An evidence-based policy for the provision of subsidised fertility treatment in California: Integration of array comparative genomic hybridisation with IVF and mandatory single embryo transfer to lower multiple gestation and preterm birth rates

Abstract

Common to other practice settings, standard in vitro fertilisation (IVF) in California strongly skews the multiple gestation/preterm birth rate upward to approximately 50% of all deliveries, while unassisted conceptions yield this outcome in only 3% of births. Preterm/multiple gestation babies from IVF are “super-utilisers” and consume a disproportionate share of healthcare resources, particularly during the first year of life. However, early experience with molecular cytogenetic techniques has shown that single embryo transfer (SET) with IVF can now lift pregnancy rates to an acceptable level while not altering the normal multiple gestation rate. This approach would effectively solve the preterm and multiple gestation problem historically associated with IVF. Building on the author’s previous research in medically assisted reproduction, the current proposal describes a new public health policy to incentivise SET by modifying the California Insurance Code (benchmark health plan), when it may next be revised in 2015. The proposal would partially cover IVF costs for qualified California residents with the proviso that only one embryo is transferred per procedure after comprehensive chromosomal screening of embryos with array comparative genomic hybridisation (aCGH). This investigation considers the interconnected problems of preterm birth and multiple gestation in a demographic context, showing that although the contribution made by conventional IVF to these adverse outcomes in California is numerically minor, substantial costs can still be recovered by redirecting expenditures away from high-risk IVF deliveries when the increased multiple gestation/preterm birth rate from standard IVF is corrected. This analysis is the first to examine costs calculated for all delivery types in California as a function of antecedent IVF treatment vs. unassisted conception, based on 2009 birth records, and apply this to a new model of comprehensive embryo testing and mandatory SET. These data reveal that even if partially subsidised IVF with aCGH and SET were provided for every California IVF cycle initiated in 2009 (n=18,405), the state would still realise a net surplus of at least $20M per year by stabilising the IVF multiple birth rate at ~3.2%. Thus, California can avoid up to 4,810 iatrogenic preterm/multiple gestation births by shifting the prevailing approach to IVF away from multiple embryo transfers. The proposal is net revenue positive for California because although IVF with aCGH and SET is expensive, the price to obtain this technology is always lower than the cost for one high-risk preterm/multiple birth. While a compelling primary interest exists to lower the multiple birth rate with IVF, this proposal also yields a socially valuable secondary public health benefit by improving general access to this advanced reproductive treatment for all Californians