How public funding has changed IVF in Ontario

Tom Hannam saw a change in his patients after the Ontario Fertility Program (OFP) was introduced three years ago. It wasn’t a clinical change; it was more emotional. The OFP allowed people to see in vitro fertilization as a “real thing,” says Hannam, who founded and runs one of Ontario’s largest fertility clinics, “something that they really could pursue for themselves in their lives.”

IVF involves the harvesting, extraction and fertilization of human eggs, followed by the implantation of embryos into the uterus. Shortly after the first IVF-conceived baby was born in Canada in 1983, Ontario began funding the procedure. Then in 1994, the province de-insured IVF, in part because it did not consider it to be medically necessary (except for women who had complete bilateral anatomical fallopian tube blockage, for whom three cycles of IVF continued to be covered).

In the subsequent two decades, the use of private fertility services for IVF treatment proliferated in Canada. (The national infertility rate is estimated to be about 16 percent—one in every six couples experiences infertility, and there are many people who are single or in same-sex relationship who rely on assisted reproductive technology to have a baby.) In 2001, 22 fertility clinics in Canada initiated 7,884 IVF cycles; in 2017, 36 clinics initiated 33,092 cycles. In the past five years alone, there has been a more than 30 percent increase in the number of IVF cycles initiated in Canada. Currently, between one and two percent of live births in this country are the result of fertility treatments (though not exclusively IVF).

Alongside this growth, there has been ongoing debate over whether or not IVF should be funded. In 2009, an expert panel convened by the government of Ontario strongly recommended that the province significantly expand funding for IVF. The panel found that the high cost of private IVF was the biggest barrier to people wishing to build their families through assisted reproduction, and that it also contributed to elevated rates of multiple births (as patients often opted for multiple-egg transfers).

In 2015, Ontario delisted IVF from the Ontario Health Insurance Plan (or OHIP, the public insurance plan which covers doctors’ fees) and moved it to a separate program, the OFP, whose overall budget is $70 million annually. (This allotment is also for intrauterine insemination, or IUI, which was previously covered quite expansively under OHIP, and which has also been moved to the OFP.)

The OFP covers one IVF cycle per lifetime for women who have an OHIP card and are under 43 years old, and for single men or men in same-sex partnerships of any age who have an OHIP card. A cycle is defined as starting with ovarian stimulation and ending with the transfer of all embryos resulting from fertilization until either a pregnancy results or the embryos run out. The OFP only allows single-embryo transfers. This is meant as both a safety and money-saving measure, aimed at cutting the roughly 30 percent multiple-birth rate that results from IVF. Most paying patients opt for multiple embryo transfers because they increase the likelihood of a pregnancy. But they also increase the likelihood of multiple births, which in turn can lead to low-birth weights and consequent hospitalizations.

OFP funding is allocated to fertility clinics according to the volume of patients they treat, and the clinics are responsible for determining eligibility. The funding is limited to 5,000 cycles annually—this means that if more than 5,000 eligible people apply for it in a given year, some will receive it, and some won’t.

Those who don’t, can opt to pay for it out of pocket, which amounts to between $10,000 and $20,000 per cycle (not including the necessary drugs). And this is what makes OFP so unusual: It renders IVF a service that is both publicly and privately available—to the same people—in Ontario.

Impact of OFP for patients

Taunya Johnston and her husband, Rob spent more than $35,000 trying to get pregnant. “We sold our house,” says Johnston. “I took time away from work and from school. Everything we could think of that would possibly give us the hope of having a child, we were doing.” The couple conceived their daughter through IVF after being in fertility treatment for five years. She was born five years ago.

Johnston and her husband tried for a second pregnancy with the remaining frozen embryos, but it didn’t happen. And just when they were thinking about how they could afford to pay for a new cycle—Taunya, now 34, is a college professor and Rob, who is 37, is an insurance protection specialist—their fertility clinic called, asking whether they wanted to sign up as potential candidates for a funded cycle. They started one in January 2016.

“It was a completely different experience,” says Johnston, who is on the board of Conceivable Dreams, a fertility advocacy group in Ontario. When you’re paying out of pocket, she says, “You get that desperation of, ‘Oh my goodness, we can’t afford to keep paying for this, this has to work.’ That’s not helpful stress.”

Johnston and her husband had five embryos from the funded cycle—two were transferred but ended in loss; one was an unsuccessful transfer. With the fourth, they conceived their son, who was born in October 2017. “[The funded cycle] gave us a feeling of validity, that this is something that’s important,” she says. “We were prepared for the possibility that the cycle wouldn’t work. But we were still so grateful that we had the opportunity to try.”