Article
Working to eliminate multiple pregnancies: a success story in Québec

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Abstract

In August 2010, the provincial government of Québec, Canada introduced funding of assisted reproduction treatment through the provincial health programme. Alongside this benefit, legislation was introduced to control assisted reproduction treatment activities in the province, including restrictions on the number of embryos that could be transferred in any one cycle. The aim of the programme was to transfer a single embryo in every cycle; multiple embryos could be transferred under suboptimal conditions but required physician justification. In the first 3 months of this programme, 1353 cycles of IVF were performed in five Québec assisted reproduction centres, with an overall clinical pregnancy rate of 32% per embryo transfer and 50% of transfers used elective single-embryo transfer (eSET). The multiple-pregnancy rate was only 3.7% per clinical pregnancy. In 2009, prior to the introduction of the programme, eSET was used in only 1.6% of embryo transfers, resulting in a multiple-pregnancy rate of 25.6%. These data demonstrate that providing provincially funded assisted reproduction treatment created an environment in which the aggressive use of eSET was not only possible, but also rapidly implemented. The result was a dramatic drop in multiple-pregnancy rates, approaching those for natural pregnancies.

In August 2010, the provincial government of Québec, Canada introduced state-covered assisted reproduction through the provincial health programme. Alongside this, legislation was introduced to control assisted reproduction activities in the province, including the number of embryos that could be transferred in any one cycle with the aim of reducing multiple pregnancies, which are the major negative side effect of assisted reproduction treatment. Multiple embryos could be transferred under suboptimal conditions but required physician justification. In the first 3 months of this programme, 1353 cycles of IVF were performed in the five Québec-based assisted reproduction centres, resulting in an overall clinical pregnancy rate of 32% per transfer and with 50% of transfers of a single embryo. The multiple-pregnancy rate was only 3.7%. Prior to the introduction of the programme, the elective transfer of only one embryo (elective single-embryo transfer or eSET) was used in only 1.6% of cycles in Québec, resulting in a multiple-pregnancy rate of 25.6%. These data demonstrate that having state-sponsored assisted reproduction treatment created an environment in which the aggressive use of eSET was possible, implemented and resulted in a significant drop in multiple-pregnancy rates approaching natural levels of multiple pregnancies.

Introduction

Huge advances have been seen in IVF success rates over the more-than 30 years that this treatment has been applied clinically. Improvements in laboratory practices, ovarian stimulation protocols, cryopreservation techniques and genetic aspects of treatment have all served to increase implantation and live-birth rates. However, despite these advances, one major drawback of IVF has remained constant: the disproportionately high rates of multiple pregnancies, including high-order multiple pregnancies, and the associated risks seen with such outcomes.

In Canada, professionals working in the field of assisted human reproduction meet under the auspices of the Canadian Fertility and Andrology Society (CFAS). For the last 11 years, the CFAS has managed a registry of assisted reproduction cycles performed across the country. Participation in the Canadian ART Register (CARTR) is not mandatory but all Canadian assisted reproduction clinics participate and provide funding for this initiative. The registry allows Canadian clinics to monitor the outcome measures associated with treatment in the country. Although only aggregate data are released to participants and the general public, the CARTR outcome-improvement committee has confidential access to clinic-specific data, permitting them to identify and offer help to clinics whose results fall below the national standard.

Looking at published data from 2005, it is clear that North America has the greatest problem with multiple births from assisted reproduction treatment; Canada and the USA topped the statistics with >30% multiple-birth rates, whereas the lowest rates were seen in countries with state coverage for assisted reproduction treatment, such as Sweden (6%), Australia/New Zealand (14%) and Belgium (13%) (Assisted Human Reproduction Canada, 2011).

Data from CARTR shows the progression of the multiple-birth rate compared with the live-birth rate in Canada from 2001 to 2008 (Figure 1) (Gunby et al., 2010). The live-birth rate has improved gradually over the years, but the multiple-pregnancy rate fluctuates consistently around the 30% rate. Although the use of elective single-embryo transfer (eSET) for assisted reproduction in Canada has been slowly increasing, by 2009 it remained at a very low rate (Figure 2). The low use of eSET can be attributed to the fact that, when patients are paying for their treatment, the pressure to achieve a pregnancy with as few attempts as possible becomes a driving force for both the patient and treating physician. In the absence of strict guidelines, a clinic may be tempted to transfer more embryos to improve its pregnancy rate.

Table 1 shows comparative data for 2009 between Québec and the rest of Canada, according to CARTR. It is clear that, although the multiple-pregnancy rate in Québec was slightly lower than the rest of Canada (25.6% versus 29.3%), the use of eSET was more popular in the rest of Canada (6.5% of embryo transfers) than in Québec (1.6%).

A large number of studies have discussed the potential benefits of eSET and the financial issues, comparing ongoing costs associated with multiple pregnancies and repeated IVF cycles due to reduced pregnancy rate when using eSET (Bromer et al., 2011, Fauque et al., 2010, Gerris, 2009, McLernon et al., 2010, Moustafa et al., 2008, van Peperstraten et al., 2008).

In Canada, health care is the responsibility of the individual provinces; thus, each province determines healthcare coverage. In Québec, the provincial government decided to include assisted reproduction treatment for infertility under the provincial health plan starting on 5 August 2010. The policy provides for any woman of reproductive age to have to up to three cycles of IVF with ovarian stimulation or up to six cycles of natural or modified natural cycle IVF at no charge; this applies whether the cycles are performed within a hospital unit or a privately owned facility. A cycle counts once an embryo transfer has been performed. Patients who have excess embryos cryopreserved following an IVF cycle are obliged to have those embryos thawed for transfer before embarking on another ovarian stimulation cycle, but frozen–thawed embryo transfers do not count against their three attempts.

In exchange for this coverage, the government imposed a limit on the number of embryos that could be transferred in any one cycle. In effect, the law states that only one embryo should be transferred in either a fresh or frozen IVF cycle. However, an option to transfer up to two embryos in a woman aged 36 years or younger and up to three embryos (including no more than two blastocysts) in a woman aged 37 years or older is available, but the physician must justify his decision (An Act Respecting Clinical and Research Activities related to Assisted Procreation, 2010).

The purpose of this study is to report on the outcomes (pregnancy rates and multiple-pregnancy rates) of IVF cycles in Québec from the first 3 months of provincially funded assisted reproduction treatment.

Section snippets

Materials and methods

All IVF cycles started in Québec assisted reproduction centres from 5 August to 5 November 2010 were recorded. The average patient age was 37 years, with patients ranging from 22 to 46 years old. Each of the five centres applied its own standard protocols for ovarian stimulation and laboratory procedures. Ovarian-stimulation protocols, including long gonadotrophin-releasing hormone (GnRH) agonist, short GnRH agonist and GnRH antagonist, were selected based on physician preference and patient

Results

From 5 August to 5 November 2010, a total of 1353 IVF cycles were started in Québec centres, 1276 cycles had egg retrieval and 1103 cycles resulted in embryo transfer. For comparison, only 517 IVF cycles were started in the same time period in 2009.

Overall, the clinical pregnancy rate was 32% and eSET was used in 50% of embryo transfers (Table 2). In the younger patient group (<35 years old), eSET was used in 79% of embryo transfers and resulted in a clinical pregnancy rate of 40%. There were a

Discussion

Multiple pregnancies are, undoubtedly, the major negative side effect of assisted reproductive therapies and, in countries where patients are responsible for the total cost of treatment, the multiple-pregnancy rate is often higher. An assumption that the transfer of multiple embryos will substantially increase the chance of pregnancy and, therefore, reduce the number of expensive attempts to achieve the desired live birth, places pressure on patients who, in turn, transfer this pressure to

Acknowledgements

The authors would like to thank the clinical teams from all five Québec assisted reproduction treatment centres for their hard work in achieving these results in such a short period of time.

References (9)

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Dr. François Bissonnette is the medical director of OVO, a fertility clinic in Montreal, and a professor in the department of Obstetrics-Gynecology at the University of Montreal. He completed his speciality training in obstetrics and gynecology in 1980 and was certified by the Royal College of Physicians and Surgeons of Canada in 1985. He was subsequently trained in reproductive endocrinology and infertility at the University of Louisville, Kentucky. He is currently the director of the Canadian ART Registry and has been President of the Canadian Fertility and Andrology Society in 2009.

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