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Difficulty conceiving? - How do other countries help couples

31 March 2017

A new evidence review from the Health Research Board examines the public funding mechanisms for assisted reproductive technologies (ART) in different countries.

The review looks at the associated costs and benefits for the funder, provider and patient, the criteria for accessing the public funded service and the basis for these criteria in different jurisdictions.

Background

The Government is currently drafting a General Scheme for a Bill for Assisted Human Reproduction (AHR) to regulate a range of practices such as surrogacy, embryo donation, pre-implantation genetic diagnosis of embryos, sperm/egg donation and stem cell research. The main objective of such legislation is protecting the health and safety of children born through AHR, their parents and others involved, such as donor or surrogates.

While public financing of assisted reproductive technologies (ART) is not part of the overall legislation, the Department of Health is considering potential models of public funding for ART. If funding is approved, they want a comprehensive picture of what form this funding could take.  The HRB review was planned and conducted to inform decision making.

Key findings
Public Funding mechanisms

The literature revealed that there are three public funding mechanisms applied in publicly funded healthcare systems for ART.

  1. Full public funding defined as 81% or more for at least one cycle. This approach incurs a small out-of-pocket contribution paid by service users in some of the countries. It is the funding mechanism used in the UK, Belgium, France, Israel, New Zealand, Ontario, Slovakia, Slovenia and Spain.
  2. Partial public funding defined as between 1 and 80 % for at least one cycle with a significant out-of-pocket contribution by the service user. There is a wide variation in service user contributions in countries that take this approach ranging from 30% (Austria) of the cost of the cycle to 70% (Australia) of the cost of the cycle. This approach is taken in Australia, Austria, Denmark, Finland, Germany, Greece, Iceland, Italy, and the Netherlands.
  3. No funding from the public health system is currently the practice in eight countries including Cyprus, Ireland, Japan, Lithuania, Malta, Switzerland, Romania and the United States. However some of these countries have other approaches to help pay for treatment such as a generic publicly funded high-tech drug scheme for all citizens who spend over a certain monthly limit on prescribed drugs (Ireland), a means-tested subsidy (in Japan), or mandated private health insurance to either cover or offer the option of coverage (in 15 states of the USA.).

Since 2008 the number of countries proving public funding for ART has increased but individual countries public funding has decreased and out-of-pocket payments have increased. The most common services provided through publicly funded ART are intrauterine insemination, in vitro fertilization or intracytoplasmic sperm injection and pre-implantation genetic diagnosis.

The number of cycles funded publicly varies from one in the Ukraine to limitless numbers in Australia, Czech Republic, Estonia and Israel.

Costs and benefits

From the papers reviewed, the rationale for introduction of state support for ART is greater equity of access, safer clinical practice and use of more cost effective measures.

Benefits of publicly funded ART Include:

  • Increased chance for single women and couples to become parents, particularly those under 40 years of age.
  • Improved access to treatment by reducing out-of-pocket costs. 
  • Safer clinical practice, for example, safer embryo transfer practice to reduce multiple pregnancies and associated complications for mother and child. 
  • Clinical benefits which can reduce pressure on public spending elsewhere in the system. For example, in countries where clinicians and patients agree to restrict the number of embryos transferred in one cycle, there has been a reduction in multiple pregnancies and the large costs that multiple births incur yet no decrease in cumulative pregnancy rates.
  • There are inferred (but not proven) wider societal benefits, for example, boosting population growth and long-term revenue receipts. Looked at solely from an economic projection perspective show that based on lifetime tax calculations (for 80 years), the cost of IVF-conceived children breaks even at 40 years of age compared to 38 years for a normal birth, so IVF funding by the state represents good value for money (an indirect benefit).
Costs of publicly funded ART include:
  • Direct costs include the clinical services such as laboratory fees and hospital charges which can be a significant cost to each patient. 
  • Indirect costs can include cost of treatment complications, lost productivity, low success rates and multiple births. The review reveals that the costs of multiple births can be substantial, for example, the maternal and infant cost of a twin pregnancy can be three times that of a singleton pregnancy. The healthcare and educational costs of caring for multiple birth infants may continue for many years.
Access criteria applied for public funding of ART and the rationale

Based on the papers reviewed, all countries that provide partial or full public funding for ART set criteria around receiving it. The criteria for individual countries differed and may include some of the following:

Clinical Criteria
  • Female upper age limit 
  • Medical indication (of infertility or unexplained in fertility)
  • Restrictions on number of embryos transferred 
  • Body mass index, current smoking/substance use of applicants.
Social criteria 
  • Marital or civil status 
  • Whether the applicant already has children 
  • Child protection.

Female upper age limit and medical indication are the most commonly employed criteria employed for receiving publicly funded ART. However, a small number of countries who have examined the evidence base for increasing success of ART or having better infant outcomes have included body mass index, current smoking status and single embryo transfer for women in early to mid-thirties. 

Countries’ justification for criteria

Most clinical and social criteria are justified on the grounds of safety, successful outcomes and cost effectiveness. The latter two are exemplified in an example from Quebec’s publicly funded in vitro fertilization programme where the cost to the taxpayer ranged from Can$43,153 for a single baby born to a woman of 40 to Can$103,994 per singleton baby for those aged 43. For those aged 44 years, the mean cost of failed in vitro fertilization was Can$597,800 per woman – no babies were born to this group. In contrast to this, the average cost of in vitro fertilization treatment per live new born for women under 35 years was Can$17,919.

Social and political concerns in relation to demography, changing social trends and behaviours and political pressures are equally prominent in the considerations within papers reviewed.

It appears that scientific evidence, social concerns and to some extent financial considerations are the main planks of justification when policy makers adjudicate on decisions about funding ART and setting access criteria.

From the evidence considered, we conclude that national policies are a mix of political, cultural and economic pressure, combined with clinical evidence leading to a publicly acceptable or pragmatic approach to funding ART in each country reviewed.

Approach to review

This review followed the principles and practice of a systematic review which include searching, screening, applying inclusion/exclusion criteria, data extraction, quality appraisal and analysis. This is presented in full in the methodology section of the full review.

Papers before 2007 were excluded based on the fact this review was to produce an up-to-date picture of publicly funded models and work more than nine years old would yield little benefit. A total of 825 papers and reports were screened, grey literature and citations followed up and following this, 68 papers were included in the overall analysis.

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