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Pregnant PauseWho should pay for in vitro fertilization?

By Darshak SanghaviPosted Friday, Feb. 13, 2009, at 6:52 AM ET

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In 2002, Harvard Medical School researchers found, unsurprisingly, that compared with women who pay out of pocket, those whose insurance fully covered IVF were significantly less likely to have multiples since they chose to have fewer implanted embryos. And while international comparisons are fraught with confounders, it's worth noting that Sweden and Australia have almost twice as many IVF births per capita as we do, yet their infant mortality rates remain comfortably lower. At least one difference may be that their national health insurances subsidize IVF, and thus there is less incentive to implant multiple embryos per cycle.

Another key difference is that many other countries also legally limit the number of embryos transferred in the first IVF attempts. (For example, Belgium permits only single embryo transfers.) Here, no legally binding regulations exist. The American Society of Reproductive Medicine recommends no more than two embryos in women under 35 years old, but flouting these policies doesn't lead to a loss of license.

Taken together, America has selected a policy that encourages multiples. Since insurers aren't compelled to cover costs for IVF, self-paying women attempt to get pregnant in as few cycles as possible. As a result, officials find it hard to justify legally restricting how many embryos can be implanted. Since they're paying for it, the thinking goes, women should be free to implant as many embryos as they wish. The result? More multiples, more costs, poorer child health, and, on occasion, bizarre cases like that of Nadya Suleman.

There's a cleaner way to handle the costs and regulation of IVF to reduce multiples, and that strategy was recently adopted by Sweden. In 2004, Scandinavian doctors reported that implanting one embryo at a time, repeatedly if necessary, resulted in the same final pregnancy rates as implanting several at once—with the incidence of multiples reduced to less than 1 percent of births in the sequential single-transfer group from 33 percent in the multiple-transfer group. The Swedes ran with the results: Their national health insurance now fully covers repeated IVF attempts with a single embryo but limits coverage if women instead choose to implant multiples embryos. It's too early to quantify the results, but the approach makes a lot of sense.

Ultimately, mandating coverage for IVF won't break the bank. According to one analysis, adding it would increase yearly premiums by only 0.1 to 0.3 percent (about $20 per year) and may lead to overall savings. Such coverage may also soften opponents of IVF regulation, so limits on embryo transfers could become politically viable, though it would presumably be a contentious issue. Most basically: Wouldn't it be better, in the end, to allow eight previously infertile women to experience healthy single pregnancies and deliveries, rather than invest our collective medical resources to let one woman give birth to premature octuplets?

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Darshak Sanghavi is Slate's health care columnist. He is chief of pediatric cardiology and assistant professor of pediatrics at the University of Massachusetts Medical School as well as the author of A Map of the Child: A Pediatrician's Tour of the Body.

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