Within minutes of Ontario’s recent announcement that it will begin funding, in December, in vitro fertilization (IVF) treatments for women up to the age of 43, Canadians tweeted their reaction: “So many will shed tears of joy today! #thankyou #ontario! #ohip4ivf #ivf4on #ivf” one woman wrote from her account, where she describes herself as a “wife and a mom to my 3 fur babies” in Guelph, Ont. “Someday I hope to be a mom to a human too!”
It’s impossible not to feel happy for the thousands of women and men for whom IVF is their best or last option for conceiving and eventually raising a child of their own. But the celebration is tempered by the situation unravelling in Quebec, where public funding for IVF faces imminent extinction because the government says it can’t afford the program in future. There, tears are also being shed—but by individuals who see their chances of having a baby fading fast.
While Ontario’s promise to invest another $50 million a year to expand access to IVF treatments—on top of the $20 million it already spends on assisted-reproduction services—has been lauded by many patients and doctors, now the focus is shifting to determining how to maximize the funds. “The next step is: Really, how do you actually spend that money?” says Dr. Clifford Librach, chair of the reproductive biology section of the Ontario Medical Association, and director of Create Fertility Centre in Toronto. “We can’t do what Quebec did. We have to learn from it.”
Last November, the Quebec government unveiled Bill 20, which proposes to radically change one of the world’s most progressive and effective fertility programs by restricting it in the name of cost-cutting. It would replace the current program, which began in 2010 and funds three cycles of IVF for any woman, regardless of her age and other factors.
Bill 20, which may be voted on as early as this fall, would instead offer an income-based tax credit of 20 to 80 per cent for IVF treatment, which typically costs $10,000 per cycle—except for women over the age of 42, or couples in which one partner has had tubal ligation or a vasectomy, or who have already had a child, explains Dr. Neal Mahutte, president of the Canadian Fertility and Andrology Society (CFAS), and medical director of the Montreal Fertility Clinic.
Like many fertility specialists, Mahutte is mystified by Bill 20, because Quebec’s current program has achieved every goal the province set. It has improved access to IVF across age and income brackets; demand quadrupled over the first year alone. It has reduced the multiple pregnancy rate, to seven per cent in 2013, the lowest rate in North America and among the lowest in the world. And the annual cost of the program was $72 million in 2014—several million dollars less than the government had initially forecast. “So, you look at it from that lens, and you say, ‘What is going on?’ ” says Mahutte.
Ironically, the success of the Quebec program may be the reason for its demise. It is so inclusive that observers say it has been recast as unsustainable by the new provincial government since last year, when it took power.
And it may be, in fact. A report produced in March by Mahutte and other fertility specialists in Quebec reveals a stunning snapshot of the rising cost per baby, according to the age of the woman receiving IVF treatment. (The data pertain to the period between August 2010 and December 2012.) For a woman under the age of 35 who had a baby using IVF, her treatment cost $17,919. For a woman aged 35-39, the cost was $27,493. By age 40, the amount rose to $43,153. At age 41, the cost was $62,290. For a 42-year-old, it jumped to $79,100. By age 43, the cost for one woman to have a baby using IVF totalled a whopping $103,994.
By comparison, the number of babies born varied dramatically by maternal age, as well. The youngest group of women (those under 35) receiving IVF produced the most babies: 1,304; the oldest group of women (age 43) produced the least: 20. Women under 35 also accounted for the most number of IVF cycles undertaken (5,503), and women age 43 accounted for the least (488).
In essence, “The older the patient, the fewer the babies, and the higher the cost per cycle” of IVF treatments, says Dr. Jeffrey Roberts, co-director of the Pacific Centre for Reproductive Medicine in Vancouver, and a national director of CFAS. Adding to the expense, older women often require more cycles of IVF, which include stimulation of the ovaries, egg retrieval and embryo transfer.
The astounding cost difference of IVF treatment by age in Quebec has not deterred Ontario in its decision to fund women up to age 43. But the province has implemented other criteria that may offset the expense, including limiting a woman to one IVF cycle in her lifetime—rather than three fresh cycles per baby, as is the case in Quebec.
What’s more, Ontario defines a “cycle” as one egg retrieval; in Quebec, a cycle is defined as an egg retrieval that results in an embryo transfer, which has resulted in some “poor-prognosis” patients having more than three egg retrievals before completing their third embryo transfers, says Mahutte.
In light of these significant differences, he hopes the Ontario program will be “economically sustainable,” says Mahutte. “It may serve as a model for other provinces, going forward.” He also believes Quebec could adjust its funding program in similar ways rather than implement Bill 20.
But first, Librach and other fertility specialists will meet with the Ontario government as part of its implementation advisory committee to figure out how to roll out its program. In the next three months, many issues must be resolved, he says, including how the funds will be allocated—whether fertility clinics will receive a lump sum based on how much IVF they performed last year, or whether patients should receive the money through OHIP or an application system.
Librach is concerned that Ontario doctors will not be able to keep up with the sudden demand—that clinics might run through their allocated funds before the next year’s replenishment and, as such, patients will have to delay their treatments. He also worries that clinics aren’t prepared for the deluge: “We might have to hire new staff, and we only have so many incubators to fit the embryos in.”
Last year, women in Ontario underwent more than 5,000 IVF cycles. “We anticipate that number could go up 50 to 100 per cent,” says Librach. The day after the province announced its funding plan, his clinic began receiving calls from patients anxious to get started. Librach’s team has begun assembling a wait list to manage the influx. “It will be challenging at the beginning, for sure,” he says.
For now, many women and men in need of IVF are celebrating the Ontario announcement. But they are a careful group: They have waited for good news, only to be disappointed in the past. This time, they hope it will different.