitro Fertilization (IVF) are at increased risk of getting pregnant with twins, triplets or more. While this may seem like good news for women who might not otherwise get pregnant, multiple pregnancies are bad news. The pregnant woman is at increased risk for a number of medical complications including pre-eclampsia, pregnancy-induced hypertension, and toxemia. The pregnancy is at increased risk of ending in a miscarriage. And, the potential offspring are at increased risk of being born premature (< 37 weeks) with all of the negative health consequences that entails.
In August 2010, the province of Quebec introduced public funding of IVF under the provincial health insurance plan. At the same time, it introduced regulations on the number of embryos that could be transferred into a woman per cycle: one or two embryos in women 36 years of age or under, and up to 3 embryos (including no more than two blastocyst stage embryos) in women 37 years of age or over. Predictably, these regulations resulted in a dramatic reduction in the number of multiple pregnancies in the province (from 27.2% in 2009 to 5.2% in 2013). This is an impressive achievement, about which Quebec physicians can rightly be proud.
Four years later, the Quebec government is looking to radically revamp its IVF program (see here and here). On November 28, 2014, the government tabled Bill 20, which replaces public funding of IVF under the provincial health insurance plan, with a sliding scale of tax credits. As well, Bill 20 further reduces the number of embryos that may be transferred into a woman per cycle: one embryo in women 36 years of age or under, and up to 2 embryos in women between the ages of 37-42.
In response to the government’s decision to amend public funding of IVF, Dr. Bissonette (President of the Quebec Fertility and Andrology Society) and Dr. Mahutte (President of the Canadian Fertility and Andrology Society) issued a press release on November 28 condemning this decision. Therein, they celebrate Quebec’s success in dramatically reducing the rate of multiple pregnancies and denounce the government’s decision to continue funding artificial insemination, which is responsible for the highest number of multiple pregnancies. It is misleading to suggest (even indirectly), however, that reducing the rate of multiple pregnancies is reason enough to maintain public funding of IVF.
Since at least 2006, clinicians and advocacy groups have suggested that funding IVF reduces the multiple pregnancy rate. This is inaccurate, however. Reducing the multiple pregnancy rate does not depend on public funding, rather, it depends on the practice of evidence based medicine. Evidence based medicine is about “integrating individual clinical expertise and the best external evidence,” regardless of who pays.
So, what is the current best evidence on the number of embryos physicians should transfer per IVF cycle? According to guidelines issued in April 2010, by the Joint Society of Obstetricians and Gynaecologists of Canada –Canadian Fertility and Andrology Society Clinical Practice Guidelines Committee, best available evidence supports the increased use of single embryo transfer in good-prognosis patients in order to avoid multiple pregnancies. Good prognosis patients are women 35 or under (and sometimes 36 and 37), in their first or second attempt at IVF with at least two good quality (preferably blastocyst stage) embryos. In select cases, where the chance of pregnancy is poor, the Committee allows that it is reasonable to proceed with double embryo transfer to increase the chance of a live birth.
In an ideal world, all Canadian IVF docs would willingly follow these clinical practice guidelines. If they did so, there would be country wide reductions in the multiple pregnancy rate similar those achieved in Quebec. We have not witnessed similar reductions in other provinces not because of the absence of public funding, but because of the absence of will and an absence legislation mandating something close to evidence based medicine.
To be clear, the reduction in multiple pregnancies in Quebec is not the result of public funding, but rather the result of legal limits on the number of embryos that can be transferred per cycle. Such limits were in the original 2010 regulations introducing IVF funding, and they are in the 2014 regulations amending IVF funding. It follows that whether IVF is funded through the Quebec health insurance program (2010 regulations) or through tax credits (2014 regulations), the number of multiple pregnancies will remain low. To make the point most forcefully, if Quebec had cancelled and not merely amended IVF funding, but still had legal limits on the number of embryos that could be transferred, the number of multiples would remain low.
An earlier version of this commentary appeared on Impact Ethics.