Does Mandated IVF Coverage Help Lower the Rate of Multiple Births?

With more than 7 million infertile women in the United States, the need and demand for effective IVF treatment remains high. Unfortunately for these women/couples, the cost for such treatment is also relatively high.

With more than 7 million infertile women in the United States, the need and demand for effective IVF treatment remains high. Unfortunately for these women/couples, the cost for such treatment is also relatively high. As such, some states have enacted legislation that requires insurance companies to provide varying degrees of coverage for infertility treatment; a few states have specifically mandated coverage for IVF. With these mandates has come an increased concern over the rate of multiple births. For instance, even though IVF successes have improved over the years, resulting in high pregnancy rates with a lower number of embryos transferred, the rate of multiple live births was still elevated at 34.3% in 2006.

To determine the impact of the increase in mandated coverage, Dr J. Ryan Martin, assistant professor of obstetrics, gynecology, and reproductive sciences at Yale University School of Medicine, and colleagues analyzed data collected as part of Society for Assisted Reproduction (SART) and Centers for Disease Control and Prevention on all fresh, nondonor IVF cycles performed in the United States in 2006. Their retrospective review included 91,753 fresh, nondonor IVF cycles; 27,565 (30%) of which were performed in mandated states (ie, states in which legislation mandated coverage for at least one cycle of IVF; Table), and the remaining 70% (64,188) were performed in clinics in non-mandated states.

Table. States That Mandate At Least One Cycle of IVF

The researchers found that clinics in states without insurance mandates for IVF treatment had higher pregnancy and live-birth rates, but also transferred significantly more embryos than those states with mandated coverage. As a result, the clinics in non-mandated states reported higher rates of multiple births (ie, twins and triplets) in patients under the age of 35 years (Figure). Similar results were seen in the 35 to 37 age group. In this age group, the average number of embryos transferred was statistically higher in the states without mandated coverage as compared to states with mandated coverage. As a result, the triplet and multiple birth rates were also statistically higher. Although similar trends were found in the 38 to 40 and 41 to 42 age groups, those results were not statistically significant. Interestingly, the states with mandates were more likely to follow the American Society for Reproductive Medicine’s 2006 recommendations, which encouraged single embryo transfer for those patients with a favorable prognosis: no more than 2embryos in patients younger than 35 years, and 2 embryos but no more than 3 in those patients aged 35 to 37 years.

Figure. Birth results for 35 year or younger age group





Martin and colleagues hypothesized that financial incentives were at play, stating that patients in insured states may be more willing to transfer fewer embryos since they know a subsequent IVF cycle would be covered if the first attempt failed. On the other hand, in states where there was no mandate, they hypothesize that patients tried to optimize their efforts with increased embryo transfer.

Since women with multiple pregnancies are at increased risk for maternal and fetal complications as compared with women with singletons, these findings have significant clinical and policy implications. Indeed, the increased complications associated with multiple pregnancies have led many countries to limit the number of embryos transferred.

“The simplest way to reduce the incidence of multiple pregnancies in IVF is to transfer fewer embryos. Financial coverage for IVF is strongly and consistently associated

with responsible ET [embryo transfer] practices both in the United States and internationally,” Martin et al noted.

“This study and past comparisons of IVF practices in mandated and non-mandated US states cement the argument that an effective way to significantly reduce the practice of transferring many embryos and the subsequent complication of multiple pregnancies is through IVF state insurance mandates.”

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