After more than a year of anticipation, the government of Ontario announced earlier this month its intention to expand public funding for in vitro fertilization (IVF). Those needing IVF in the province have eagerly awaited details about the program, all the while weighing the risks of waiting longer for care — a woman’s fertility declines over time — against the financial benefits of receiving funded access. While Ontario has long funded three cycles of IVF for women with bilateral fallopian tube blockages, the new program will also fund one cycle of IVF for all other women living in the province under the age of 43. If any embryos are left over from that cycle, which would be frozen in storage, the province will also fund the subsequent use of those embryos one at a time.
But despite the funding program’s important goals, from reducing multiple births to increasing access to care, the way it has been introduced falls short of achieving either — and misses a few key issues.
The new funding program’s stated goals are twofold. First, the province aims to reduce the number of multiple births, such as twins or triplets, that may result when more than one embryo is implanted during an IVF treatment. While multiple births involve important health risks for both mother and child, in addition to increased costs to the health care system, multiple embryo implantation is often chosen in order to improve the chance of pregnancy or to have more than one child at a time, ostensibly to avoid the time, difficulty and expense of undergoing IVF again. The province has argued that the provision of funding gives it impetus to mandate embryo transfer into the uterus one-by-one. This strategy has certainly worked in Quebec, where, according to researchers studying the program, the public funding of IVF enabled an “aggressive use” of single-embryo transfer.
Ontario’s program is also intended to improve access to this expensive health care intervention. Research has suggested that Quebec’s current program, which includes three cycles of IVF, has led to increased diversity in the ethnicity, socio-economic status and education level of those accessing IVF services. (Although it should be noted that those accessing IVF clinics in Quebec, as elsewhere, continue to be predominantly white, older, wealthier and more educated than the general population).
However, Ontario’s IVF plans miss a number of pressing issues when it comes to reproductive assistance as it exists in Ontario’s medical landscape today. As a method to reduce multiple births, such funding is unnecessary in Ontario as in Quebec. Single-embryo transfer is widely recognized as the best practice for IVF, and should be practiced everywhere, regardless of who foots the bill. The assumption that single-embryo transfer needs to be tied to public funding is also concerning, as it demonstrates government reticence to simply regulate or otherwise intervene in IVF and other reproductive technologies.
There are also a wide range of other areas related to assisted reproduction that the province can, and should, be regulating that are not tied to the funding of IVF. Given that assisted reproductive technologies in Ontario are largely delivered in private-for-profit clinics and without substantive regulation, the province should be mandating data collection about the delivery of reproductive technologies to ensure that clinics are meeting a high quality of care. It should also establish practice guidelines to identify the parameters of that care. These recommendations were amongst those made in the 2009 report of an Expert Panel on Infertility and Adoption (convened by the government of Ontario), yet there has been no indication that such regulations will occur under the new funding program.
As for the program’s potential to improve access to care, it is indeed likely that more people will be able to access IVF with the new funding, but this financial assistance will only prove useful to some. Whereas Quebec provided a tax break for medications and direct funding for embryo freezing and storage, Ontario has made clear it will not be funding medications or embryo freezing and storage in any way. This is no small matter: IVF medication is expensive, at an estimated price tag of $3,000 to $5,000 per cycle, and some of these medications are not usually insured under private pharmacare plans. For poorer Ontarians, these costs will continue to make access impossible. Those without the funds to freeze and store embryos (and therefore unable to pursue future embryo transfers) will be put in the precarious position of hoping against hope that their one funded cycle will work.
Overall, the expansion of Ontario’s public funding program at once goes too far, and yet not far enough. Since the province has announced so little about the funding program thus far, there is still hope that these concerns will be resolved, and perhaps a broader regulatory framework or differentiated subsidies will be made available. As the Government of Ontario moves forward with plans for implementation, it must grapple with how it will use the province’s health care resources to achieve the program’s goals in ways that are at once prudent and fair to Ontarians.
Alana Cattapan is a CIHR Postdoctoral Fellow in the Faculty of Medicine at Dalhousie University. Her research examines the intersections of gender, public policy, and assisted reproduction in Canada.
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