Funding in vitro fertilization treatment for persistent subfertility: the pain and the politics

OBJECTIVE: To consider the arguments for and against funding for in vitro fertilization (IVF) and to explore potential avenues for policy change. DESIGN: Narrative literature review, policy analysis. SETTING: University Department of Obstetrics and Gynecology. PATIENT(S): Sub-fertile women and men. INTERVENTION(S): Fertility treatments, in particular IVF. RESULT(S): The two main arguments used against funding for IVF are that [1] subfertility is a social, not a medical problem, and therefore its treatment is not medically indicated or necessary, and [2] the clinical effectiveness of IVF is unproven. These and other major arguments are critiqued. CONCLUSION(S): Dismissing IVF as medically unnecessary seems premature because medical necessity has not been operationally defined. Demonstrating IVF effectiveness through a randomized trial has not been done but is feasible: a multicenter trial is currently underway in Canada. Dealing with the concern that subfertility treatment challenges the role of women in society, as well as with questions of cost-effectiveness, are more difficult challenges that deserve further debate. The potential for unethical uses and broader social implications of IVF add to its dubious status and provide a convenient rationale for refusing to pay. However, none of these concerns is unique to IVF: many currently covered health services are susceptible to the same criticisms. For all services, judgments of eligibility for coverage should be consistent and transparent and should explicitly separate the issues of cost from other factors.