Fact Check: Are millions of taxpayer dollars being wasted on poorly performing IVF clinics?

Updated

The Australian fertility industry has been facing scrutiny over the issue of in vitro fertilisation (IVF) success rates.

The claim: A leading IVF expert claims secrecy around IVF clinic success rates is wasting millions of dollars worth of Medicare rebates, as poorly performing clinics take more cycles to have a baby.

A leading IVF expert claims secrecy around IVF clinic success rates is wasting millions of dollars worth of Medicare rebates, as poorly performing clinics take more cycles to have a baby. The verdict: Clinic success rates are based on a number of complex factors, an straightforward comparisons between clinics and the subsequent costs to the government do not account for these. There's more to the story.

Although data has been collected for over 30 years and outcomes are published for the industry as a whole, success rates that identify clinics are not released to the public and patients have no way of comparing how one clinic stacks up against another.

Richard Henshaw, a senior fertility expert with the Monash group of IVF clinics, says: "The general public, Medicare and the private health industry have no idea who is good and who is bad."

Dr Henshaw said the disparity in success rates means extra costs for the government.

"For Medicare... clinics in the top 25th percentile cost around $2 million of Medicare money to produce 100 live births, whereas clinics in the bottom 25th percentile spend around $6 million to produce 100 live babies," Dr Henshaw told Radio National's Health Report on May 8.

Is secrecy about IVF success rates costing the Commonwealth millions of dollars in Medicare rebates? ABC Fact Check investigates.

How does IVF work?

IVF is a common form of assisted reproductive technology (ART), and typically involves five steps to complete a cycle.

Where do success rates come from?

The Fertility Society of Australia, which is the peak industry body representing scientists, doctors and other people involved in reproductive medicine, pays for the collection of data on the outcomes of fertility treatments.

It provides funding to NSW University's National Perinatal Epidemiology and Statistics Unit to collect and manage the data in the Australian and New Zealand Assisted Reproduction Database (ANZARD).

The most recent ANZARD report containing IVF success rates from 2012 was published in November 2014, based on data collected from 37 fertility centres operating 73 clinics in Australia and seven in New Zealand.

The director of UNSW's statistics unit, Georgina Chambers, said since the focus is on live birth outcomes, there is about an 18 month delay between the end of a calendar treatment year and the time a report can be published.

Most women undergoing IVF treatment use their own eggs. This is known in the industry as an "autologous fresh" cycle.

Embryos created during a typical IVF cycle don't have to be used all at once, and excess embryos can be frozen and then thawed and transferred in later treatments.

When this occurs, it is known in clinical speak as an "autologous thaw" cycle.

In order to improve pregnancy outcomes, some clinics start a fresh cycle, collect and mature the eggs, but then freeze all the embryos instead of transferring them straight away.

Every time a woman starts a treatment cycle, whether it is with fresh or frozen embryos, it is counted in the ANZARD data as a new cycle.

The report does not record results per clinic for the cumulative number of cycles that an individual woman undergoes.

What are the current statistics on success rates?

The latest ANZARD report shows a total of 70,082 cycles of Assisted Reproductive Technology treatment were performed across Australia and New Zealand in 2012.

Although success rate data is based on both countries, the majority of all cycles, over 92 per cent, were carried out in Australian clinics.

In the Health Report interview, Dr Henshaw said the secrecy around clinic success rates "means that if you are a patient in the lowest performing clinic you have to undergo seven times more treatment cycles than if you're a patient attending the top clinic".

Dr Henshaw also acknowledged that the clinic he works for, Repromed, stands to benefit from attracting more patients through the publication of its high success rates.

Fact Check asked Dr Henshaw about the source of his claims, including that the "top clinic had a live birth rate of 30.9 per cent, and the bottom clinic had a live birth rate of 4 per cent" in 2012.

To support his claims, Dr Henshaw pointed to the section of the ANZARD report that deals with the rate of live babies born from a woman's own eggs (that haven't been frozen) from each commenced cycle.

The rates for frozen embryo transfer cycles were similar in 2012, ranging from 4.7 per cent to 32 per cent per cycle initiated.

Live delivery rates per cycle initiated, Australia and New Zealand 2012 Type of cycle Overall (per cent) First quartile clinics Second quartile clinics Third quartile clinics Fourth quartile clinics Autologous fresh 16.7 19.7 - 30.9 17.3 - 19.6 13.3 - 17.2 4.0 - 13.2 Autologous thaw 20.5 23.7 - 32.0 19.0 - 23.6 14.9 - 18.9 4.7 - 14.5 Source: ANZARD report 2012

Dr Henshaw told the Health Report there was about a sevenfold difference between the highest rate in the top performing clinics, and the lowest rate in the bottom performing clinic.

Based on this, Dr Henshaw claims a patient attending the bottom clinic would need "seven times more cycles" to get the same result.

The factors for success

Australian patient advocacy group, Access, put together a fact sheet for patients looking to find an IVF clinic.

It says success rates depend on a number of factors, including "the number of eggs recovered, fertilisation rates, the quality of embryos and embryo transfer technique".

Experts contacted by Fact Check say treatment practices can skew success rates and that not all women have the same chance of conceiving, which can affect the comparability of success rates between clinics.

The fertility society's vice president Michael Chapman, who is a professor of obstetrics and gynaecology at UNSW, the chairman of the ANZARD management committee, and a senior specialist with fertility clinic IVF Australia, said more women are freezing all of their eggs in an IVF cycle, which can affect success rates.

Professor Chapman said these type of cycles are known as "freeze all" cycles, and can lead to misleading results: "A clinic that does a lot of freeze all cycles will apparently have a very low success rate in that cycle started."

David Molloy, clinical director of the Queensland Fertility Group and the chair of the Fertility Society of Australia's IVF Directors Group, agreed success rates for a typical IVF cycle do not account for these frozen egg collection cycles, and that can mean that some clinics that show up with poor live birth results are actually using different technology that isn't taken into account when simply measuring cycles.

"It may well be that the patients who are in those lower quartile units are achieving fewer live births in their fresh full IVF cycles, but what they are doing is having their embryos tested. Then when they have their frozen embryo cycle they actually achieve a much higher pregnancy rate."

Experts also said the clinic success rates can be dependant on the patients they are treating.

A woman's age, the cause of infertility, and the number of IVF cycles already undertaken will all determine likely chances of success.

UNSW's Georgina Chambers said that unfortunately some women could have multiple cycles and still be unsuccessful.

"So saying you need seven cycles to achieve a pregnancy – you can't just average it out like that," she said. "Success rates depend on a number of factors, many of which have to do with the patient, such as age and type of infertility."

Comparing success rates not straightforward

When making mathematical comparisons based on success rates, differences between patients are not taken into account.

Instead, every woman is assumed to have the same chance of success, when in reality this is not the case.

In the United States and the United Kingdom where live birth rate figures for clinics are publicly available, patients are still cautioned against making success rate comparisons.

The UK government's Human Fertility and Embryology Authority warns "it is not meaningful to directly compare clinics' success rates" due to a range of factors: "the age, diagnosis and cause of infertility of patients, the type of treatment the clinic carries out and a clinic's treatment practices".

America's Society for Assisted Reproductive Technology also warns that: "Patient characteristics vary among programs; therefore, these data should not be used for comparing clinics".

Steve Bowe, a senior research fellow in biostatistics from Deakin University, told Fact Check it would be "misleading" to suggest a patient in the lowest performing clinic would need to undergo seven times more treatment cycles to have success.

Dr Bowe said it is unclear from the ANZARD report how many women underwent treatment or how many cycles a particular woman has at each clinic, and that "there is just not enough information from the tables [in ANZARD] to compare the clinics based on success rates".

Just over a week after Dr Henshaw's interview, the Fertility Society of Australia issued a technical bulletin warning clinics not to make comparative statements using the ANZARD data on success rates.

The bulletin said: "This is particularly important because the patients to whom services are provided vary between units."

It quoted a policy of the Australian Health Practitioner Regulation Agency that says "using comparative advertising often risks misleading and/or deceiving the public because it can be difficult to include complete information when comparing one health service with another".

The average cost of treatment

Common associated fees for IVF Procedure Medicare rebate Extended Medicare safety cap IVF treatment cycle $2,333.10 $1,675.50 Egg collection $265.85 $70.35 Embryo transfer $83.35 $48.70 Intracytoplasmic sperm injection for male infertility $313.50 $108.15 Planning and management fee for specialist $63.55 $10.90 Total rebate amount $4,972.95 Note: after the first cycle, each subsequent IVF cycle receives $2,182.35 Source: Richard Henshaw, based on Department of Health, Medicare benefits schedule

Dr Henshaw said the commonly quoted cost to the Government is closer to $6,000, by the time additional rebates for anaesthetists' fees for the egg collection procedure are added, along with drugs for the IVF cycles funded through the pharmaceutical benefits scheme.

The total cost to the Government

Fact Check asked Dr Henshaw to explain the calculations behind his claim that patients attending top quartile clinics incur "around $2 million" in Medicare rebates, compared to "$6 million" for the lowest performing clinics to produce 100 babies.

He said that based on the ANZARD data, the top quartile clinics have an average birth rate of around 30 per cent.

According to Dr Henshaw this means "it will take three cycles to produce one live birth and 300 cycles to produce 100 live births".

He calculates 300 cycles x $6,000 per average rebate = $1,800,000.

Adding "10 per cent" extras for contingency, he says gives a total of around $2 million.

Similarly, Dr Henshaw calculates a clinic in the bottom quartile where the average live delivery rate is around 12 per cent in the same way: eight cycles will be needed to produce one live birth; 800 cycles for 100 live births; therefore 800 x $6,000 = $4,800,000 – plus 10 per cent for contingency is $5,280,000.

He says this is "around $6 million".

How many cycles are typically undertaken?

Professor Chapman said in his experience it is an "extrapolation beyond reality" that people will continue to undergo many cycles if the pregnancy rates are poor.

"In Australia, the cumulative data that we have in ANZARD shows that in all patients that start cycles in a given year, only something like 1 per cent will actually get to more than five cycles," he said.

The ANZARD report contains a long-term study of women who started their first autologous fresh cycle (the typical IVF cycle) in 2009.

It tracks the number of cycles these 16,565 women undertook between 2009 and the end of 2012. It does not publish results per clinic.

Of these women, 39.5 per cent had only one cycle, 22.6 per cent had two and 14 per cent had three, a total of 76.1 per cent.

Those who had seven or more cycles were 6.2 per cent of the total.

Money well spent?

The Vice President of the Royal Australian and New Zealand College of Obstetrics and Gynaecologists, Stephen Robson, told Fact Check there are differences between clinics in the "levels of experience and knowledge" of the doctors, nurses and scientists involved in IVF.

Dr Robson said he supported the claim that poorly performing clinics cost both patients and the Government more: "In the end the Government is rebating exactly the same amount for a treatment whether it is successful or not".

"So if you have a cycle of IVF treatment the funding you get isn't incumbent on whether the person is pregnant or not, it's whether they had the treatment," he said.

Dr Robson said while the same approach can also apply to other areas of medicine, the difference with IVF is the relatively high associated costs.

He told Fact Check that recent concern about the availability of a clinic's performance does deserve some closer attention: "Somebody somewhere who is holding the purse strings really has to say: well, do we need to make sure money is well spent?"

Loretta Houlahan is a former embryologist and current member of the Fertility Society's patient review panel, and has also publicly criticised the secrecy surrounding success rates.

In a recent article, she said unsuccessful patients "are otherwise known as return business", and said it is "inconceivable that these rogue poor-performing clinics are financially rewarded by return customers for their incompetence and exploitation".

While Dr Houlahan says that identifying clinics would allow patients to make comparisons and to make an informed choice, she also says that "the release of the league table may not give patients a clear picture of the likelihood of success in their specific circumstances".

The verdict

While there are differences between IVF clinics leading to concerns about the transparency of success rates, the way they are currently calculated can be misleading when trying to make comparisons.

Experts contacted by Fact Check say these rates are dependent on a number of factors, like patient characteristics and treatment types performed at the clinics.

Straightforward mathematical comparisons do not account for these variables, and subsequent calculations of the cost incurred to the Government through Medicare rebates cannot be substantiated.

There's more to the story.

Sources

Topics: reproduction-and-contraception, fertility-and-infertility, womens-health, science-and-technology, australia

First posted