COMMENTARY

Does Insurance Coverage of IVF Lead to Better Outcomes?

Peter Kovacs, MD, PhD

Disclosures

September 04, 2015

Embryo Transfer Practices and Perinatal Outcomes by Insurance Mandate Status

Boulet SL, Crawford S, Zhang Y, et al; States Monitoring ART Collaborative
Fertil Steril. 2015;104:403.e1-409.e1

Background

The ultimate goal of fertility treatment is to help couples have healthy children as a result of the procedure. To achieve this, both patients and providers have to make multiple decisions during a treatment cycle.

First of all, the patient has to decide where to go for treatment. After many years of unsuccessful attempts, couples will consider the success rate as the most important parameter to look at; therefore, they will focus on the implantation, pregnancy, and live birth rates. However, we cannot expect the patient to be able to analyze the data; they are more likely to look at the raw numbers only.

When it comes to the pregnancy rate, the same figure may indicate a poor outcome or an outstanding result, depending on whom we treat and how we provide treatment. Outcome variables can be compared only when patient groups are similar. Age, race, body mass index, male parameters (sperm count, motility, morphology), ovarian reserve, order of treatment cycle, and medical and gynecologic problems, among other factors, all influence the outcome of an IVF cycle.

In addition to looking at the statistical figures, one has to evaluate the outcome of the pregnancy. Is it a full-term pregnancy or preterm? Is it a normal-weight newborn or one with low birthweight? Can the newborn be discharged with the mother, or does he or she need prolonged hospital care for neonatal complications?

All patients wish to have healthy children as a result of assisted reproductive technologies (ART), yet they very rarely ask about perinatal outcome. They are primarily concerned about their chance of becoming pregnant and focus on how the number of embryos transferred will affect this chance. Obviously, the chance of achieving a pregnancy will be higher when two or more embryos are transferred. However, if we take the time to explain the excess maternal and perinatal complications that may occur with a twin or triplet pregnancy, the majority of patients will understand the benefit of a single-embryo transfer.

Experts have been saying for a long time that success should be defined as the delivery of a healthy, full-term singleton, and the whole treatment should be considered when evaluating outcome.[1]

Professional societies have an important role in shaping embryo transfer practices, because they can propose guidelines that clinics are expected to follow.

Insurance companies also have to look at the whole picture. For them, the expenses will not stop with the embryo transfer but will continue during pregnancy and in the perinatal period. It is not the IVF treatment that is expensive, but the prolonged hospital care of a prematurely born baby. For the patient, the infertility evaluation, treatment, and medication expense can pose a significant financial burden that may push them to accept risks in exchange for a higher likelihood of immediate success; in contrast, insurance companies should be interested in uncomplicated singleton pregnancies.

Therefore, insurance coverage is likely to influence IVF practices. This study compared transfer practices and treatment outcome in three states: two without and one with mandated insurance coverage.

Summary

ART and perinatal data were collected from databases in three states. In Massachusetts, there is mandatory insurance coverage for ART services, whereas in Michigan and Florida, there is no coverage.

ART and non-ART live-birth deliveries were compared. Patient- and treatment-related factors were compared and controlled for during the analysis. The outcome of cycles with elective single-embryo transfer and cycles in which three or more embryos were transferred were compared. Gestational age at delivery and birthweight were assessed as perinatal outcome variables.

The analysis is based on 230,038 deliveries in Massachusetts and 1,026,804 deliveries in Michigan and Florida. There were almost four times as many ART deliveries in Massachusetts than in the other two states (2.9% vs 0.8%). In Massachusetts, elective single-embryo transfer was more common (8.6% vs 2.5%) and the transfer of three or more embryos was less frequent (23.1% vs 33.6%). The proportion of multiple gestations was also lower in Massachusetts (25.7% twins and 1% triplets or higher vs 33.6% twins and 2.3% triplets or higher in Michigan and Florida).

The risk for preterm delivery was higher in Michigan and Florida (30.7% vs 22.6% in Massachusetts). The proportion of normal-weight newborns was also lower in the states with no insurance coverage of ART (56.3% vs 64.6%).

Women younger than 35 years with no insurance coverage were four times more likely than those with insurance coverage to have three or more embryos transferred (26.9% vs 7%; relative risk, 4.18; 95% confidence interval, 2.74-6.36). A similar though less pronounced trend was seen in older age groups.

The authors concluded that mandatory insurance coverage affects the way in which ART is practiced.

Viewpoint

Without insurance coverage, IVF poses a significant financial burden to infertile couples. Many can only afford one attempt and, therefore, will try to maximize their chance of success and will request that several embryos be transferred.

With the transfer of multiple embryos, especially in young patients with a good prognosis, the risk for multiple pregnancy increases as well. A multiple pregnancy increases the risk for maternal and neonatal complications and leads to suboptimal perinatal outcome. Therefore, at least for good-prognosis patients, elective single-embryo transfer is recommended.[2]

Current cryopreservation technologies allow us to transfer the rest of the embryos later on—preferably one at a time, to avoid multiple gestations. Cryopreservation and frozen embryo transfer, however, will further increase the costs of treatment.

In some countries, such as Belgium, the transfer of a single embryo is mandatory. This practice has resulted in a significant reduction in the multiple pregnancy rate.[3]

It is also known that a twin or even higher-order pregnancy will cost significantly more than a singleton pregnancy.[4,5] It was shown by one group that the cost of elective single-embryo transfer plus (if needed) the cost of elective single frozen embryo transfer is similar to the cost of a double-embryo transfer.[6] A study based on UK data showed that the total cost (maternal and infant) was increased threefold for twin pregnancies and 10-fold for triplet pregnancies.[7]

Many studies have shown that expense is lowest in the case of a singleton pregnancy. Therefore, it would make sense for insurance companies to pay for infertility services and implement certain restrictions at the same time. Insurance coverage per cycle should pay for all related expenses (fresh cycle, cryopreservation, and frozen embryo transfer). Upon providing coverage, certain restrictions in the number of embryos transferred could be made mandatory. This would improve perinatal outcome and would keep the overall expenses low.

Until a more universal insurance coverage becomes available, it remains our job to educate patients about the risks associated with multiple pregnancies and recommend a more conservative transfer approach to keep the proportion of multiples low and to eliminate high-order multiples.

Abstract

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