First, looking at assisted reproduction techniques themselves, there has been a continued increase in the practice of eSET throughout the period of public coverage as well as a sustained decrease in multiple pregnancy rates. As demonstrated in Fig. 24.1, the rate of elective single embryo transfer dramatically increased after the implementation of public funding, from 1.6 % of all transfers to 49 % after 6 months, 62 % after 12 months, and 71 % of all transfers after 2 years. This change in practice remains the main explanation for the subsequent decrease in multiple gestations, from 27.8 % to 6.8 %. However, this success was at the cost of a decrease in the clinical pregnancy rates per single fresh cycle from 37.6 % to 22.4 % over the 3 years [6]. A clinical pregnancy was defined as intrauterine gestation (presence of a gestational sac on ultrasonography), ectopic pregnancy, or miscarriage diagnosed by histology. Cycles with only a positive pregnancy test (biochemical pregnancy) were not considered to have a clinical pregnancy [7].

It is intriguing to explore whether this decrease in multiple pregnancy is translated into a clinically significant difference in neonatal outcomes. The hypothesis is that less multiple pregnancies should result in a diminution in premature births and consequently less neonatal intensive care admission. Data available from hospitalization of patients and admission codes was published in the commissioner’s report and is presented in Fig. 24.2. Overall, in the assisted reproduction population, the rate of preterm birth at less than 32 weeks and less than 37 weeks has diminished over the course of the program: from 4.9 % to 3.8 % and from 29.6 % to 19.1 %, respectively. Interestingly, NICU admissions were also decreased, from 18.8 % down to 11.8 % of all the births following assisted reproduction. However, average hospital stay was increased, especially for neonates born under 36 weeks of gestation. Neonatal death rate remained unchanged. Whereas the diminution in preterm birth and NICU admission is significant when analyzing the population of neonates born after ART, the effect is not seen when the whole population of newborns is taken into account. This is likely due to the fact that the ART-issued babies account for only 2 % of the newborn cohorts in Québec and therefore not in a proportion large enough to affect the overall population outcomes. The main limitation of this data however is the fact that it was obtained retrospectively, from charts review. Also the MED-ECHO databank is not linked with the RAMQ billing figures; hence, not all IVF cycles are necessarily accounted for.

It is well known that ART pregnancies and especially multiple gestations are associated with adverse obstetrical outcomes. Cesarean section rate, maternal hospitalization frequency, and stillbirth rate were analyzed in the commissioner’s report. Interestingly, cesarean delivery rate in the assisted reproduction patients increased, mainly in singleton pregnancies, from an initial rate of 28.0 % to 37.0 %. The reasons for this are unclear and may reflect increased numbers of patients with concomitant diseases now accessing treatment. For the multiple pregnancies, there was a decrease in the rate of cesarean birth from 74.4 % to 66.0 %. Maternal hospitalization rate also increased, from 32.2 % to 37.4 %. The main reason documented for maternal hospitalization was “increased surveillance for advance maternal age” (Fig. 24.3).