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 f ertilization (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 treatme nt is not medically indicated or necessary, and [2] the clinical effectiven ess of IVF is unproven. These and other major arguments are critiqued. Conclusion(s): Dismissing IVF as medically unnecessary seems premature beca use 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 con cern that subfertility treatment challenges the role of women in society, a s well as with questions of cost-effectiveness, are more difficult challeng es that deserve further debate. The potential for unethical uses and broade r social implications of IVF add to its dubious status and provide a conven ient rationale for refusing to pay. However, none of these concerns is uniq ue to IVF: many currently covered health services are susceptible to the sa me criticisms. For all services, judgments of eligibility for coverage shou ld be consistent and transparent and should explicitly separate the issues of cost from other factors. (Fertil Steril(R) 2001;76:431-42. (C) 2001 by A merican Society for Reproductive Medicine.).