Published 07 January 2021
Large Canadian study finds state-funded ART linked to a higher rate of SET and a lower risk of adverse neonatal outcomes for mother and baby.
Faced with declining birth rates, many countries offer some form of state-funded fertility treatment usually with single embryo transfer (SET). This policy governing ‘free’ programmes has been shown to reduce multiple pregnancies as evidenced by studies in Australia and Belgium where a one-baby-at-a-time approach is legally enforced in ART.(1,2)
What has remained unknown is the impact of publicly funded ART on outcomes for mothers and their babies.
Now a study of nearly 600,000 pregnancies has found that state-funded access is associated with a reduced chance of negative events (preterm birth, preeclampsia), with findings more pronounced for infants, and suggests SET could account for lower overall risks than found in schemes financed wholly or partly by patients.(3) Moreover, the health benefits of public programmes with SET may extend beyond prevention of multiple births, say the authors of this study, who observed many improvements that could not be explained by the lower risks of conceiving one baby at a time.
The findings are based on hospital discharge records for all pregnancies (n = 597,416) resulting in a live birth/stillbirth between July 2008 and September 2015 among women in Canada’s Quebec province. To increase access and lower multiple pregnancy rates, the government introduced public ART funding with SET in August 2010, with private treatment unavailable throughout the programme’s duration.
Participants in the study conceived either by ART (n = 14,309, <43 years with autologous IVF and <51 years with donor oocytes) or spontaneously (n = 583,107), and the main exposure measure was conception before and during the programme’s introduction.
The results show 2638 ART pregnancies were conceived before public funding, and 11,671 after the programme’s introduction, with the latter phase including a greater proportion of obese older women with co-morbidities. Compared with no public funding, when embryo transfers per cycle were unlimited, pregnancies during the period of state-funded treatment was associated with a statistically lower chance of severe maternal (RR 0.64) and neonatal morbidities (RR 0.75).
The risks of pre-eclampsia, preterm birth and low birth weight were all significantly reduced, as was the likelihood of neonatal intensive care unit admission for the baby (RR 0.65). When multiple pregnancies were excluded, the risks of pre-eclampsia and preterm birth were still lower, although the protective effect of publicly funded treatment with SET was weakened for other outcomes. Indeed, the authors found ‘little evidence’ of negative associations with the free programme, except for a greater risk of gestational diabetes, which they point out is not uncommon in obese women.
However, there were acknowledged limitations to the study - such as no information on ART type, number of IVF cycles and of embryos transferred (the policy allowed a three-embryo limit depending on quality and maternal age), and none for lifestyle factors.
The message from the study, say the authors, is clear: publicly funded ART is better for maternal and infant outcomes. Yet they add that this comes with considerable economic implications for governments who are facing an increased healthcare burden associated with the current pandemic.
Indeed, it’s noteworthy that the Quebec programme itself came to an end for healthcare cost reasons. The authors put forward the financial pros and cons of state-funded provision in the province, with some evaluations putting a decrease in medical costs against an increase in government expenditure or others highlighting the financial toll of neonatal intensive care.
The picture globally for state-funded/reimbursed ART is mixed, including in Europe where provision varies widely both across and within countries, with some offering partial funding if patients meet certain criteria and/or up to a limited number of cycles. A recent review of funding in Europe performed by ESHRE’s EIM consortium suggested that this disparity creates inequality for patient access to treatment, in particular for those living where no financial assistance whatsoever is offered (as for example in Switzerland).(4) Age, existence of previous children, and widely varying definitions over the type of expenses covered per cycle are among the barriers for those seeking free treatment – and potentially better outcomes.
The present situation for SET seems more positive, according to the latest evidence. While the transfer of two embryos (51.9% of total in this Quebec study) appears the most frequently performed approach, the latest EIM data for Europe show SET increasing in use and accounting for more than two in five transfers carried out in 2016.(5)
The fact remains though that SET is by no means mandatory everywhere. So, the compromise put forward by the Canadian study authors is for countries to consider guidelines or laws to increase elective SET ‘when public funding of ART is not possible’ in order to protect the health and welfare of mothers-to-be and their children.
1. Chambers G, Illingworth P, Sullivan E. Assisted reproductive technology: public funding and the voluntary shift to single embryo transfer in Australia. Med J Aust 2011; 195: 594-598. https://doi.org/10.5694/mja10.11448
2. Peeraer et al 2014. The impact of legally restricted embryo transfer and reimbursement policy on cumulative delivery rate after treatment with assisted reproduction technology. Human Reprod 2014; 29: 267-275. https://doi.org/10.1093/humrep/det405
3. Qin Wei S, Bilodeau-Bertrand M; Lo E, Auger N. Effect of publicly funded assisted reproductive technology on maternal and infant outcomes: a pre- and post-comparison study. Human Reprod 2020; https://doi.org/10.1093/humrep/deaa270
4. Calhaz-Jorge C, De Geyter C, Kupka M, Wyns C, Mocanu E et al. Survey on ART and IUI: legislation, regulation, funding and registries in European countries: The European IVF-monitoring Consortium (EIM) for the European Society of Human Reproduction and Embryology (ESHRE). Human Reprod Open 2020 February; https://academic.oup.com/hropen/article/2020/1/hoz044/5715201
5 Wyns C, Bergh C, Calhaz-Jorge C, De Geyter C, Kupka M et al. ART in Europe, 2016: results generated from European registries by ESHRE. Human Reprod Open 2020 July; https://doi.org/10.1093/hropen/hoaa032
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