Does insurance coverage decrease the risk for multiple births associated with assisted reproductive technology?

OBJECTIVE: To determine whether insurance coverage for ART is associated with transfer of fewer embryos and decreased risk of multiple births.
DESIGN: Retrospective cohort study of a population-based sample of IVF procedures performed in six U.S. states during 1998.
SETTING: Three states with mandated insurance coverage (Illinois, Massachusetts, and Rhode Island) and three states without coverage (Indiana, Michigan, and New Jersey). PARTICIPANT(S): Seven thousand, five hundred sixty-one IVF transfer procedures in patients < or = 35 years of age. MAIN OUTCOME MEASURE(S): Number of embryos transferred, multiple-birth rate, triplet or higher order birth rate, and triplet or higher order gestation rate. RESULT(S): A smaller proportion of procedures included transfer of three or more embryos in Massachusetts (64%) and Rhode Island (74%) than in the noninsurance states (82%). The multiple-birth rate in Massachusetts (38%) was less than in the noninsurance states (43%). The insurance states all had protective odds ratios for triplet or higher order births, but only the odds ratio (0.2) for Massachusetts was significant. This decreased risk in Massachusetts resulted from several factors, including a smaller proportion of patients with three or more embryos transferred, lower implantation rates when three or more embryos were transferred, and greater rates of fetal loss among triplet or higher order gestations. CONCLUSION(S): Insurance appears to affect embryo transfer practices. Whether this translates into decreased multiple birth risk is less clear.