The state funding of fertility treatment through public reimbursement policies has a direct influence on national birth rates. Lower levels of reimbursement are correlated with higher unmet needs for treatment, while more generous reimbursement policies increase access to treatment and may even make a measurable contribution to national birth rates.
The findings come from a study reported here today at the annual meeting of ESHRE (European Society of Human Reproduction and Embryology). The results, says health economist Dr Mark Connolly from the University of Groningen in the Netherlands, reflect the wide variety of reimbursement policies throughout Europe and come at a time when many national and local authorities have made plans to cut back their IVF funding as a cost-cutting initiative.(1)
Dr Connolly and colleagues quantified the reimbursement policies of 23 European countries, using an index score ranging from 0 to 18; the higher index scores indicated fuller state funding/reimbursement for treatment. The countries with the most generous funding policies were Belgium, France and Slovenia (with scores between 14 and 18); those with the least generous were the UK, Russia and Ireland (all with scores under 3).
These index scores were then correlated with treatment practice and outcomes in each of the 23 countries. Results first showed a significant relationship between the level of reimbursement and the annual contribution of assisted reproduction (ART) births to national birth numbers. " This finding," said Dr Connolly, "has important policy implications for national authorities concerned about ageing populations and interested in policies for influencing national birth rates. Although the influence on birth rates is small, the relationship is positive and provides an opportunity to compare with other policies implemented by local and national governments to influence birth rates."(2)
Results also showed that in countries with higher levels of reimbursement a higher volume of ART cycles is performed. For example, ESHRE monitoring data for 2008 showed that more ART cycles per million population were performed in Belgium and Denmark (2479 and 2450 ART cycles per million population in 2008) than in Germany, Italy and UK (801, 807 and 825 cycles). "If one considers medical need is similar across countries," said Dr Connolly, "then the data here suggest a great unmet need in those countries with limited reimbursement."
However, the study did not show any significant relationship between reimbursement policies and access to care for women of different age groups. This would suggest, said Dr Connolly, that there is no oversupply of treatment in countries with generous state funding. "This is a welcome finding," he added, "because it suggests treatment is based on medical need and not simply on the availability and accessibility of reimbursed treatment."
While the study did not find correlations between reimbursement and patient age (or deliveries per cycle, or multiple embryo transfers), there was a trend towards more singleton deliveries in countries with higher levels of reimbursement, suggesting that results in poorly reimbursed countries are more dependent on a single cycle of treatment than on single embryo transfers in cumulative cycles.
The authors of the study hope that health ministries at this difficult economic time consider the broader implications of access to fertility care and the cost consequences of not funding. As shown by this study, limited funding for ART will result in fewer children being born each year and inequitable access to treatment.
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More information: 1. The sudden introduction of a 50% co-payment scheme in Denmark in 2011 resulted in a reduction in the number of ART cycles performed, and in the number of referrals. According to Professor Anders Nyboe Andersen, from Rigshospitalet in Copenhagen and a co-author of the study, this was calculated to represent the loss of approximately 700 children from 2010, 1.2% of the national birth cohort. Annual birth rate in Denmark in 2011 was the lowest for 13 years. Conversely, the introduction in Belgium in 2003 of a scheme to reimburse the costs of six cycles of treatment has seen Belgium's multiple pregnancy rate decline from 20 to 7%, and its rate of access to treatment increase to that of Denmark (2479 cycles per million population in 2008).
2. There has been a slow-down in the EU's population growth in recent decades. A total fertility rate of around 2.1 live births per woman is considered to be the replacement level, but TFR has declined to a level well below this. The lowest total fertility rate of 1.45 live births per woman was registered in 2002. For country-by-country TFRs and EU policy on fertility, see epp.eurostat.ec.europa.eu/statistics_explained/index.php/Fertility_statistics