As the techniques improve in reliability, applicability, and cost-effectiveness, they will be universally applied to all embryos resulting from ART procedures, to the extent that only genetically “normal” embryos will be transferred. This has the potential to drive all infertility therapy in the direction of ART, to maximize the likelihood of a positive outcome from any intervention.
Surgery, superovulation will dwindle. The necessity of infertility surgery will continue to diminish and use of superovulation as an isolated therapy will disappear, since the number and quality of resulting fetuses cannot be controlled.
CDC study: Insured patients may opt for fewer embryos
Reynolds MA, Schieve LA, Jeng G, Peterson HB. Does insurance coverage decrease the risk for multiple births associated with assisted reproductive technology? Fertil Steril. 2003;80:16-23.
Multiple births have soared over the past generation, primarily because of ART, specifically superovulation and in vitro fertilization. The initial emphasis was simply to achieve pregnancy, but now, the medical and financial risks related to multiple gestation are a target of concern. Strategies to decrease multiple pregnancies and yet maintain high pregnancy rates are now a health policy priority.
CDC examines assisted reproduction outcomes in insured vs noninsured states. This CDC study compared ART practices and outcomes in 3 states with mandated ART insurance coverage (Illinois, Massachusetts, and Rhode Island) to 3 states without such mandated coverage (Indiana, Michigan, and New Jersey). Outcome measures were number of embryos transferred, multiple-birth rate, triplet or higher order birth rate, and triplet or higher order gestation rate. The study utilized data from the national registry for 1998.
A smaller proportion of procedures included transfer of 3 or more embryos in 2 of the 3 states with mandated insurance (Massachusetts, 64% and Rhode Island, 74%) than in the noninsurance states (82%), and the multiple-birth rate was lower in 1 of the mandated states (Massachusetts, 38%) than in the nonmandated states (43%). A trend toward fewer triplet or higher order births was seen in all mandated states, but was statistically significant only in Massachusetts.
Implication: Insurance may be a tool to reduce multiple births. While the magnitude of the differences in the number of embryos transferred and the multiple-birth rate was not great, this study does suggest that insurance coverage may be an effective way to modify practice patterns and outcomes. Higher order multiple-birth rates are substantially lower in countries with national health insurance and restrictions on the number of embryos transferred. In the United States, where most states have not mandated ART insurance and there is no restriction on number of embryos transferred, the decision and risks are assumed by the patient and practitioner.
The natural tendency is to maximize the yield from an expensive procedure, and accept the increased risk.
Without insurance, the motivation is maximum yield. Unlike health decisions where cost is less central, the natural tendency is to try to maximize the yield from a single expensive procedure and accept the increased risk. This study suggests that reducing personal financial risk can modify those decisions.
Would long-term savings offset higher insurance costs? The move to find ways to reduce the rate of multiple gestations is welcome news for the practicing Ob/Gyn. While any attempt to increase health-care coverage may seem counterintuitive in an era of escalating health costs, a subsequent reduction in the multiple-birth rate would provide long-term savings by reducing the number of multiple gestations and their well-documented increase in premature deliveries and long-term costs.
Be alert for cost-analysis studies in the upcoming year.
Dr. Randolph reports no affiliations or financial arrangements with any companies whose products are mentioned in this article.