Quebec proposes to ban women over 42 from having IVFBMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g7724 (Published 18 December 2014) Cite this as: BMJ 2014;349:g7724
Quebec, which five years ago became the first Canadian province and the only jurisdiction in North America to publicly fund in vitro fertilisation (IVF) treatment, has announced plans to ban all IVF treatment for women aged over 42, even if they are willing to pay for it themselves.
Currently before Quebec’s national assembly, Bill 20 is the first legislation in the world to impose an absolute age limit on IVF treatment. The ban applies even to women using donated or previously frozen eggs, unless they were frozen during a medical crisis such as cancer.
Bill 20 also imposes fines of up to $C50 000 (£27 000; $43 000; €34 000) on doctors who refer women over 42 for IVF treatment outside the province. It removes IVF treatment from the realm of public health insurance altogether, offering instead a means tested tax credit varying from 20% to 80% of the full cost of roughly $C10 000 per treatment cycle. The tax credit will cover one cycle of treatment for women aged under 37 or two cycles for women aged 37-42. The current regime offers three cycles of treatment for all women that are effectively free beyond a nominal copayment.
The bill also mandates that couples who need to use donated eggs or sperm must undergo a psychosocial assessment of their fitness for parenting. This clause immediately drew fire from gay rights advocates, who noted that same sex couples would automatically require such a clearance while most heterosexual couples, using their own gametes, would not.
Doctors feature prominently in the Liberal government that is tabling Bill 20, including the premier, neurosurgeon Philippe Couillard, and the health minister, radiologist Gaétan Barrette. But the government is focused on reining in public spending, and its first year has been marked by battles over cuts to, and reorganisation of, the health services. Funding IVF treatments cost about $C70m last year, providing 10 600 cycles.
Barrette, former president of the Federation of Medical Specialists of Quebec, once criticised the IVF programme as an “open bar” that profited private clinics. Explaining Bill 20 on CBC Radio’s The Current, he said that the IVF service had been abused. He cited a case in which a young woman began IVF treatment on her 18th birthday and is now a single mother and others in which couples’ home environments were so bad that their child was removed by social services at birth.
“It’s not a cost issue, it’s a medical issue,” said Barrette. Noting that women over 42 are more likely to give birth prematurely, he linked premature birth to childhood learning difficulties. “It is one thing to promote the technical prowess of a procedure and say ‘it works!’ But does it work, down the road?”
Barrette told CBC Radio that the last Liberal government, in which the current premier was a health minister, had acted hastily in creating the IVF programme under pressure from a powerful lobby led by Neal Mahutte, president of the Canadian Fertility and Andrology Society.
Mahutte, who is also medical director of the Montreal Fertility Centre, told The BMJ that the government “has a case” in refusing to fund IVF treatment in older women using their own eggs, given the steep decline in success rates after 42. “But to prevent them from paying for their own treatment is discrimination, in my view,” he said. He added that the legislation also took no account of the fact that women aged over 42 have IVF live birth success rates close to those of younger women when using eggs donated by younger women.
Mahutte said that Barrette’s radio interview showed that he had not thought his legislation through. Asked what would happen to embryos or eggs previously frozen by women now aged over 42, the minister initially replied that “they would have to be destroyed,” but when challenged by the interviewer he conceded that they were the woman’s property and she could take them if she wished for treatment elsewhere.
This was “preposterous,” said Mahutte. “You can’t just turn up with an ice cooler and say you’re taking your eggs or embryos. You need the help of the clinic that froze them. But the legislation, as it’s written, prohibits any physician from assisting.”
Cite this as: BMJ 2014;349:g7724
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