Funding in vitro fertilization: exploring the health and justice implications of Quebec's policy.

AuthorCarsley, Stefanie


On August 5 2010, Quebec became the only jurisdiction in North America to provide publicly funded in vitro fertilization (IVF). (1) This decision came about as a result of a campaign promise by Premier Jean Charest that if reelected on December 8 2008, the Quebec Liberal Party would modify Quebec's Health Insurance Act to include certain assisted reproductive technologies as insured medical services. (2) Pursuant to this, on June 18 2009 the National Assembly passed Bill 26, An Act respecting clinical and research activities relating to assisted procreation, (3) and then in July 2010 the Quebec government adopted two regulations, the Regulation respecting clinical activities related to assisted procreation and the Regulation to amend the Regulation respecting the application of the Health Insurance Act, (4) which collectively provide the legal and regulatory framework for this policy. (5)

Under the resulting program, the Quebec government has agreed to pay all costs related to up to three stimulated cycles, or six natural or modified natural cycles, (6) of in vitro fertilization for women of childbearing age. (7) Doctors are only permitted to transfer one embryo at a time, but exceptionally may transfer two to three if they feel that this is justified based on the embryos' quality and the patient's age. (8) The government has also stipulated that no retroactive reimbursements will be provided for medication or assisted procreation services that had been previously received. (9)

Although the motivations for this program may have been largely political, (10) proponents of this policy have pointed to its demographic, financial, health, and social benefits. The Quebec Liberal Party and Health Minister, Yves Bolduc, have emphasized that allowing free access to in vitro fertilization and related services will improve Quebec's birth rate, by allowing an estimated additional 1,500 babies to be born per year. (11) It has also been explained that funding IVF is economically sensible, as it will lower neonatal costs and the government's health care expenses, by discouraging multiple embryo implantations and reducing the number of twins, triplets and higher-order multiple births. (12) This reduction in multiple pregnancies and multiple births has also been promised to decrease the health risks associated with IVF for both mothers and their children. (13) Finally, this policy has been deemed to have positive social justice implications, as it allows individuals of various socioeconomic backgrounds to access these services. (14)

This paper will explore the health and social justice implications of this policy. It will demonstrate that although Quebec's program is laudable, it nonetheless has some limitations and may still result in negative health and justice outcomes for Quebeckers. It will argue that the Quebec government could do more to ensure the health of Quebeckers and to provide equitable support for individuals seeking to develop their families. In making these arguments this paper will contribute to the existent, albeit limited, scholarship on Quebec's controversial policy, (15) as well as to wider conversations about the potential promises and pitfalls of funding in vitro fertilization. (16)

Part I will discuss the health implications of Quebec's policy. It will explain that while this program is desirable given its ability to reduce multiple births and the health risks these entail, it should nonetheless be kept in mind that IVF may result in negative health consequences that go beyond multiple births. It will also stress that this policy will not necessarily prevent all Quebeckers from becoming pregnant with multiples as a result of assisted reproductive technologies; despite the financial incentive of state-funded reproductive services, lowered success rates for single embryo implantation or long wait times for treatment may drive some Quebeckers to seek IVF outside the province, or to make use of artificial insemination with ovarian stimulation, both of which could result in multiple gestations.

Part 2 will consider this policy's favourable social justice consequences, but will also suggest that this policy perpetuates further inequities. While this program allows individuals of different socio-economic backgrounds to afford IVF treatment, single men and same-sex male couples cannot benefit from fully subsidized assisted reproductive technologies in order to develop their families. Individuals who would need to use a surrogate might not be able to access IVF funding in Quebec, and would still have to pay the additional expenses associated with altruistic surrogacy. In addition, the regulations and legislation associated with Quebec's program arguably suggest--through their silence and their provisions--that this policy is meant to assist medically infertile couples, sending a message that socially infertile individuals, like same-sex couples or single Canadians, are not a priority and that certain types of families and children are more desirable and worthy of state funding.

Finally, Part 3 will offer suggestions for how Quebec might try to rectify some of its policy's current deficiencies. It will propose that Quebec could provide funding for adoption, mandatory counselling for patients undergoing IVF, and increased public education on the risks of multiple pregnancies and births. It could also amend the current regulations to clarify who has access to government subsidized reproductive services and to provide restrictions on the use of ovarian stimulation with artificial insemination. Moreover, it could take steps to increase the physicians and resources available to treat, monitor and care for the increased number of women who will make use of IVF treatment and the children born through these technologies. These recommendations are not without their limitations and it is beyond the scope of this paper to consider fully the practical implications of implementing these changes. However, this paper stresses that if the government is committed to ensuring the health of Quebeckers, as well as allowing more equitable access to means of having children, then it is paramount to consider some of the negative health and justice implications of IVF funding, and attempt to address some of this policy's limitations.

  1. Health Implications of Funding IVF

    1. Beneficial Health Outcomes

      Quebec's decision to publicly fund in vitro fertilization and to introduce regulations mandating single embryo implantation, promises to have beneficial health consequences for Quebeckers, as it will reduce multiple pregnancies and the health risks associated with twins, triplets or higher-order multiple gestations. In the absence of regulations requiring single embryo transfers, or government subsidized IVF treatments, most patients and doctors elect to implant multiple embryos as this increases the success rate of each in vitro cycle, and reduces the chance that they will have to undergo and pay for multiple rounds of expensive treatment. (17) Thus, according to the Canadian Assisted Reproductive Technology Register, in 2008 only 12% of the reported IVF cycles in Canada involved single embryo transfers. (18)

      While multiple embryo transfers increase the chance that a woman will become pregnant with one child, they also result in a higher number of twins and triplets than occurs naturally. (19) Where a doctor has implanted an even larger number of embryos these can result in very high-order multiples, like the Suleman Octuplets born in the United States in 2009. (20) As a result of the popularity of multiple implantations, Canada currently has one of the highest multiple pregnancy and multiple birth rates among industrialized countries. (21)

      These multiple pregnancies may result in various health complications both for mothers and their children. Studies reveal that multiples are often born premature and underweight, are at greater risk of dying within the first year of life and have a higher risk of cerebral palsy and other congenital malforrnations. (22) A 2011 study out of Universite de Montreal found that over a two-year period, 82 babies who were admitted to the neonatal intensive care unit (NICU) at Montreal's Royal Victoria Hospital were from multiple births that resulted from the use of assisted reproductive technologies. (23) They represented 17% of all NICU babies in those years. 75 had been conceived through the use of IVF, and of these IVF babies, twenty were born extremely premature after less than 29 weeks of gestation, six died, five developed severe bleeding in their brains, five had chronic lung conditions, while four developed severe eye conditions requiring surgery. (24) Mothers pregnant with multiples are also more likely to have complications like high blood pressure, gestational diabetes, blood clots or obstetric hemorrhage from their pregnaneies. (25)

      In response to the risks and costs associated with these multiple pregnancies, several Canadian scholars and doctors have argued in favour of funding in vitro fertilization. For example, Renda Bouzayen, Head of Reproductive Endocrine and Infertility at Dalhousie University, has suggested that funding IVF would discourage multiple embryo implantations, as patients would not need to be concerned with paying for the costs of multiple cycles. (26) He also points out that other countries that have financed single embryo transfers have been successful at reducing the rate of multiple pregnancies. (27) Doctor Jason K. Min and Professors Edward Hughes and David Young have similarly argued in favour of state-funded IVF, stressing that a number of studies have shown that funding IVF can encourage individuals to accept single embryo transfers. (28) Annie Janvier, Bridget Spelke and Keith Barrington, who coauthored the aforementioned study on multiple births in Montreal's Royal Victoria Hospital, have also argued in favour of funding in vitro; however...

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