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CADTH » Search All Products » Environmental Scanning » Health Technology Update » Issue 10 - March 2009 » Assisted Reproductive Technologies in Canada

Assisted Reproductive Technologies in Canada

Assisted reproductive technologies (ART) are a policy concern in Canada due to the continued prevalence of infertility and the recent rise in the number of multiple pregnancies. The issue of access, funding, and the regulation of ART’s —
in vitro fertilization (IVF) in particular —  has generated considerable debate.

The Issue

Currently, universal IVF is not publically funded in Canada. Only 15 % of couples affected by infertility can afford IVF treatment;1 consequently, they turn to cheaper fertility treatments that are believed to significantly increase the rate of multiple pregnancies (e.g., two or more babies). 2,3

There are immediate and long-term health complications associated with multiple  pregnancies, such as an increased risk of fetal or neonatal mortality, preterm birth and low birth rate,4 as well as mental5 and physical6defects. Maternal complications, such as preeclampsia, gestational diabetes, placental previa, placental abruption, and caesarean delivery are also associated with multiple pregnancies. 

IVF with single embryo transfer (SET) has been shown to almost completely eliminate multiple pregnancies.5 There is a belief that the public funding of IVF with SET is a more sustainable strategy, as it offsets the downstream costs associated with the ramifications of multiple pregnancies. However, many couples prefer dual embryo transfer because it maximizes the possibility of pregnancy whilst potentially eliminating the need for subsequent costly IVF cycles.

More than 30% of ART pregnancies are multiples and over 50% of all ART neonates are the product of multiple gestations.4,7 This represents a significant short- and long-term health and monetary concern.

How it Works

Assisted reproductive technologies are infertility treatments that involve fertility drugs and the management of eggs, sperm, and/or embryos outside of the human body. This typically includes IVF and IVF- related procedures such as intracytoplasmic sperm injection. Some definitions also include intrauterine insemination.5

Conventional IVF treatment involves the stimulation of the ovaries using hormonal medications, the retrieval of eggs from the ovaries, the fertilization of the eggs outside the body, and the transfer of the resulting embryo into the uterus.

Provincial Activity

In December of 2008, Quebec’s Ministry of Health pledged to reimburse the cost of IVF treatment. In 2009, under a new plan, a minimum of two cycles of IVF will be remunerated in Quebec.8

Quebec will be the only province to reimburse universal IVF treatment. Canada’s current access to publicly funded IVF is limited to women living in Ontario who have bilaterally blocked fallopian tubes.

In response to the mounting concerns about infertility, Ontario appointed an expert panel to examine options for people facing reproductive challenges. In the summer of 2009, the panel will publish recommendations on ways to increase the accessibility and affordability of fertility treatments.8

At this time, Alberta is considering policy options with regard to ART regulation and the funding of fertility treatments. Other jurisdictions may revisit their policies in light of Quebec’s decision.

Who Might Benefit

Infertility is a significant problem in Canada, affecting about 8.5% to 16% of couples of reproductive age.5

Regulatory Status

In 2004, the federal government enacted legislation to regulate assisted reproduction.  The Assisted Human Reproduction Act, which governs the clinical and research activities of medically assisted human reproduction, identifies activities that either are prohibited or are subject to regulation.

In 2006, Assisted Human Reproduction Canada was established to implement and enforce the Act’s principles.

The constitutional validity of the Act has come under attack from several provinces. In 2008, the Quebec Court of Appeal challenged several provisions of the Act, contesting that they are not matters of criminal justice and do not put the public’s health at risk and, therefore, should be governed by provincial legislation.


The Supreme Court of Canada will hear the matter in April of this year. If the Quebec judgment is confirmed, sections of the Act could be handled by each provincial jurisdiction.

Cost

One cycle of IVF costs approximately $7,750 to $12, 250 ($250 for semen analysis, $2,500 to $7,000 for medications, and $5,000 for IVF).9 In comparison, IUI costs approximately $450, in addition to the cost of medications ($27-$2,500).9

Evidence

Two Canadian technology assessments5,10 have reported on IVF and multiple pregnancies, the most recent of which, from the Institute of Health Economics, will be published early this year. The purpose of this report was to clarify the cost burden of multiple pregnancies on health resources and potential cost impacts of ARTs in Alberta.

According to Dr. Anderson Chuck, the lead author of the Institute of Health Economics report, the evidence indicates that reducing the number of embryos transferred per IVF cycle to a SET reduces the number of multiple births, health complications, and costs associated with multiple gestations. Transferring one embryo was regarded as being less costly than transferring two embryos; however, the effectiveness of SET was closely related to a woman’s age. In women younger than 37, transferring one embryo was noted as being as effective as transferring two embryos. In women older than 37, SET was less effective than transferring two embryos and, subsequently, more IVF cycles are required to achieve comparable birth rates. The evidence from this report indicates that reimbursing IVF procedures which transfer fewer embryos was associated with a decrease in the number of multiple births and health services costs. However, a greater number of single embryo transfer cycles may be required to produce equivalent results (i.e., transferring more than one embryo per in vitro fertilization cycle). Hence, savings from reduced multiple pregnancies and births will be offset by the number of additional single embryo transfer cycles needed to produce acceptable birth rates and health outcomes.

A 2006 assessment of IVF treatment and its role in reducing the rate of multiple births was published by the Ontario Ministry of Health and Long-Term Care. This clinical- and cost-effectiveness assessment concluded that IVF-SET is an effective treatment for infertility that avoids multiple pregnancies. However, an Ontario-based economic analysis included in the assessment showed that reduced costs associated with a reduction in multiple pregnancies after IVF-SET did not compensate for the cost of universal IVF-SET coverage; furthermore, the province currently funds intrauterine insemination, which has been shown to be as effective as IVF for certain types of infertility and is significantly less expensive.5

A newer enhanced IVF technology is being developed that is intended to double the chance of conception while reducing the prospect of multiple pregnancies. The technology, known as array comparative genomic hybridization, is in the early stages of development but it could potentially make the current ART landscape obsolete.

National Canadian Guidelines and Recommendations

References

1. Nisker J. JOGC 2008;30(5):425-31.
2. Bissonnette F, et al. Reprod Biomed Online 2007;14(6):773-90.
3. Human assisted reproduction live birth rates for Canada. Montreal: Canadian Fertility and Andrology Society; 2008. Available: http://cfas.cfwebtools.com/index.cfm?objectid=FB99277D-FF33-EC88-991F86750424B6A7
4. Gerris J, et al. J Obstet Gynaecol 2005;5(1):26-47.
5. Medical Advisory Secretariat. In vitro fertilization and multiple pregnancies. Toronto: Ontario Health Technology Advisory Committee; 2006. Available: http://www.health.gov.on.ca/english/providers/program/ohtac/tech/reviews/pdf/rev_ivf_101906.pdf
6. El-Chaar D, et al. Fertil Steril 2008.
7. Reddy UM, et al. Obstet Gynecol 2007;109(4):967-77.
8. Talaga T. Toronto Star 2008 Dec 27.
9. Seeking life through ART: the cost of treatment. London (ON): London Health Sciences Centre; 2009. Available: https://www.lhsc.on.ca/programs/infertility/
10. Chuck A. Assisted reproductive technologies: Economic evaluation [in press]. Edmonton: Institute of Health Economics; 2009.