How public funding has changed IVF in Ontario
Tom Hannam saw a change in his patients after the Ontario Fertility Program (OFP) was introduced three years ago. It wasn’t a clinical change; it was more emotional. The OFP allowed people to see in vitro fertilization as a “real thing,” says Hannam, who founded and runs one of Ontario’s largest fertility clinics, “something that they really could pursue for themselves in their lives.”
IVF involves the harvesting, extraction and fertilization of human eggs, followed by the implantation of embryos into the uterus. Shortly after the first IVF-conceived baby was born in Canada in 1983, Ontario began funding the procedure. Then in 1994, the province de-insured IVF, in part because it did not consider it to be medically necessary (except for women who had complete bilateral anatomical fallopian tube blockage, for whom three cycles of IVF continued to be covered).
In the subsequent two decades, the use of private fertility services for IVF treatment proliferated in Canada. (The national infertility rate is estimated to be about 16 percent—one in every six couples experiences infertility, and there are many people who are single or in same-sex relationship who rely on assisted reproductive technology to have a baby.) In 2001, 22 fertility clinics in Canada initiated 7,884 IVF cycles; in 2017, 36 clinics initiated 33,092 cycles. In the past five years alone, there has been a more than 30 percent increase in the number of IVF cycles initiated in Canada. Currently, between one and two percent of live births in this country are the result of fertility treatments (though not exclusively IVF).
Alongside this growth, there has been ongoing debate over whether or not IVF should be funded. In 2009, an expert panel convened by the government of Ontario strongly recommended that the province significantly expand funding for IVF. The panel found that the high cost of private IVF was the biggest barrier to people wishing to build their families through assisted reproduction, and that it also contributed to elevated rates of multiple births (as patients often opted for multiple-egg transfers).
In 2015, Ontario delisted IVF from the Ontario Health Insurance Plan (or OHIP, the public insurance plan which covers doctors’ fees) and moved it to a separate program, the OFP, whose overall budget is $70 million annually. (This allotment is also for intrauterine insemination, or IUI, which was previously covered quite expansively under OHIP, and which has also been moved to the OFP.)
The OFP covers one IVF cycle per lifetime for women who have an OHIP card and are under 43 years old, and for single men or men in same-sex partnerships of any age who have an OHIP card. A cycle is defined as starting with ovarian stimulation and ending with the transfer of all embryos resulting from fertilization until either a pregnancy results or the embryos run out. The OFP only allows single-embryo transfers. This is meant as both a safety and money-saving measure, aimed at cutting the roughly 30 percent multiple-birth rate that results from IVF. Most paying patients opt for multiple embryo transfers because they increase the likelihood of a pregnancy. But they also increase the likelihood of multiple births, which in turn can lead to low-birth weights and consequent hospitalizations.
OFP funding is allocated to fertility clinics according to the volume of patients they treat, and the clinics are responsible for determining eligibility. The funding is limited to 5,000 cycles annually—this means that if more than 5,000 eligible people apply for it in a given year, some will receive it, and some won’t.
Those who don’t, can opt to pay for it out of pocket, which amounts to between $10,000 and $20,000 per cycle (not including the necessary drugs). And this is what makes OFP so unusual: It renders IVF a service that is both publicly and privately available—to the same people—in Ontario.
Impact of OFP for patients
Taunya Johnston and her husband, Rob spent more than $35,000 trying to get pregnant. “We sold our house,” says Johnston. “I took time away from work and from school. Everything we could think of that would possibly give us the hope of having a child, we were doing.” The couple conceived their daughter through IVF after being in fertility treatment for five years. She was born five years ago.
Johnston and her husband tried for a second pregnancy with the remaining frozen embryos, but it didn’t happen. And just when they were thinking about how they could afford to pay for a new cycle—Taunya, now 34, is a college professor and Rob, who is 37, is an insurance protection specialist—their fertility clinic called, asking whether they wanted to sign up as potential candidates for a funded cycle. They started one in January 2016.
“It was a completely different experience,” says Johnston, who is on the board of Conceivable Dreams, a fertility advocacy group in Ontario. When you’re paying out of pocket, she says, “You get that desperation of, ‘Oh my goodness, we can’t afford to keep paying for this, this has to work.’ That’s not helpful stress.”
Johnston and her husband had five embryos from the funded cycle—two were transferred but ended in loss; one was an unsuccessful transfer. With the fourth, they conceived their son, who was born in October 2017. “[The funded cycle] gave us a feeling of validity, that this is something that’s important,” she says. “We were prepared for the possibility that the cycle wouldn’t work. But we were still so grateful that we had the opportunity to try.”
In some ways, the OFP is more inclusive than funded IVF was 20 years ago, when providers had the power to withhold the procedure (from people they thought would make poor parents, for example). It is available to single people of any gender and to non-heterosexual couples (men in same-sex partnerships are effectively eligible for two cycles). But for people without means—and especially for those without employee drug coverage—the cost of IVF remains prohibitive. Clinics sometimes recommend corollary treatments such as genetic testing which aren’t covered, and which can run into the thousands of dollars.
And then there’s geography. Fifty clinics participate in the OFP but only about half actually perform IVF (with the rest offering other fertility treatment services such as IUI and IVF monitoring), and most of these are south of Barrie.
It is noteworthy that there is no legislation governing assisted reproduction in Ontario, no mechanism for quality assurance in this sector, and no requirement for fertility clinics to report outcomes (though many clinics from across Canada voluntarily send data for measures such as treatment cycles completed, clinical pregnancies, and multiple pregnancies to the Canadian Assisted Reproductive Technologies Register, or CARTR). The need for better regulation and data collection was addressed by the advisory group appointed in 2014 to help the province set criteria for the OFP.
When the OFP first came in, more people applied for funded cycles than there were funded cycles available—clinics had to establish wait lists, and some of those wait lists were three years long. In effect, there are people who have been waiting for funding since the program started; some have opted to pay out of pocket rather than wait (after age 35, a woman’s fertility decreases significantly every year).
Impact of OFP for providers
Despite some skepticism among fertility physicians as to how the OFP would work, most are highly supportive of the program, says Shawn Winsor, a bioethicist who conducted surveys of patient and provider perceptions of the program with respect to quality of and access to care. (The results will be out later this year.) Tom Hannam says: “You can only imagine how great it was to be able to offer [people] the right care, the care that they needed, without finances being as much of a barrier.”
But the volume of people who applied for a funded cycle caught fertility clinics off-guard, says Winsor, who also co-founded ethics programs at fertility clinics in Toronto and Mississauga. “It was like a floodgate opened. And my sense is that some clinics could have used more time to develop a more effective, robust process [for managing their wait list].”
A survey of how fertility centres prioritized patients for funded IVF during the first three months of the program found that of the 22 (out of 25) that responded, eight managed their wait lists on a first-come, first-served basis; two used a lottery; and 11 used multiple factors, including age and how long they had been patients of the clinic. The survey asked the clinics who was involved in deciding what process to use. All 18 clinics that responded reported that physicians were involved; 15 included other members of their teams (nurses, embryologists, social workers and admin staff); six consulted ethicists; and five consulted lawyers. None of the clinics reported consulting current or past patients.
Hannam originally used a lottery to determine when people would receive funding. “Because it was super fair,” he says. “And it was a complete nightmare. It was horrible. It was fair to a fault; it was joyless. No one knew what to do. ‘Oh, your name didn’t come up—we’re doing another draw in four months, good luck.’ So I just moved to a regular old first-come, first-served.”
The wait lists have improved considerably, says Winsor. “There was a backlog originally,” he says. “People worked very hard [to reduce the wait lists]. Some patients dropped out, but a lot of patients have been seen.”
But wait times vary clinic to clinic. Hannam says his is six years long—“I was getting calls this summer from colleagues at competing clinics asking if we had patients for them,” he says. He would prefer to see a system whereby funding was assigned to patients rather than clinics. That way, he says, the patients can then choose the location they want to go to.
This may not do away with wait lists if the number of funded cycles remains finite, but it would give people more control over where they receive treatment. People we interviewed said they chose to receive IVF both at clinics with longer wait times and further away from home on the basis of their comfort level with the setting and staff. Fertility treatment is a very intimate and sensitive process, says Johnston. With respect to clinic choice, she says, “Peace of mind is very, very important.”
Shortly before this article went to press, the Globe and Mail reported that the Ontario government has indicated that it plans to continue funding IVF through the OFP indefinitely.