Ruminations

Return on Investment

"They are basically spending money for nothing, and subjecting their bodies to hormonal treatments and all sorts of invasive procedures with very little chance of actually going home with a baby."
"[Numbers are] very telling for women everywhere who are paying out of pocket for this [in vitro fertilization procedure]."
"These are little businesses [for-profit fertility industry] -- it wouldn't be in their interest to publish this [poor success rate after age 40]."
"I don't think it's the job of any government to tell a woman at 43 or 44 that she is not allowed to take her chances [through banning IVF beyond age 42]."
"I'm really scared of these numbers being used to justify what I see as draconian measures of just banning a practice altogether, which to me is none of the government's business."
Dr. Vardit Ravitsky, associate professor of bioethics, University of Montreal

One in seven heterosexual couples are thought to experience fertility problems and the numbers seeking help have risen. Photograph: Alamy

"Any government that's planning to introduce public funding [for IVF procedures] should be aware of this relationship and should at least consider age eligibility criteria in order to maximize the return on their investment."
"[Older women run [a] higher risk of producing no eggs or those of poor quality resistant to fertilization, or embryos that will not properly divide] so that in the end nothing gets transferred."
"You had an awful lot of patients in Quebec who actually underwent more than three egg retrievals, particularly older women. [Under a taxpayer-funded scheme] they have very little to lose by trying to do another cycle and everything to gain."
"I don't fault them. They say, 'Look, I really want a baby, if it takes three, four or five attempts I'll do it."
Dr. Neal Mahutte, medical director, Montreal Fertility Centre

Dr. Ravitsky's objections to government interference in setting objective standards for IVF fertilization, based on the experience that informs them that tax-payer dollars are being hideously wasted in acceding to the wishes of women whose biological clock has run out, despite which they wish to undergo multiple series of IVF processes in the hope that something will work for them which nature has no intention of aiding in makes little sense.

On the other hand, should over 44s insist on paying the cost themselves there is little to stop them. Even so, a case can be made for the fact that pregnancy-related and age-related admissions to hospital would increasingly result, representing an additional burden on an already-overstressed universal health care system.

Quebec was the first province in Canada to provide tax-paid universal coverage for IVF in 2010. The Province of Ontario is now prepared to pay for one round of in vitro fertilization for thousands of women unable to conceive on their own without medical intervention, inclusive of women who can claim "social infertility", which is to say women in same-sex relationships. Quebec's experience with its program is proving instructive, and Ontario should look closely at the results.

Quebec's program was set up to be available to a wide spectrum of residents and there was no age limit on the procedure. As a result it was wildly popular. Through its experience the province plans to end public coverage of IVF, offering instead tax credits in their place. New research points to the difficulties of women in their 40s to have successful in vitro fertilization treatments.

A newly completed study examined the program's outcomes against the costs of the province's publicly funded program for IVF in women over 40 who used their own eggs. [IVF works with a woman taking powerfully effective fertility drugs to stimulate her ovaries in the release of multiple eggs which are retrieved, made fertile with sperm in a laboratory setting, with the resulting embryo transferred into the woman's womb again.]

In two years' time Quebec paid out over $16-million in IVF treatments for older women and in that time frame about 3,700 IVF cycles began, with women aged 40 to 44. A total of 2,681 embryos were transferred, and of that number 246 babies resulted, successfully delivered. The IVF cost worked out to $43,153 for each baby produced for those women aged 40. For women aged 42, the cost was $79,100 per baby.

For 43-year-old women, the cost to the program worked out to $103,994 for each live birth. Compare that to the IVF procedure cost per baby born to women under 35 coming out at under $18,000. In the two-year study period $497,800 was spent for women in the 44-year-old age group in the IVF program. For that investment there was not one live birth. "We couldn't calculate what the cost of a live birth could be, simply because there were no live births", commented the study co-author, Dr. Neal Mahutte.

Even so, he explained, the costs are underestimated, reflecting only what doctors were reimbursed for the procedures. The cost of medications, prenatal visits, labour and delivery long with hospital admissions for pregnancy-created complications were not included in the total. Despite a dramatic drop in the multiple pregnancy rates (under the Quebec plan one embryo only was transferred at a time), admissions to hospital increased close to 40 percent for women undergoing IVF.

A mere nine percent of the cycles in women aged 40 to 44 undergoing IVF resulted in a live birth. Daunting odds, those. Dr. Mahutte, a past-president of the Canadian Fertility and Andrology Society, feels that provinces should set an age limit and also define the meaning of a cycle, or round of IVF. Ontario holds that a cycle represents one egg retrieval for women under 43.

Quebec, on the other hand, paid for up to fully three attempts at IVF, leaving it to the discretion of the province's fertility clinics to set an age limit. Since they are profit-oriented, how likely is it that the usefulness to the older woman would be considered, as well as potential consequences to her health resulting from exposure to a procedure that is doubtful for success in producing a live birth, yet the use of powerful drugs expose the woman to future health concerns.

The study results will be presented by Dr. Mahutte at the American Society of Reproductive Medicine's annual meeting this week in Baltimore.