Ethical Considerations in Publicly Funded Fertility Treatment

Due to the high cost of in vitro fertilization (IVF), fertility treatment is out of reach for many individuals who must self-pay for assisted reproduction therapy.¹ However, infertility is increasingly recognized as a disease, leading some countries, such as Canada and New Zealand, to provide government funding to cover fertility treatment.^1-3 Public funding of IVF raises new questions regarding who should receive access to IVF treatment and how access should be provided.

Endocrinology Advisor spoke with Michael H. Dahan, MD, from McGill University Health Centre in Quebec, Canada; Claire Jones, MD, from Mount Sinai Fertility of Sinai Health System in Toronto, Canada; and Kelton Tremellen, MBBS(Hons), PhD, from Flinders University, Adelaide, Australia, about the ethical issues associated with government-funded IVF in the Canadian provinces of Quebec and Ontario and in New Zealand.

According to Dr Dahan, providing publicly funded IVF treatment carries several major advantages. “A major barrier to IVF treatment is inequity based on income. There is a group of haves who can get fertility care and a group of have-nots who cannot get care. By funding IVF, you remove this inequity,” he said.

Another important benefit of expanding access to IVF is that doing so can significantly increase the population birth rate. When Quebec provided government funding for IVF from 2010 to 2015, the provincial birth rate increased significantly — by almost 1%.²

“Increasing the birth rate is important, because birth rates in our society today are so low.” Dr Dahan said. “For the population to maintain itself, you need more than 2.2 children born per couple. The current birth rate in Quebec is 1.5 per couple.”

Dr Dahan also noted that in industrialized countries people are waiting longer to have children, which may lead to an increasing need for fertility treatment. “You don’t want people to feel like they need to make a choice. For example, some women may feel like they need to decide between their career or starting a family. I think you can remove some of that pressure by covering things like fertility care or egg freezing.”

While programs that provide public funding for IVF have important benefits, they are vulnerable to changes in policy concerning the healthcare budget, Dr Dahan said. Quebec started providing IVF coverage in 2010, but the program was discontinued in 2015 when a new government administration reallocated funds to other areas, including cancer care. The 2014 Advisory Report on Assisted Reproduction in Québec cited cost control as another concern: the yearly budget for IVF coverage ranged from $30 million to $47 million, but annual costs exceeded $60 million.⁴

The same year that the Quebec program ended, Ontario launched the Ontario Fertility Program (OFP). While Quebec did not restrict IVF funding by patient age or total number of IVF cycles per year, the OFP limits the overall number of cycles covered to 5000 per year. Limiting the number of IVF cycles performed per year may help control costs, but it also raises new ethical questions about access to fertility treatment.¹

Under the OFP, individual fertility clinics were responsible for establishing criteria for determining which patients should receive the highest priority for IVF treatment. In a recent study, Dr Jones and Tamas Gotz, MD, of the department of obstetrics and gynaecology, University of Toronto, Toronto, Ontario. Canada, found that clinics in Ontario used a variety of methods to prioritize patients seeking fertility treatment. Of the 22 clinics surveyed, 11 prioritized patients based on multiple patient factors; 8 prioritized patients on a first-come, first-served basis; 2 chose patients via a lottery; and 1 clinic declined to respond.¹

“The stated goal of the OFP program was to increase access to IVF services,” Dr Jones said. “If physicians made this the priority, then they should be prioritizing patients who would otherwise be unable to access care — in other words, patients of lower socioeconomic status. Otherwise, all patients should be allowed to access care equally, regardless of prognosis.”

However, Dr Jones noted that putting this concept into practice is often difficult, since physicians cannot easily determine a patient’s socioeconomic status. Instead, some physicians may prioritize patients whose chances of success will significantly worsen over time compared with other patients with a better prognosis. Other physicians may focus on patients with the greatest chance of success, which may lead to a higher birth rate under the OFP and, consequently, continued funding for the program.

“Many physicians felt conflicted about prioritizing poorer prognosis patients who need to access IVF services sooner before the opportunity is lost over better prognosis patients who are more likely to successfully achieve a pregnancy from IVF,” Dr Jones said. 

“In order to mitigate this conflict, most clinics have since moved to a first-come first-served model since our study was published, although some clinics still have a system allowing for exceptional cases to be brought forward to be considered to go ahead of the queue,” she said. 

New Zealand also provides government funding for IVF, but it restricts coverage to women with a body mass index (BMI) <32 kg/m²;³ guidelines published by The Royal Australian and New Zealand College of Obstetricians and Gynaecologists state that BMI ≥35 kg/m² should be considered a contraindication to IVF.⁵ The rationale for these policies is that obesity is associated with an increased risk of miscarriage and pregnancy complications.³ But does the evidence support barring obese women from fertility treatment? 

According to Professor Tremellen, while morbidly obese women (BMI 35 to 40 kg/m²) have lower live birth rates per IVF cycle than women of normal weight, the difference is small — only 16% in one large American registry.⁶

“This small decline in IVF efficiency is certainly not enough to mandate a blanket ban on severely obese women accessing IVF,” Professor Tremellen said. “If such a minor decline in IVF efficiency is considered justification for blocking access to IVF treatment, then we should not be allowing any woman older than 35 years of age to access treatment as this is when IVF success rates start to fall by a similar magnitude. Obviously, such an argument is not sustainable.”

In addition, the BMI restriction for IVF access essentially mandates that women must lose weight prior to pursuing fertility treatment. According to Professor Tremellen,  weight loss is difficult to achieve and physicians may be setting obese women up for further failure by requiring them to lose weight to be eligible for IVF. “Two recent randomized controlled studies have reported that mandated periods of attempted weight loss prior to IVF failed to improve any IVF- or pregnancy-related outcome significantly,”^7,8 he said.

“Having a family is a basic human right so fertility treatment should be made freely available for anyone with infertility, unless there is clear evidence that they would be unable to effectively parent a child,” Professor Tremellen said. “However, as obesity per se does not reduce the effectiveness to parent, we cannot withhold treatment on this basis.”

Dr Dahan and Dr Jones report no relevant disclosures. Professor Tremellen reports financial relationships with Monash IVF.

References

1. Gotz T, Jones C. Prioritization of patients for publicly funded IVF in Ontario: a survey of fertility centres. J Obstet Gynaecol Can. 2017;39(3):138-144. doi:10.1016/j.jogc.2016.11.011.
2. Shaulov T, Belisle S, Dahan MH. Public health implications of a North American publicly funded in vitro fertilization program; lessons to learn. J Assist Reprod Genet. 2015;32(9):1385-1393. doi:10.1007/s10815-015-0530-2. 
3. Tremellen K, Wilkinson D, Savulescu J. Should obese women’s access to assisted fertility treatment be limited? A scientific and ethical analysis [published online March 16, 2017]. Aust N Z J Obstet Gynaecol. doi:10.1111/ajo.12600. 
4. Blancquaert I, Cleret de Langavant G, Ganache I. Summary advisory on assisted reproduction in Quebec. Commissaire a la sante et au biene-etre Quebec; 2014. www.csbe.gouv.qc.ca/fileadmin/www/2014/Procreation_assistee/CSBE_PA_SummaryAdvisory_2014.pdf. Accessed August 22, 2017.
5. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Ovarian stimulation in assisted reproduction. C-Gyn 2; 2014. www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women’s%20Health/Statement%20and%20guidelines/Clinical%20-%20Gynaecology/Ovarian-Stimulation-in-infertility-(C-Gyn-2)-Review-Mar-14.pdf?ext=.pdf. Accessed August 22, 2017.
6. Provost MP, Acharya KS, Acharya CR, et al. Pregnancy outcomes decline with increasing body mass index: analysis of 239,127 fresh autologous in vitro fertilization cycles from the 2008-2010 Society for Assisted Reproductive Technology registry. Fertil Steril. 2016;105(3):663-669. doi:10.1016/j.fertnstert.2015.11.008.
7. Mutsaerts MA, van Oers AM, Groen H, et al. Randomized trial of a lifestyle program in obese infertile women.s N Engl J Med. 2016;374(20):1942-1953. doi:10.1056/NEJMoa1505297.
8. Einarsson S, Bergh C, Friberg B, et al. Weight reduction intervention for obese infertile women prior to IVF: a randomized controlled trial. Human Reproduction. 2017;32(8):1621-1630. doi:10.1093/humrep/dex235.