Article in ST

Fertility clinics must disclose success rates by Andy HoThe Straits Times31 July 2007
A LOWER court had awarded a middle-age couple $32,000 for in-vitro fertilisation (IVF) treatment, but the High Court reversed this recently. The couple had lost both their teenage sons in a car accident and were asking for, among other things, IVF costs as replacement expenses in their effort to have a child.
The couple may appeal, so one may not comment on the case which involved, quite unusually, a motor vehicle insurer. But this tragic case does bring into focus the need for an IVF-specific law, which must address, if nothing else, two big issues.
First, given that Singapore needs more babies, it seems odd that there isn’t a law that requires (health) insurers to cover IVF treatment - or at least to offer coverage for it.
Insurers have argued that infertility is not an illness. Even if it were, they say, IVF does not treat the illness since it does not cure the underlying infertility. And, even if it did, coverage should be left to the market. After all, most plans here do not cover dental or psychiatric services.
Mandates to provide or offer coverage would distort markets, they say. That is, people who do not need IVF would have to bear part of the costs in higher premiums.
But I am pooled together with smokers anyway, so my insurance premium is already higher than it would be if my pool was smoker-free. After all, the essence of insurance is to socialise, or share out, risks.
Moreover, the lack of coverage means that health insurers are not helping to rein in IVF fees. It also means that IVF utilisation is probably less than that which would give Singapore more babies.
If so, instead of leaving it to the courts to decide piecemeal - someone must actually bring a suit for them to even consider the issue - Parliament should debate the question of coverage thoroughly.
And while Parliament is at it, it might also consider another issue, that is, how to regulate the sector.
Comprising mainly fee-forservice procedures, the sector is currently largely unregulated. Specifically, patients have no access to reliable information to help them choose service providers optimally, so they depend on word of mouth.
Most couples go through much pain for many years before they attain success, but many do not get that far.
IVF involves using drugs to urge a woman’s ovaries to produce eggs at each menstrual cycle, surgically retrieving the eggs, fertilising them with sperm in the lab to produce embryos, and then implanting the embryos into the woman’s womb. Women endure physical pain and couples are buffeted emotionally by the trials and tribulations the process puts people through. Moreover, each cycle of IVF treatment costs about $10,000.
Also, it is risky. Unlike most medical technologies, fertility treatments were introduced with little rigorous testing, except on animals. Most governments have simply left oversight of the sector to the medical profession’s self-regulation - and the courts.
Unsurprisingly then, it was merely five years ago that scientists were able to pin down the fact that IVF babies are six times more likely to have low or very low birth weights, and twice more likely to have major birth defects. Although clearer information has surfaced in the last dozen years, much is still unknown about the technology’s risks.
True, there is always some reluctance to regulate sectors where technology is rapidly evolving, since any law enacted today will have a hard time keeping up with the science tomorrow. But perhaps regulation can be targeted specifically to help with what customers really care about: results.
So whether we eventually pass a law to mandate insurance coverage or not, a law could be passed to mandate that providers report their individual success rates.
This is important because the infertile are very vulnerable and may persist in trying even when success is very unlikely. What they need is reliable data to make informed decisions that optimise their chances of getting a healthy baby.
However, providers in Singapore do not publicly report such statistics, so patients just go by word of mouth. And in jurisdictions where clinics do report their success rates, providers have been known to manipulate their data.
For example, some clinics count pregnancies rather than live births in their ’success’ rates, but some of those pregnancies end in miscarriages. Or, clinics may compare the number of live births to the number of embryos transferred, but this leaves out those cycles that are cancelled when eggs are harvested but cannot be fertilised.
However, the number of egg retrievals done does matter because the invasive procedure involved is painful and not risk-free. Any statistic that excludes failed cycles underplays the number of painful procedures (and risks) a woman might have to bear.
What to do?
We should pass a law to require service providers to disclose their success rates, specifying also how success-rate statistics are to be presented.
An unusually good model is that found in the American state of Virginia, where the law requires that before IVF treatment can commence, the clinic must give the patient a signed disclosure form detailing its success rates in specific ways. (This law specifies three statistics: First, the total number of live births, which is what couples care about most; second, the proportion of live births per menstrual cycle of retrieving eggs - which measures the true rate of success per attempt; and lastly, the numbers of both pregnancies and live births per retrieval cycle - which indicates the woman’s risk of miscarriage.)
The provider must also break down its data by age groups, since success rates drop as women age.
I urge Parliament to consider enacting a similar law. With uniform statistics among clinics, consumers can comparison shop and optimise the quest to make babies. And while Parliament is at it, mandate coverage of IVF services as well.