Mandating Elective Single Embryo Transfer: Should Ontario and the rest of Canada follow Québec’s lead?

Rather than include this short brief in my Writing Samples, I thought I would just post it here as a blog post. It was written in 2012 while I was working under the direction of Dr. Kerry Bowman (Bioethicist at Mount Sinai Hospital).

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Mandating Elective Single Embryo Transfer: Should Ontario and the rest of Canada follow Québec’s lead?

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This brief addresses the following question:

Can we nationally or provincially say we are going with single embryo transfer, is it justifiable?

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Before In-vitro fertilization (IVF) couples who were infertile were left with few options, typically only that of adoption. With the introduction of IVF those same couples now have a chance at conceiving a child of “their own”. As such, IVF has been heralded as a major breakthrough in the health sciences. Despite its popularity there are major concerns associated with IVF derived from the practice of implanting multiple embryos at a time to increase the chances of conception. With multiple implantations the odds of having twins and triplets are greatly increased. However, unlike what has been often covered in day-time talk shows, these pregnancies are not always the blessing of a large family which they are shown to be. Typically, multiple births including that of twins are fraught with a higher risk of premature birth, cerebral palsy, respiratory diseases, blindness, deafness and death.

With the costly complications of multiple births, many countries have developed state funded policies of IVF which incorporate in them that IVF coverage is to be done with elective single embryo transfer (eSET). With eSET the chances of a multiple pregnancy are drastically reduced. These policies ensure that IVF is available to all in need while at the same time take into consideration, unlike the private sector, the costs both economic and emotional of multiple births.

Despite a positive outlook in countries such as Sweden, Canada (with the exception of Québec which has been publicly funding IVF treatments since August of 2010) is one of the few developed countries not to fund IVF. The program in Québec includes an eSET policy and is said to result in savings for Québec tax payers due to an 83% reduction in multiple birth pregnancies (27.2% to 5.2%): 77% fewer twins (twin gestation rates have dropped from 30% to 3.8%) and 95% fewer triplets. Additionally, there are approximately 1,368 fewer low-birth-weight babies. With Québec being seen as a success by many in the healthcare community through published articles supporting its implementation, the question raised is whether other provinces such as Ontario should follow Québec’s lead.

A new survey has shown that regardless of political affiliation, Ontarians support OHIP coverage of IVF. Three-quarters of Ontarians polled 25 years and older support a policy of funding IVF similar to Québec’s. With Ontario having one of the highest rates in the country of multiple births through IVF, and a need to control healthcare costs, Ontario should realize that what has worked in Québec can work in Ontario. Through OHIP funding for IVF the rate of multiples and their high cost to the healthcare system can be reduced. An expert panel came to the conclusion that the province could save $400-$550 million in healthcare costs over the next 10 years by a policy of eSET, largely through the reduced number of multiple births.

One concern with the policy in Québec is that eSET is seen as decreasing the chances of a couple having any child at all. At the moment the high cost of the procedure encourages implantation of two or more embryos in an attempt to maximize the chances of conceiving. This is in spite of the substantial medical risks for their babies and themselves. The largest trouble with an eSET policy is the parallel 40% drop in pregnancy rates. An eSET policy translates into not only fewer multiple births but fewer births altogether. For those who want to get pregnant as quickly and cheaply as possible, there seems to be good reason still for allowing the old method to continue. This would avoid an apparent penalization of many couples not being able to have children and who can afford IVF treatment as it is now offered.

Another concern is that an eSET policy similar to that of Québec’s interferes with the patient’s right to self-determination or “to choose”. This is equally true to the real risks of multiple births borne by the patient and child. The decision it is said rests with the patient not the government through an intrusion into healthcare decisions. As implemented in Québec there may be room for exemptions to eSET, where doctor-patient decision making has deemed a deviation appropriate. This would seemingly address the self-determination objection to a reasonable point by offering “wiggle room”.

 

The objections raised are solely for those who can afford the treatment. By disallowing an Ontario policy similar to that of Québec’s however, the objections raised by those who cannot afford IVF as things now stand but would be given access under a change, are not given precedence. In 2008, Ontario formed an 11-member expert panel on infertility and adoption with the objective to report on fertility treatments and to find ways to make it more accessible and affordable. A year later the panel reported that OHIP should pay for three IVF cycles for Ontarians under 42 seeking treatment.

 

When one weighs the economic and emotional costs of IVF as it is now practiced in Ontario with the costs of eSET and accompanying reduction of multiple births, we come to the conclusion that as fertility experts are saying, eSET is the way of the future. Consideration is to be given to the fact that some may in the end not conceive. At the same time equal consideration must be given to those who cannot currently afford IVF treatment. An even greater consideration absolutely must be given to the reduction of multiple births and the associated emotional and economic costs they bare. Looking at emotional suffering alone and forgetting about economic costs, it is important to note that the emotional suffering of those who have tried eSET and remain unsuccessful does not outweigh the equally real suffering of infertile people who cannot afford IVF treatments along with the emotional trauma which can be accompanied by multiple births.

 

If all of Canada implemented a policy similar to Québec, there would be as many as 840 fewer babies admitted to the Neonatal Intensive Care Unit, 40 deaths would be avoided, there would be 46 fewer brain injuries, and a total of 42,400 fewer days of NICU hospitalization. Such a policy saves lives and money wherever it is implemented.

 

Due to the tremendous reduction in multiple births and the economic and emotional costs associated with them, in addition to the emotional costs associated with being unable to afford IVF treatment, we can justifiably say that Ontario should implement an IVF policy similar to that of the one Québec did in August of 2010.