The Impact of Government-Funded In Vitro Fertilization on the Use of Intracytoplasmic Sperm Injection in Non-Male Factor Infertility.

OBJECTIVES

To evaluate the impact of Ontario's public in vitro fertilization (IVF) funding program on intracytoplasmic sperm injection (ICSI) use and reproductive outcomes in non-male factor infertility (NMFI), and to compare insemination practices and cumulative live birth rates (cLBR) between funded and self-pay cycles.

METHODS

We conducted a population-based retrospective cohort study linking the Canadian Assisted Reproductive Technologies Plus registry to the Better Outcomes Registry & Network dataset. All IVF cycles for NMFI in Ontario from 2013 to 2022 were included, excluding donor oocyte and embryo cycles, cycles with male factor infertility, split IVF/ICSI, or missing outcome data. Primary outcomes were temporal trends in ICSI use before (2013-2015) and after (2016-2022) implementation of the Ontario Fertility Program (OFP). The secondary outcome was cLBR within 1 year of retrieval. Comparisons were made between IVF versus ICSI and between OFP-funded and self-pay cycles.

RESULTS

Among 47 562 NMFI cycles, ICSI accounted for 84% of inseminations overall. ICSI use increased after OFP implementation in both funded (82.9%) and self-pay (87.7%) cycles, despite exclusion of male factor cases. Conventional IVF decreased from 22% pre-OFP to 15% post-OFP (P < 0.001). cLBR remained stable over time and did not differ between IVF and ICSI in either funded (37.8% vs. 39.6%) or self-pay cycles (38.7% vs. 38.8%). Increased ICSI utilization was not associated with improved reproductive outcomes.

CONCLUSIONS

In Ontario's NMFI population, ICSI is used far more frequently than conventional IVF, however, it provides no cLBR benefit. The increase in ICSI following public funding reflects broader practice patterns rather than funding-driven behaviour. These findings highlight opportunities to optimize evidence-based, cost-effective IVF care.