Access to Infertility Treatment Influences Outcomes


Disclosures: Dr. Zegers-Hochschild disclosed no conflicts of interest. Dr. Adamson reported receiving funding from EMD Serono Inc., Institute Biochimique SA, and LabCorp.

ATLANTA — Access to infertility treatment influences utilization rates but also changes outcomes, including high-order multiple births, research suggests.

Investigators used data collected from 2000 to 2004 from 54 countries through the International Committee Monitoring Assisted Reproductive Technologies (ICMART) to determine how economic factors influence the risk and benefit decisions made by providers and patients.

They found that assisted reproductive technology (ART) is used most frequently in societies that recognize infertility treatment as a reproductive right and consequently provide free access to treatment. When ART is funded out of pocket, it reaches only a small proportion of infertile couples, Dr. Fernando Zegers-Hochschild, ICMART vice chair, said at the annual meeting of the American Society for Reproductive Medicine (ASRM).

An estimated 64% of presumably infertile women requiring ART, aged 20-44 years, have access to ART treatment in Israel, where reimbursement is among the most generous in the world. This compares with 40% in Denmark and 32% in Australia, where cycles are free or reimbursed, and just 7% in the United States, where reimbursement is nil or limited.

In 2004, there were 1,083-2,000 ART cycles for every million inhabitants in Israel, Denmark, and Australia, while in the United States, there were only 357 cycles per million people. The number of ART cycles fell to just 50-150 cycles per million people in developing Latin American countries without reimbursement.

When ART is funded out of pocket, more embryos are transferred in order to achieve pregnancy with fewer attempts, generating an excess of twins and high-order multiple births, Dr. Zegers-Hochschild said. The financial motivation is not surprising, given the roughly $15,000 price tag per ART cycle. Financial pressure from patients and publication of performance data also are driving competition for high success rates and the transfer of more embryos.

In 2004, 67% of transfers in Sweden were single-embryo transfers, and the remaining 33% were two-embryo transfers. In contrast, 8% of transfers in the United States that year involved one embryo; 40%, two embryos; 32%, three embryos; and 20%, four or more embryos.

During the same year, the twin and high-order multiple birth rates in Sweden were 5.6% and 0.1% vs. 30.4% and 1.1% in the United States, the latter down from 4.3% in 2000. Part of the reduction in the U.S. triplet rate has been achieved through the use of embryo reduction, which is not reported by the Centers for Disease Control and Prevention, said Dr. Zegers-Hochschild of the unit of reproductive medicine, Clinicas las Condes, Santiago, Chile.

This relationship between access and infertility treatment outcomes is also present within countries. In a separate presentation at the same meeting, Yale University investigators in New Haven, Conn., led by Dr. J. Ryan Martin, reported that the number of embryos transferred per cycle, cancellation rate, twin rate, and multiple live birth rate were all significantly higher in states that did not mandate insurance coverage for in vitro fertilization (IVF). Only six states mandate coverage of two or more IVF cycles: Connecticut, Illinois, Massachusetts, Maryland, New Jersey, and Rhode Island.

Single-embryo transfer (SET) policies are being considered in several states to reduce multiple births, notably in California where residents are wrestling with the cost of premature octuplets born to “octomom” Nadya Suleman after she had six embryos transferred during infertility treatment. SET mandates have been put in place in countries like Belgium, with the potential cost savings from neonatal care of premature ART babies used to help fund infertility treatment, Dr. Zegers-Hochschild said in an interview.

Although ASRM immediate past president and fellow ICMART officer Dr. David Adamson agreed that the U.S. twin and triplet rates need to be reduced, he urged caution regarding SET mandates.

“This is very complicated medicine,” he said in an interview. “The delivery rate per retrieval in the United States is almost 50% better than in other countries. So, how much do you bring down the success rate to limit poor outcomes or complications?”

Evoking across-the-board regulations would interfere with the physician's ability to treat patients individually and does not address what happens if treatment fails. For example, ART treatment is reimbursed in Sweden, but if the treatment fails, a woman has to go back to the end of the line and possibly wait a year for another cycle, said Dr. Adamson, an ob.gyn. who specializes in reproductive endocrinology and infertility in Palo Alto, Calif. This can have devastating consequences, particularly for older women, and has prompted increasing use of private infertility clinics and personal financing.

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