Editorials
Women's health
Volume 195 - Issue 10

The power of one and its cost

Author:  Robert J Norman

Med J Aust 2011; 195 (10): 564-565. || doi: 10.5694/mja11.11283
Published online: 21 November 2011
Assisted reproductive technologies, including in-vitro fertilisation (IVF), are now mainstream treatments in Australia, strongly supported by public opinion and accessible to most patients via adequate Medicare funding. Over the past 30 years, the growth in uptake of IVF in this country has been remarkable, with nearly 4% of all live births resulting from this mode of conception.
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The case for continued public funding of IVF using single embryo transfer

Assisted reproductive technologies, including in-vitro fertilisation (IVF), are now mainstream treatments in Australia, strongly supported by public opinion and accessible to most patients via adequate Medicare funding. Over the past 30 years, the growth in uptake of IVF in this country has been remarkable, with nearly 4% of all live births resulting from this mode of conception.1 This is associated with a loss of stigma surrounding infertility and the increased acceptability of IVF as a treatment option. Technologies such as intracytoplasmic sperm injection, use of donor gametes and embryos, preimplantation genetic diagnosis, improved access through an expansion of clinics, and the rapid commercialisation of the industry have all combined to expand services available to patients.

One of the international blights on the practice of IVF has been the very high multiple pregnancy rate that has resulted from economic pressures due to the expense of the technology (as seen in the United States and parts of Europe) or the relatively poor chance of one embryo producing a pregnancy (as seen in many developing nations). Large numbers of twins, triplets or higher-order multiples are conceived, and the consequences for the pregnancy and perinatal life are suboptimal.2 Even in Australia, the perinatal mortality rate for IVF multiple births is 32.1 per 1000, compared with 15.3 per 1000 for singleton babies born by IVF and 10.2 per 1000 for all babies born in Australia.1 There are also significant long-term health, social and economic consequences of multiple births.3 Unlike in some parts of the world, selective fetal reduction is not widely used in these circumstances.

The close proximity of fertility clinics to major obstetric hospitals, with joint appointments of fertility specialists, led to a strong desire in Australia to reduce multiple pregnancies to the lowest level achievable. Coupled with advances in embryo culture and ovarian stimulation, key Australian clinics started to move to single embryo transfer a decade ago. Indeed, a large clinical trial of single versus double embryo transfer (ASSET: the Australian Study of Single Embryo Transfer) failed to achieve anticipated recruitment because the patient information sheet painted such a poor outcome for twins that patients were not prepared to be randomly assigned to receive double embryo transfer. With this change in practice came a dramatic reduction in multiple pregnancies, such that the rate has dropped from more than 25% to 8% across Australia1 and to less than 5% in some clinics. This has been achieved by self-regulation without any restriction on federal funding that would mandate single embryo transfer, as is the case in Scandinavia, other parts of northern Europe and the Canadian province of Quebec. Widespread acceptance of this practice has also occurred in New Zealand, despite a different funding model.1

From the evidence of a number of randomised trials, there is little doubt that single embryo transfer results in a lower pregnancy rate than double embryo transfer, but this can be compensated by the subsequent transfer of frozen embryos from the cycle, leading to the concept of “as many embryos as you like, but one at a time”.4 This means that cycle numbers per couple may increase, and adequate Medicare reimbursement must be maintained to allow responsible practice. The appropriate level of this contribution is constantly debated and has often been subject to political and economic scrutiny in light of the underlying pressures on health care budgets. In this issue of the Journal, Chambers and colleagues make a case for continuing this funding on the basis that the clear reduction in multiple pregnancies from the use of single embryo transfer partially covers the cost of increased IVF activity.5 They claim that the savings in public funding from the reduced need for obstetric and neonatal care for multiple births pays for around 50% of the financial costs associated with the increase in assisted reproductive services. The ongoing health benefits later in life are not factored into their calculations, so the savings are probably even greater.

Multiple pregnancies remain a serious problem in several other areas of infertility treatment. There is little information in Australia on multiple pregnancy rates following ovulation induction with gonadotrophins or clomiphene citrate, or stimulated intrauterine insemination. Anecdotal data from reputable, experienced units show rates above the current IVF multiple pregnancy rates. In addition, the success of IVF in older women is much less predictable and, while single embryo transfer is widely practised for women under 38 years of age, the use of two or more embryos in a transfer in women over this age has received less attention because of their uncertain fertility potential. The development of non-destructive whole chromosome detection in an embryo and enhanced embryo selection through laboratory advances may help in selection and prediction of the number of embryos that should be replaced in these women.6

How much further growth will occur in the IVF market is uncertain, given that Australian IVF rates per head of population are among the highest in the world.7 There are few other countries that do not cap the number of cycles or impose some age restrictions on treatment. A cost-effectiveness analysis of IVF in Australia indicated that the cost of a baby born by IVF to women aged 42–45 years was $131 000, compared with $27 000 for women aged 30–33 years.8 In an era of economic health challenge, even if scrutiny is needed in other areas of IVF, Medicare IVF funding seems a good investment to benefit those with an excellent chance of success, while keeping complications for women and their babies to a minimum.

Author

  • Robert J Norman FRANZCOG, FRCPA, CREI1,2
  • 1. Robinson Institute, University of Adelaide, Adelaide, SA.
  • 2. Fertility SA, Adelaide, SA.

Correspondence: robert.norman@adelaide.edu.au

Competing interests

I and my institution have received research and travel grants and honoraria from companies producing gonadotrophin hormones used in IVF. I am a shareholder in a reproductive medicine company, Fertility SA.

References

View this article on Wiley Online Library