In a recent paper, Stewart et al. (1) report the probability of a live delivery over real time in a population-based cohort of women undergoing in vitro fertilization (IVF) treatment at clinics in Western Australia. They suggested that women should persevere in IVF treatment. However, they did not mention any limit on IVF cycles. Moreover, in the report by Stewart et al., the success rate of live deliveries reaches a plateau (meaning zero new deliveries) long before the 180 months and the number of cycles for which they had data. This means that women may continue with IVF treatment even when the probability of a successful outcome is “zero,” which begs the question of whether there should be any limit on IVF cycles. Undoubtedly, IVF has been a milestone in reproductive medicine, as millions of babies (five million up to 2006) have already been born with the aid of IVF. However, many questions about IVF still remain (2). One of these questions is the effect/s of long-term IVF treatment on women (3).
An example of a policy of limitless rounds of IVF cycles (looked upon by many as the north star for IVF policies) can be found in Israel, where the Israeli National Health Insurance (NHI) covers unlimited cycles of IVF for all female Israeli citizens up to two children in a given relationship (even if the woman already has children). While at first look the Israeli policy might be taken as an example to be followed worldwide (as it seems to be a win-win situation, with all the stakeholders enjoying equally under the ultra-permissive policy), a closer examination suggests that this may not be the case. Israeli women seem to enroll in massive IVF treatment for many years, ending up worse off in too many cases (4, 5).
The implication of a policy of unlimited rounds of IVF from the perspective of the “culture of perseverance” that develops in IVF clinics has not yet been fully assessed, either in Israel or elsewhere (3). Moreover, the number of IVF cycles a woman in Israel may go through remains unknown. Equally, the effectiveness of the open-ended IVF policy is unclear, as well as the side effects of long-term treatment with IVF. Further, while the equitable access to IVF in Israel should be applauded, in the context of NHI constraints, a scheme of (almost) limitless rounds of IVF remains questionable.
The authors of this short rejoinder have been recently awarded a grant from the Gertner Israeli Institute for Health Policy Research to analyze the effect/s of the open-ended Israeli IVF policy from the perspective of the “culture of perseverance” that develops in IVF clinics. We believe that before reassuring women to persevere with IVF, a systematic long-term assessment of the health and welfare of the women after IVF – especially after prolonged treatment with IVF – is necessary. In a global context, an evidence-based policy about Israeli ART may improve both the allocation of resources and the duty of care, not only in Israel, but also in other countries.
Frida Simonstein, Ph.D.
Michal Mashiach, Ph.D.
Dept. of Health System Management
Yezreel Valley College
1. Stewart LM, Holman CDJ, Hart R, Finn J, Mai Q, Preen DB. How effective is in vitro fertilization, and how can it be improved? Fertility and Sterility 2011;95:1677-83.
2. Holm S. The medicalization of reproduction – a 30 year retrospective. In: Simonstein F, ed. Reprogen-ethics and the Future of Gender. London: Springer, 2009:29-36.
3. Simonstein F. Assisted reproduction policies with emphasis on Israeli practices. Health Policy 2010;97:202–8.
4. Remennick, L. Childless in the land of imperative motherhood: Stigma and coping among infertile Israeli women. Sex Roles 2000;43:821-41.
5. Birenbaum-Carmeli D. ‘Cheaper than a Newcomer’: On the political economy of IVF in Israel. The Sociology of Health and Illness 2004;26 (7):897-924.
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.09.016
The Authors Respond:
We thank Drs. Simonstein and Mashiach for their interest in our article (1). Unfortunately, they appear to have misinterpreted some of our findings. Our results did not show that “women may continue with IVF treatment even when the probability of a successful outcome is ‘zero’,” and our paper does not provide support for a policy of limitless IVF. Rather, we found that many women cease IVF cycles at a point well before the success curve appears to saturate, thus raising the possibility that for some women additional cycles could confer reproductive benefit.
We agree with Drs. Simonstein and Mashiach that the long-term health consequences of IVF treatment need to be investigated. This is the subject of our current research.
Louise Maree Stewart, B.Sc.(Hons), GradDipPHa
C D’Arcy J. Holman, M.P.H., Ph.D., F.A.F.P.H.M.a
Roger Hart, M.D., C.R.E.I.b
Judith Finn, Ph.D., R.N.c
Qun Mai, M.B.B.S., M.P.H.a
David B Preen, Ph.D.a
aSchool of Population Health
The University of Western Australia
bSchool of Women’s and Infants Health
The University of Western Australia and Fertility Specialists of Western Australia
cDiscipline of Emergency Medicine
The University of Western Australia
1. Stewart LM, Holman CD, Hart R, Finn J, Mai Q, Preen DB. How effective is in vitro fertilization, and how can it be improved? Fertil Steril 2011;95:1677-83.
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.09.017