OMG, We’re infertile? How did that Happen?

Trillium used as the official symbol for the Province of Ontario. (Photo credit: Wikipedia)

As a member of the Conceivable Dreams blogging team here in Ontario, I pretended for a minute to put myself in an infertile couple’s shoes this family day long-weekend, so I Googled “infertility education in Ontario” and we quite shocked and disappointed by the resources which came up in Infertility education, below.

Notice that while there are many helpful resources on infertility in Ontario, there are none from the Ontario government’s own Ministry of Health.  If the intent of Family Day is to allow families to have a day to spend together then am I wrong to expect the government to also look for ways to help couples become families – through funding of IVF and educating Ontarians about causes of infertility…

Look at what came up in my search before anything from the Ontario government;

The first link belongs to a doctor, Thomas Hannam, and his views on infertility, here.  Do you know how to treat your eggs?  “If you are fortunate, you may already know that you have good quality eggs.  However, if you have reason to doubt the situation, then you may wish to try to “maximize” egg quality. Lifestyle matters: sleep well, quit smoking, and minimize caffeine to one cup of coffee a day.”

As a male, maximizing the quality of a female’s eggs never even occurred to me, however those items Dr. Hannam mentions are common lifestyle choices I think we should all be choosing anyways.  I was just surprised to know they had such an impact and egg quality… Should this not be taught to children in school?

My next hit was an OHIP4IVF post from one of our team members, following that was a link to the expert panel on infertility and adoption.

Then came a link to a London Health Sciences Fertility Ontario site (which is not a government education site, but rather a clinic here in Ontario run by a Doctor who cares about infertility.

After that came a site – not in Ontario – suggesting that infertility be taught in school, and that article can be read here;

I agree with that viewpoint.

Then came another article through the Infertility Awareness Association of Canada and while this site is not currently being updated there are significant resources there.

Still missing is the education platform of the Ontario Government.  Everyone knows that educating people is a less expensive and proactive way to address an issue, rather than waiting 20 or 30 years down the road and having to deal with an epidemic on mass.  Not that this Liberal government is the absolute cause of this problem but they are certainly not helping with the solution by constantly disregarding OHIP funding of IVF treatments for infertile couples who are trying to have children at all ages and in all socio-economic groups.  This government constantly refers to their own education program, however, it must be hidden or by invitation only because I could not find it.

Furthermore, the only Ontario government department with any published opinions on infertility is the Ministry of Child and Youth Services.  At least here they say they are going to on their website; “Infertility is a medical condition that often requires medical treatment. Infertility has wide-reaching consequences for individuals, families and society.”

Simple and too the point.  It continues;

“We believe that all Ontarians should have the opportunity to build a family. Infertility is a medical condition that prevents some Ontarians from doing so. These medical problems often require medical treatment(s) to overcome infertility. Right now in Ontario, one in eight couples is struggling with infertility. One in  six couples has experienced infertility at some point in their lives. Both male and female infertility are on the rise. And many other Ontarians – same-sex and single people and people with illnesses like cancer or HIV – need help to start a family.”

Then the government confirms what many of use feel is a major issue with IVF treatment costs – equal access to everyone;

“Access to assisted reproduction services should be free from any discrimination.  Every year, tens of thousands of Ontarians turn to assisted reproduction and other services like acupuncture and naturopathic medicine to help them conceive. Thousands more never seek help.  People who have experienced fertility problems or who have sought help told us about the barriers they face;

• It’s difficult to get information: many people didn’t know about the factors that affected their fertility.
• They are not sure where to go for help. Some facilities and practitioners offering assisted reproduction services are not accredited. Are the treatments safe? Where should they go to get the best care?
• The procedures are too expensive. Many treatments are beyond the reach of most Ontarians.
• There isn’t enough emotional support to help them deal with the grief over fertility problems, the stress fertility issues place on relationships or the challenges of treatments.
• Many people have trouble accessing services because of where they live.
• For same-sex and single people, and people with HIV, social and legal barriers can keep them from getting the services they need.
• The fertility needs of young cancer patients are often forgotten by treating cancer specialists.
• There is still a sense of failure or stigma about infertility that keeps many people silent and in pain.”

While I never would have come to this Ministry for information on infertility, and equality in IVF, I suspect many others would not looking here either.  If this next piece quoted from their website is not a cry to be heard, I don’t know what is;

“Ontario can do better. Ontario must do better. The status quo is not acceptable.  We see a province where all Ontarians have the information they need to protect their fertility, where they are confident that they are receiving safe, high quality care, and where other barriers – such as cost, geography and stigma –  do not keep them from getting the services they need.

To be the best place to create a family, Ontario must act now.

1. All Ontarians should know how to protect their fertility.
2. Assisted reproduction services should be safe and meet the highest, evidence-based    standards.
3. Ontario cannot afford to NOT fund assisted reproduction services.
4. All Ontarians who could benefit should have access to assisted reproduction services.”

Way to go, Ministry of Youth and Child Services!  Now walk down the hall to the Ministry of Health and give them the link to your website and ask them to get their asses in gear, please.

We already know that knowledge IS power so the more people know about their health, the better they will be able to make informed decisions, not only to improve their health but also to manage their fertility – early enough when there is still time to make changes and see the results of those changes.  We also know that age is one of the most important factors affecting the ability to conceive as couples are waiting until later in life to have children than ever before.

Lifestyle factors such as smoking, alcohol consumption and the use of some recreational drugs also affect fertility as does being at an unhealthy weight and certain medical treatments.

The Ministry discusses the benefits of “Fertility monitoring” which can assist couples to make informed choices about their fertility, including when to start a family and when to seek help with fertility. It can also facilitate timely referrals to fertility specialists.

“To give people the information they need to protect their fertility and make informed decisions, we recommend:

• All primary care practitioners, including doctors of naturopathy and traditional Chinese medicine, should be encouraged to make fertility education/counselling a routine part of care for all patients beginning in their 20’s – male and female, in a relationship or single (including those who are not trying to start a family), regardless of sexual orientation.
• All primary care providers, gynecologists and other specialists should give special consideration to age when diagnosing fertility problems in women beginning at age 28 up to age 30, who have been unable to conceive naturally after one year, and include their male partners in assessments.
• All primary care providers, gynecologists and other specialists should offer fertility testing/ monitoring to women who are age 30 and older who want to start a family, and their male partners, so as to facilitate timely referrals to fertility specialists.
• All primary care providers, gynecologists and other specialists should consider a referral to an infertility specialist to women age 30 and older who have been unable to conceive naturally after six months.
• The government should fund and support the development of clinical practice guidelines for fertility education and monitoring, including an algorithm to assist practitioners in assessing their patients for fertility problems.
• The Ministry of Health and Long-Term Care (MOHLTC) should continue to fund existing tests for ovarian reserve and semen analysis tests, standardize these tests province-wide, and introduce newer tests that are more accurate and easier to use as they become available and are approved.”

Why should Ontario invest in fertility education and monitoring?  Because many Ontarians are unaware how to protect their fertility. The Ontario government estimates that 1 in 8 Ontarians are struggling with infertility, however many suspect the number is closer to 3 in 8.

For most women, fertility begins declining around age 30 – even for women with healthy lifestyles, because:

• Every woman is born with all of the eggs she is ever going to have. Each month, for every egg that is released and available for fertilization, many eggs mature and most are absorbed into the body. Most women will ovulate about 400 times in their lifetime.
• Eggs get older as women age, making conception more difficult and increasing the chance for chromosomal abnormalities, which often causes miscarriage.
• Many women are not aware of how they can be proactive in protecting their reproductive health.

A man’s fertility are affected by many factors most men usually do not even think twice about, including:

• Age.
• Cigarette smoking.
• Heavy use of alcohol.
• Use of prescription medications
• Recreational drug use.
• Anabolic steroid use.
• Occupational hazards that expose men to toxins or high temperatures.
• Treatment for cancer.
• Any injuries to the testicles or health conditions that affect the male reproductive organs, such as varicocele, vasectomy, impotence, birth defects and autoimmune disorders.

The Ministry of Youth and Child Services realizes how important it is for primary care practitioners to discuss the relevant factors for  infertility with their patients, both men and women.  Ontarians should know how to best protect their  fertility, but also be aware that no amount of prevention can reverse age-related fertility decline.

Back to the one Ministry in the Ontario government that gets it;

“More and early fertility education can help Ontarians to make informed decisions about their reproductive health and childbearing decisions.  Also, the sooner that Ontarians are aware they may have a problem with fertility, the sooner they can be referred for treatment.  The goals of a provincial fertility education and monitoring program should be to ensure that;

• All Ontarians can receive fertility education.
• When fertility monitoring indicates a possible problem, Ontarians are referred quickly to a specialist.
• Health care resources are used wisely.”

All this talk about a fertility / infertility education program, complete with education sounds like there has been nothing put in place as of yet, and this is all still at the planning stage, but just how long does it take to put these measures in place?

Typically, the Ontario government, this one at least, likes to push the onus back to the individual / couple even though we just read about how couples are not aware of their fertility, nor are doctors bringing it up.  So does it make sense then for the government to recommend that;

“One of the best ways for Ontarians to learn about any risks that might affect their fertility is to talk to their family doctor, nurse practitioner, naturopathic doctor  or other primary health care provider. Primary care providers can and should play a key role in fertility education and monitoring. Primary care providers see patients  at all ages.   Women in their teens, 20’s and early 30’s are more likely than men to go for regular check-ups. In 2006, 33% of 28 year-old women saw a family doctor for a general assessment  compared to 13% of 28 year-old and 17% of 35 year-old males.  Family doctors should  be supported in incorporating fertility counselling into routine preventive healthcare.”

Right now in Ontario, (in)fertility is discussed and assessed way too late, far often after several years of failed conceiving.  In addition, couples also need to be given enough time to try to conceive naturally instead of overtaxing the system, because after a year of trying to conceive naturally, about 90% of couples will conceive.

Some takeaways for the Ontario government might be;

• A fertility monitoring program to provide a measurable timetable for younger Ontarians so they can conceive naturally before being referred to a fertility specialist.
• As the current OHIP fee schedule allows for physicians to bill for fertility counselling under a common counselling code there should be a distinct billing code number in order to track how many Ontarians are receiving fertility counselling.
• Address the fact that single heterosexual people, lesbian women and gay men are  less likely than heterosexual couples to receive fertility education and monitoring because like the rest of the population – a proportion of these people will have fertility issues.
• Research, research, research, because the last Ontario government report was dated October 19th, 2006 and called In Vitro Fertilization and Multiple Pregnancies.  A lot can and has happened in 7-years which needs to be addressed.

So now I’ve gone off and performed a targeted search of the Ontario Government website in search of information from the Ministry of Health regarding their education programs on fertility.  Boy, was I disappointed.

Here is what came up;

“Pulications – In Vitro Fertilization (IVF)

Generally, In vitro fertilization (IVF) services consist of:

1. blood work, ultrasounds and physician procedures (egg retrieval and embryo transfer)
2. embryology laboratory services.

IVF is not an OHIP insured physician service except in the limited circumstances listed in Regulation 552 under the Health Insurance Act.  It is only insured for the first three treatment cycles where the infertility is due to complete bilateral anatomical fallopian tube blockage that has not resulted from a sterilization procedure. A treatment cycle includes preparation, oocyte retrieval and embryo transfer.

Where IVF is insured (that is, for blocked fallopian tubes), the blood work, ultrasounds and physician procedures are insured in all hospital and non-hospital community based fertility clinics in Ontario.

When insured IVF is provided in hospital (that is, in the Mount Sinai Hospital Reproductive Biology Unit, London Health Sciences Fertility Clinic) or in the Ottawa Fertility Centre, associated embryology services are funded (in addition to the blood work, ultrasounds and physician procedures noted above).  Patients cannot be charged for such services provided in those three facilities.

The ministry does not fund fertility drug costs, intracytoplasmic sperm injection (ICSI) or costs associated with the freezing and storage of sperm, eggs and embryos, regardless of where insured IVF services are provided.

March 2012″

Yeah.

Thanks Ministry of Health.  Maybe they missed the announcement that “The Government of Ontario has made a commitment to make fertility monitoring available to women earlier in life.”  That announcement came from the Ministry of Youth and Child Services.

So instead of being proactive and helping today’s generation understand fertility, fund IVF where needed and make sure going forward all Ontarians are educated on factors impacting fertility – the government remains silent. Instead of speaking to the medical community to ensure they have the knowledge and availability to counsel people on infertility, this government is going to ignore the warning signs and the unhappy infertile couples in Ontario then end up having to pay for it at the end of the day when it is the least use and the most expensive.  It’s just our tax dollars after all.  The government can simply tax us more or just cut or de-list more services, right?

So to conclude, if you are infertile in Ontario, or want to make sure that you remain fertile, do not bother searching through the Ministry of Health’s website, but instead, head over to the Ministry of Youth and Child Services and follow their guidelines and information aimed at all Ontarians and what they should know to protect their fertility;

1. Education – The Government of Ontario should ensure that all primary care practitioners are educated about fertility and related issues including: the impact of age on fertility, male and female infertility, and the important risk factors that affect fertility; the reproductive needs of non-traditional families; and the complementary services available to enhance fertility or treat infertility.

2. All primary care practitioners – including naturopathic doctors and doctors of traditional Chinese medicine – should make fertility education/counselling a routine part of care for all patients, beginning in their 20’s. This includes males and females, those in a relationship or single (including those who are not trying to start a family), regardless of sexual orientation.

3.  The government should ensure that printed and web-based educational materials are developed and made available to primary care practitioners to share with their patients.

4.  Counselling – The government should adjust OHIP fee schedule to allow physicians to identify counselling services that are provided specifically for infertility so that practitioners can make the time for this in their busy practices and the government can understand how many Ontarians are receiving this information.

5.  Fertility Testing/Monitoring – All primary care providers, obstetrician/gynaecologists or fertility specialists should offer fertility testing/monitoring to:

• Women age 28 and over who have been unable to conceive naturally after one year without using contraception.
• Women age 30 and older when they want to start a family (to estimate their ovarian reserve and the need for referral).
• Women age 30 and older who have been unable to conceive naturally after six months.
• The male partners of women who are undergoing testing.

and anyone who appears to have a fertility problem should receive a timely referral to a fertility specialist (e.g., women under 30 should be referred after 12 months of trying to conceive naturally without success; women aged 30 and older should be referred after six months).

6.  Clinical practice guidelines – Developed for fertility education and monitoring and include:

• Guidelines for fertility education.
• The important risk factors for female and male fertility.
• An algorithm that could help primary care practitioners assess patients’ risk factors for infertility and the appropriate diagnostic tests to use.
• Criteria for diagnosing infertility in women and men.
• Single validated methods for measuring each of: the follicle stimulating hormone, antral follicle count and semen analysis tests to be used across the province.
• The specific test ranges or thresholds to use to make timely appropriate referrals to specialists.”

If Ontario was doing an effective and proper job of educating all Ontario residents about infertility as they say they are doing, then why do we still have couples struggling with infertility? And where is the evidence they are doing what they claim to be doing?   Would there not be statistics showing a decline in infertility rates?  Then no one would need IVF at all, but we can now clearly see that the Ministry that is in the know is not the Ministry making the decisions.

When can we expect to see that education that the Ministry of Youth and Children Services calls for?  Funding it is the first step to make this right, and here on Family Day in the province of Ontario would have been the appropriate time to announce the long-awaited plan on tackling this issue.

It’s not going to happen.

What are they waiting for?