The Use of Assisted Fertilization in Finland:Health Effects and Equity

Abstract

Koeputkihedelmöitys ja munasarjojen lääkkeellinen induktio ovat yleisiä hedelmöityshoitoja Suomessa. Niiden käytöstä ja terveysvaikutuksista hoitoja saaneille naisille ja hoitojen jälkeen syntyneille lapsille ei kuitenkaan vielä tiedetä riittävästi.

Tämän tutkimuksen tarkoituksena oli selvittää hedelmöityshoitojen jälkeisiä sairaalahoitoon johtaneita komplikaatioita ja keskenmenoja sekä hoitojen seurauksena syntyneiden lasten terveyttä terveydenhuollon rekistereitä käyttäen. Sen lisäksi tavoitteena oli kuvata hoitojen käyttöä ja koeputkihedelmöityshoitoihin käytettyjen resurssien jakautumista naisten taustatekijöiden mukaan.

Tutkimuksen mukaan koeputkihedelmöityksen seurauksena syntyneillä lapsilla oli enemmän terveysongelmia kuin muilla lapsilla, vaikka suurin osa lapsista syntyikin terveinä. Osa lasten lisääntyneistä riskeistä liittyi monisikiöisten raskauksien suureen lukumäärään. Naisten merkittävin riski oli munasarjojen hyperstimulaatiosyndrooma. Noin 15 % koeputkihedelmöityshoitoa ja 8 % muita hedelmöityshoitoja saaneista naisista päätyi komplikaatioiden tai keskenmenon takia sairaalahoitoon. Keskimääräiset kustannukset koeputkihedelmöityshoidosta olivat syntynyttä lasta kohti laskettuna 12 851 euroa alle 30-vuotiailla naisilla ja yli 40-vuotiailla 40 662 euroa. Koeputkihedelmöityshoitojen käytössä julkisella sektorilla ei juuri ollut sosiaaliryhmien välisiä eroja. Sen sijaan yksityissektorilla hoitoa saaneiden naisten sosioekonominen asema oli vertailuryhmää korkeampi. Alueelliset erot hoitojen käytössä ja resurssien jakautumisessa olivat vähäisiä.

Tutkimustuloksia voidaan hyödyntää harkittaessa hedelmöityshoitoa ja neuvottaessa hoitoon hakeutuvia pareja. Yhteiskunnan kannalta tieto hoitojen alueellisen vaihtelun vähäisyydestä, sosiaaliryhmien välisistä eroista ja hoitojen kustannuksista on tärkeää. Lisätutkimuksia tarvitaan selvittämään hoitoja saaneiden naisten ja heidän lastensa pidemmän ajan terveyttä.

Klemetti R. The Use of Assisted Fertilization in Finland: Health Effects and Equity

Background: Though Assisted Fertilization (AF), consisting of in vitro fertilization (IVF, including intracytoplasmic sperm injection and frozen embryo transfer) and ovulation induction (OI with or without inseminations), is widely used as a treatment for infertility, not enough is known about its utilization and health effects. Equity in health care should mean equal access to care according to need and an equitable distribution of health care resources by gender, age, living area, and socioeconomic position. IVF is a costly treatment in which effectiveness and appropriateness decrease by women's age while need and complications increase.

Objective: The purpose of this study is to investigate via nationwide registers the use of AF, i.e. IVF and OI, the occurrence of serious complications and miscarriages of treated women, and the health of their children, as well as to describe equity in the allocation of resources to IVF by women's age and socioeconomic position and by the treatment sector (public vs. private). Finally, the aim is to discuss whether the usual criteria of equity apply to IVF.

Materials and methods: In this register-based study, women who received IVF (N=9175) and OI (N=10 254) between 1996 and 1998 were identified from the reimbursement records of the Social Insurance Institution (SII) that cover all Finns and were followed until 2000 by means of register linkages (The Hospital Discharge Register and The Cause-of-Death Register). Population controls, matched by age and municipality, were selected for IVF women (N = 9175). IVF women's children (N = 4559) and OI women's children (N = 4467) were identified from the Medical Birth Register (MBR) and followed until 2003 by using the Hospital Discharge Register, the Register of Congenital Malformations, the Cause-of-Death statistics, and reimbursements records of the SII. Two control groups were selected from the MBR: all other children from the same period (N = 190 398, for studying perinatal health, hospitalizations and mortality) and also a random sample of them (n = 26 877, for studying congenital anomalies (CAs) and health-related benefits). Information on treatment costs were received from IVF clinics and the SII.

Results: During a mean follow-up period of 1.5 years, older women received 1.4 times more IVF treatment cycles than younger women (2.2 vs. 3.0). In the private sector, women in the highest socioeconomic position were over-represented and had more cycles than other women. The success rate live-births per cycle decreased by women's age: from 22% among women aged below 30, to 6% among women aged 40 or older.

After IVF, 23 per 1000 and after OI, 1 per 1000 women had a serious case of OHSS (ovarian hyperstimulation syndrome) during the study period (mean of 2.7 treatments). The rates of registered miscarriages after both IVF and OI were 42 per 1000 treated women. Overall, 15% of IVF and 8% of OI women had at least one hospital episode during the study period. Perinatal outcomes of IVF children were worse and hospital episodes were more common than among control children; odds ratios (OR) for cerebral palsy (2.9, 95% CI 1.6­5.3) and psychological and developmental disorders (1.7, 1.1­2.5) were increased as well as OR for congenital anomalies (1.3, 1.1­1.6). These results were partly explainable by the great number of twins among IVF children. Among IVF singletons, poorer results were found for perinatal outcomes and hospitalizations, while for singleton IVF boys an increased risk of major CAs were also found. The health of IVF multiples was comparable to the health of control multiples.

The mean cost of a live birth after IVF increased by women's age from EUR 12 851 among women aged under 30 to EUR 40 662 among women aged 40 or older. Calculated per population, society contributed most to the women aged 30­39 years and women from the highest socioeconomic position. Regional differences were not remarkable.

Conclusion: Although the health of most IVF children was good, they had more health problems than other children. The risk of complications for women after each IVF treatment cycle was low, but repeated attempts resulted in serious complications for many women, and these occurred much more often than after OI alone. Further studies are needed to examine the long-term health of IVF and OI women and their children. No information on the need for IVF and OI treatments, i.e. infertility rates and the wish for a child, was available in the study. It is therefore uncertain whether women from a certain age-group are favoured in treatments in Finland. Due to the higher costs, increased health risks and decreased IVF success for older women, concentrating on the treatment of younger women is a fairer solution than provision solely based on need.

Socioeconomic differences in the use of IVF services and the allocation of resources may indicate inequality.