GRSJ224/Assisted Reproduction Therapy in Canada

What is Assisted Reproduction Therapy?

Otherwise known as ART for short, Assisted Reproduction Therapy is the process of human reproduction with the use of medical technologies. Since the first 'test tube baby' named Louise Joy was born to parents Lesley and Peter Brown in Manchester, England, it is estimated that over 8 million babies have been born thanks to ART . In Canada, the 1984 prevalence of past-12-month infertility rate of 5% rose drastically to 12-16% in 2010. This staggering number will affect thousands of women each year as 1 in 6 couples in Canada experience infertility. This is an important topic for women to be aware of the options available for treatment, the costs and the legal aspects of ART in Canada.

Common ART Technologies

ART Category	Common Treatments and Procedures
Fertility Drugs	Some women are prescribed medications in the form of injections such asgonadoprins that stimulate egg growth and ovulation allowing the uterus increased likelihood of allowing an embryo to grow successfully, clomifene citrate is a drug not made of human hormones that has been proven to stimulate egg growth. While there have been concerns of a link between the use of fertility drugs and an increase of ovarian cancer, a recent Danish study claims that no convincing association exists.
Reproductive Surgery	Procedure to unblock fallopian tubes, retrieve eggs or sperm to be used in fertility treatments, or reverse sterilization surgery such as a vasectomy or tubal ligation called tubal reanastomosis
Intrauterine insemination (IUI)	A thin tube (catheter) carries sperm directly into a woman's womb (uterus) through the vagina. Often, the woman must take fertility drugs to help her ovaries produce one or more eggs. This procedure can be done with sperm from a partner or donor.
In Vitro Fertilization	This process involves a number of steps that will let fertilization happen outside a woman's body. Fertility drugs help a woman's ovaries to produce one or more eggs. Then the woman undergoes surgery to remove the eggs from her body. Inside a lab, the eggs are fertilized with sperm in a dish to produce one or more embryos. If successful, an embryo is transferred to the woman's womb (or uterus) through a thin tube to achieve a pregnancy.
Intracytoplasmic sperm injection (ICSI)	A glass tool is used to hold an egg in place. A tiny glass tube is used to put one sperm into the egg. After culturing in the lab overnight, eggs are checked to see if they've been fertilized. After incubation, the eggs that have been successfully fertilized or have had 3 to 5 days to further develop are selected. One or more are placed in the uterus using a thin flexible tube (catheter) that is inserted through the cervix. Your doctor will recommend how many embryos to transfer, based on your age and other information about you. The other embryos may be frozen for future use.
Gamete intrafallopian transfer (GIFT)	This procedure uses multiple eggs collected from the ovaries. The eggs are placed into a thin flexible tube (catheter) along with the sperm to be used. The gametes (both eggs and sperm) are then injected into the fallopian tubes using a surgical procedure called laparoscopy. The doctor will use general anesthesia.
Zygote intrafallopian transfer (ZIFT)	This procedure combines the technology used IVG and GIFT. Eggs are stimulated and collected using IVF methods. Then the eggs are mixed with sperm in the lab. The fertilized eggs are then laparoscopically returned to the fallopian tubes where they will be carried into the uterus. The goal is for the zygote to implant in the uterus and develop into a fetus.
Donor eggs and embryos	Birth rates are affected by whether ART procedures use a woman's own eggs or donor eggs. Many women over age 40 choose to use donor eggs, which greatly improves their chances of giving birth to healthy babies. Using her own eggs, a woman's chances of having a live birth decline from over 40% in her late 20s, to 30% at about age 38, and to 10% by about age 43.Live birth rates are about the same among younger and older women using donor eggs. Women in their late 20s through mid-40s average about a 55% birth rate using fresh (not frozen) embryos.Frozen embryos versus fresh embryos. Donor-frozen IVF embryos from a previous IVF cycle that are thawed and transferred to the uterus are less likely to result in a live birth than are donor-fresh (newly fertilized) IVF embryos however frozen embryos are less expensive and less invasive for a woman, because superovulation and egg retrieval aren't needed.
Surrogacy	The legalities surrounding surrogacy in Canada are very stringent. While it is legal to reimburse a surrogate for costs directly involved with pregnancy (such as reimbursement for maternity clothes, travel for medical appointments, and medications) there are many strict regulations in place to deter any misinterpretation of funds exchanged as illegal activities. According to the Assisted Human Reproduction Act, it is illegal in Canada to Under the AHR Act, it is illegal in Canada to pay, offer to pay or advertise the payment to a third party to arrange the services of a surrogate mother. This would include paying a surrogacy company that matches infertile couples with surrogate mothers. To accept payment for arranging the services of a surrogate mother. Offering to make a surrogacy arrangement and advertising this kind of arrangement is also illegal. It is illegal for the exchange of goods or services or to be disguised form of payment providing financial or other gain to a third party for arranging the services of a surrogate mother. It is illegal under the AHR Act to pay third parties to hire a surrogate mother. For example, third parties include fertility clinics that match infertile couples with surrogate mothers. Indirect and disguised payments are also illegal. These could include: paying a surrogate mother's mortgage, credit card bills, or school tuition. All potential surrogate mothers must be older than 21 years of age and intentions must be altruistic in nature, not for profit.

All of the above procedures are legal in Canada and have been for some time. Medical technology is improving the way we are able to help with reproductive challenges that women experience while trying to conceive. As technology changes rapidly, so must Canadian laws and regulations. In Canada, the legalities surrounding reproduction are put in place to protect Canadians' best interest. In 2004, Canada introduced the Assisted Human Reproduction Act . The Assisted Human Reproduction Agency was created in 2006, dismantled in 2013 and is now regulated by Health Canada. The mandate of this legislation is to help Canadians to build their families safely and with peace of mind. .

• Issuing and reviewing licences under the AHR Act

• Carrying out inspections and enforcement related to activities prohibited or controlled under the AHR Act

• Collecting, analysing and managing health reporting information relating to controlled activities

• Providing information to the public and professions on AHR and other matters under the Act, including risk factors associated with infertility

• Providing advice to the Minister of Health on issues relating to assisted human reproduction

• Monitoring and evaluating scientific and clinical developments within Canada and internationally on AHR and other matters to which the Act applies

• Consulting persons and organizations within Canada and internationally

• Maintaining relationships with international bodies with an interest in the quality, safety and ethical practices of fertility procedures.

Legal Applications for ART in Canada

According to the Assisted Human Reproduction Act section 5(1), there are numerous activities and or procedures that are strictly prohibited.

No person shall knowingly:

• create a human clone by using any technique, or transplant a human clone into a human being or into any non-human life form or artificial device;

• create an in vitro embryo for any purpose other than creating a human being or improving or providing instruction in assisted reproduction procedures;

• for the purpose of creating a human being, create an embryo from a cell or part of a cell taken from an embryo or foetus or transplant an embryo so created into a human being;

• maintain an embryo outside the body of a female person after the fourteenth day of its development following fertilization or creation, excluding any time during which its development has been suspended;

• for the purpose of creating a human being, perform any procedure or provide, prescribe or administer any thing that would ensure or increase the probability that an embryo will be of a particular sex, or that would identify the sex of an in vitro embryo, except to prevent, diagnose or treat a sex-linked disorder or disease;

• alter the genome of a cell of a human being or in vitro embryo such that the alteration is capable of being transmitted to descendants;

• transplant a sperm, ovum, embryo or foetus of a non-human life form into a human being;

• for the purpose of creating a human being, make use of any human reproductive material or an in vitro embryo that is or was transplanted into a non-human life form;

• create a chimera, or transplant a chimera into either a human being or a non-human life form; or

• create a hybrid for the purpose of reproduction, or transplant a hybrid into either a human being or a non-human life form.

• No person shall offer to do, or advertise the doing of, anything prohibited by this section.

• No person shall pay or offer to pay consideration to any person for doing anything prohibited by this section.

ART Costs Covered by Provincial Medical

There are only 4 Provinces in Canada that assist in the cost of fertility treatments:

Province	Coverage
Manitoba	Residents of Manitoba are able to claim tax credits that are equal to 40% of the cost of fertility treatments provided by a Manitoba licensed medical practitioner or infertility treatment clinic with no limit on the number of treatments that are claimable. The maximum claim annually is $20,000 for eligible costs for a maximum yearly Fertility Treatment Tax Credit of $8,000.
New Brunswick	Residents of New Brunswick are eligible for a one time grant of $5,000.
Ontario	Residents of Ontario are covered for procedures with varying limitations per cycle however the actual fertility drugs necessary to undergo the treatments and procedures are not covered. Costs for these medications average $1,000 per artificial insemination cycle to $5,000 per IVF cycle. Some private medical insurers (through one's employer for example) do provide coverage or partial reimbursement for these types of medications.
Quebec	Residents of Quebec are able to claim fertility treatments on line 462 of their personal income tax. Refunds vary per income

That leaves 6 Provinces (Alberta, British Columbia, Newfoundland and Labrador, Nova Scotia, Prince Edward Island, Saskatchewan) and 3 Territories (Northwest Territories, Nunavut, and Yukon) without publicly funded coverage. Since 2015, Alberta has been attempting to pass legislation to assist residents with conception. A 2015 study in Alberta based on the Quebec Province's model of ART public funding and resulted in an economic model and improving access to treatment for infertile patients that also reduced health care costs for the Province of Alberta. Legislation has yet to be passed and there is no provincial funding for fertility treatment in Alberta three years after the completion of this successful study.

ART Controversies in Canada

The fact that healthcare is a Provincial matter and not Federal should be a concern to Canadians. Should geography limit access to fertility treatment? A fertility clinic in Alberta opened in 2016 promoting a low cost approach to fertility treatment. The clinic even offered discounts for the first 100 clients with the discounted pricing of $4,000 for their first treatments. It is estimated that a cycle of in vitro fertilization costs in the range of $5,000 to $10,000 in Canada..

In 2013, Toronto hosted an important workshop/symposium on assisted human reproduction in Canada headed by 18 feminist scholars including Alana Cattapan, Margit Eichler and Lorna Weir. Mutual areas of concern included commitments for government to include feminist input and strong advocacy for women's health needs, inclusive and diverse feminist presence in all areas of policy, and the impact of class, race, ability, sexual orientation and gender in terms of access to and experience of assisted human reproductive services. Concerns were raised about the lack of egg providers, retrieval of eggs and the short and long term illness and mortality of egg providers. Families with three or more parents are not recognized with vital statistics and are not reflected in government records. For example birth certificates are not designed to record the parentage of children carried by surrogate mothers or those conceived using donated genetic material such as sperm. For-profit fertility clinics remain a concern as socio-economic status limitations should not be a barrier for women to conceive but the reality is that these barriers do exist. The standard of counselling in private fertility clinics is far below industry standard for recognized counseling services in Canada. Clinics have been known to employ counselors that are promoting medical treatments that are ultimately funded by their clients; a conflict of interest by any professional standard. Lack of or poor enforcement of industry standards leave room for unprofessionalism by doctors and clinics such as allegations raised against Dr. Norman Barwin in Ottawa practicing out of the Broadview Fertility Clinic. In 2013 Barwin admitted to a disciplinary committee of the Ontario College of Physicians and Surgeons to using the wrong sperm in at least 4 cases within an eleven-year period (1986-2007) resulting in a suspended medical licence to practice for two months. Of the four cases against him, all were resolved out of court by 2012 with plaintiffs coming to an agreement that included confidentiality about the charges.

Assisted reproductive therapy (ART) is a field of medicine that is constantly changing with advances in medical technology. Canadians must demand that the legalities and government policies of ART are protective and inclusive of all Canadians.