Effect of publicly funded assisted reproductive technology on maternal and infant outcomes: a pre- and...

Does publicly funded assisted reproductive technology result in improved maternal and infant outcomes?

Publicly funded ART in Quebec was associated with reduced risks of preeclampsia, cesarean delivery, preterm birth, low birth weight and other adverse outcomes.

Publicly funded ART programs that provide free access to single embryo transfer are known to decrease the rate of multiple pregnancy, but the impact on other pregnancy outcomes is unknown.

We conducted a pre- and post-comparison study of 597 416 pregnancies conceived between July 2008 and September 2015 in Quebec, Canada, a region where public funding of ART began in August 2010.

We included all pregnant women who conceived by ART (n = 14 309) or spontaneously (n = 583 107) and delivered a live or stillborn infant in hospitals of Quebec. The main exposure measure was conception before versus during the publicly funded ART program. Outcomes included measures of maternal and infant morbidity and mortality. We estimated risk ratios (RR) and 95% confidence intervals for the association of publicly funded ART with maternal and infant outcomes using log-binomial regression models adjusted for maternal characteristics.

In this study, 2638 pregnancies were conceived by ART before, and 11 671 were conceived by ART, during public funding. Compared with no public funding, ART funding was associated with reduced risks of severe maternal morbidity (RR 0.64, 95% CI 0.50-0.83), preeclampsia (RR 0.55, 95% CI 0.44-0.68), cesarean delivery (RR 0.83, 95% CI 0.77-0.89), preterm birth (RR 0.67, 95% CI 0.60-0.75), low birth weight (RR 0.63, 95% CI 0.55-0.72), severe neonatal morbidity (RR 0.75, 95% CI 0.57-0.99) and neonatal intensive care unit admission (RR 0.65, 95% CI 0.53-0.78). When multiple pregnancies were excluded, ART funding continued to be associated with a lower risk of preeclampsia (RR 0.61, 95% CI 0.48-0.79) and preterm birth (RR 0.85, 95% CI 0.73-0.99). However, ART funding was associated with increased risk of gestational diabetes.

We had no information on the type of ART, number of in-vitro fertilization cycles or number of embryos transferred. We lacked data on body mass index, ethnicity and smoking and cannot rule out residual confounding.

Our findings suggest that publicly funded ART programs that encourage single embryo transfer may have substantial benefits for a range of maternal and infant outcomes, beyond prevention of multiple births.

This study was supported by grant 6D02363004 from the Public Health Agency of Canada. N.A. acknowledges a career award from the Fonds de recherche du Québec-Santé (34695). The authors declare no competing interests.

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