- Open Access
Decision making about infertility treatment: does unlimited access lead to inappropriate treatment?
© The Author(s). 2016
- Received: 31 May 2016
- Accepted: 6 June 2016
- Published: 14 June 2016
The original article was published in Israel Journal of Health Policy Research 2016 5:14
The proportion of women aged 40–44 undergoing IVF treatment covered by Maccabi Health Services increased between 2011 and 2014. Although age-specific birth rates did not substantially change over this time period, the demographic change was accompanied by an overall decrease in live births after IVF treatment. The relative contribution of changing population demographics vs. current age-related coverage policies to these trends is unclear. Additional research is needed to better understand the potential effect of changes in current policy on maternal, neonatal, and economic outcomes.
- Assisted Reproductive Technology
- Live Birth Rate
- Infertility Treatment
- Donor Oocyte
Economic incentives and disincentives clearly play a role in couples’ decision making about having children. In the United States, birth rates declined during the Great Recession, with declines greatest in those states most affected by job loss . Studies from Israel suggest that policies and practices affecting the level of child support are strongly correlated with birth rates [2, 3]. Not surprisingly, couples are more likely to try to have children when there is greater certainty that the resources needed to raise those children will be available.
For couples who are unable to spontaneously conceive, there is an additional consideration—the resources needed to undergo diagnosis and treatment of infertility. Again, there is evidence that infertility services are more likely to be utilized when those resources are at least partly covered by private or government insurance. Utilization of assisted reproductive technology (ART) varies between states in the U.S., with utilization greater in states where there is a legal mandate for insurers to provide coverage [4–6]. Increasing access in this way may have some beneficial effects—if the costs of multiple cycles is lower, couples may be less inclined to opt for more aggressive per-cycle treatment (such as replacement of multiple embryos) [4–6], which, while increasing the per-cycle success rate, also increases the probability of multiple gestations, with accompanying increased risk for maternal complications, preterm birth, and short- and long-term morbidity in the offspring.
Although there are a number of causes of infertility, a substantial proportion of couples will have no identifiable underlying pathological diagnosis; for many of these couples, the most likely reason for a decline in fecundity is the age-related decline in ovarian function in women. “Older” women make up an increasing proportion of the infertility population in many centers ; success rates in the absence of the use of donor oocytes in this population are substantially lower than for younger women .
During the past five years, the proportion of IVF treatments provided by the Maccabi Healthcare Services to women aged 40–44 has increased substantially, which has been accompanied by an overall decrease in success rates per treatment cycle. The extent to which current Israeli Ministry of Health policies regarding age restrictions on IVF treatment are responsible for this observation, as opposed to changes in the underlying patient demographics, is unclear. Potential changes in coverage policies should consider estimates of the size of the potential patient population, trends in the epidemiology of different causes of infertility, both benefits (cumulative live birth per couple) and harms (maternal and neonatal complications) of IVF treatment in women of different age groups, and the economic impact of these policies.
ART, assisted reproductive technology; IJHPR, Israel Journal of Health Policy Research; IVF, in vitro fertilization
US Agency for Healthcare Research and Quality
Patient-Centered Outcomes Research Institute
National Cancer Institute
Availability of data and materials
Dr. Myers is the Walter L. Thomas Professor of Obstetrics & Gynecology at Duke University School of Medicine. He is a member of the Duke Evidence Synthesis Group based at the Duke Clinical Research Institute, and is also a member of the Duke Cancer Institute. His research interests are primarily in the application of formal methods of evidence synthesis, including mathematical modeling, to address important clinical, research, and policy questions in women’s health.
Kol S, Yellin LB, Segal Y, Porath A: In Vitro fertilization (IVF) treatments in Maccabi Healthcare Services 2007–2014. Isr J Health Policy Res 2016, 5:14.
The author declares that he has no competing interests.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
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