[Clinical reports on IVF cycle rank--reliability and validity]

BACKGROUND

Accurate clinical reports of in vitro fertilization cycle rank (IVF-CR] are important because of their predictive value of treatment success--clinical pregnancy. This parameter, therefore, facilitates decision-making on both individual and population levels. The District of Haifa and Western GaLilee currently enrolls about 700,000 insured people, and provides hundreds of IVF cycles (pick-ups and frozen-thawed) at a cost of millions of shekels each year. Hence, accurate reports of IVF cycle rank is extremely important in order to ensure that public funds are actually directed to couples who may benefit from them.

OBJECTIVE

The study objective was to evaluate the accuracy of IVF units' reports of IVF-CR.

METHODS

Reports of IVF-CR from local IVF units were correlated with administrative data. Couples undergoing IVF treatments during one month were included in the study.

RESULTS

A total number of 108 IVF cycle treatments were reported. Accurate IVF-CR was reported for 29 patients (27%), "too high" for 30 patients (28%), and "too low" for 10 (9%). For 39 patients (36%) data was missing.

CONCLUSIONS

CLinicaL reports of IVF-CR are currently accurate in less than a third of the cases. It is recommended that national regulatory bodies should issue compulsory guidelines in relation to recording and reporting of IVF-CR.

Clomifene citrate or unstimulated intrauterine insemination compared with expectant management for unexplained infertility: pragmatic randomised controlled trial

OBJECTIVE

To compare the effectiveness of clomifene citrate and unstimulated intrauterine insemination with expectant management for the treatment of unexplained infertility.

DESIGN

Three arm parallel group, pragmatic randomised controlled trial.

SETTING

Four teaching hospitals and a district general hospital in Scotland.

PARTICIPANTS

Couples with infertility for over two years, confirmed ovulation, patent fallopian tubes, and motile sperm.

INTERVENTION

Expectant management, oral clomifene citrate, and unstimulated intrauterine insemination.

MAIN OUTCOME MEASURES

The primary outcome was live birth. Secondary outcome measures included clinical pregnancy, multiple pregnancy, miscarriage, and acceptability.

RESULTS

580 women were randomised to expectant management (n=193), oral clomifene citrate (n=194), or unstimulated intrauterine insemination (n=193) for six months. The three randomised groups were comparable in terms of age, body mass index, duration of infertility, sperm concentration, and motility. Live birth rates were 32/193 (17%), 26/192 (14%), and 43/191 (23%), respectively. Compared with expectant management, the odds ratio for a live birth was 0.79 (95% confidence interval 0.45 to 1.38) after clomifene citrate and 1.46 (0.88 to 2.43) after unstimulated intrauterine insemination. More women randomised to clomifene citrate (159/170, 94%) and unstimulated intrauterine insemination (155/162, 96%) found the process of treatment acceptable than those randomised to expectant management (123/153, 80%) (P=0.001 and P<0.001, respectively).

CONCLUSION

In couples with unexplained infertility existing treatments such as empirical clomifene and unstimulated intrauterine insemination are unlikely to offer superior live birth rates compared with expectant management.

TRIAL REGISTRATION

ISRCT No: 71762042.

The combined effect of age and basal follicle-stimulating hormone on the cost of a live birth at assisted reproductive technology

OBJECTIVE

To predict the cost of a delivery following assisted reproductive technologies (ART).

DESIGN

Cost analysis based on retrospective chart analysis.

SETTING

University-based ART program.

PATIENT(S)

Women aged >or=26 and <or=42 years with FSH levels <or=12 IU/L on day 3 undergoing a first cycle of fresh, nondonor ART.

INTERVENTION(S)

Logit regression using a fractional polynomial model of age and basal FSH was used to estimate the probability of a live birth. Cost analysis was applied to the resulting prediction.

MAIN OUTCOME MEASURE(S)

The predicted probability of a live birth following ART based on a woman's age and FSH and the associated cost of a live birth.

RESULT(S)

Analysis of 1,238 first ART cycles produced a prediction model for live birth rates following ART incorporating both age and FSH. A cost analysis based upon combination of age and FSH revealed the cost of a live birth exceeded $100,000 when the probability of a live birth fell below 15% and the cost rose exponentially at lower probabilities of live birth.

CONCLUSIONS(S)

Based upon a woman's age and FSH and expected cost for a live birth using ART may be calculated. At live birth rates <5%, the cost of ART is high and greatly exceeds the cost of donor cycles. This information is vital for patient counseling.

Utilization of infertility services: how much does money matter?

OBJECTIVE

To estimate the effects of financial access and other individual characteristics on the likelihood that a woman pursues infertility treatment and the choice of treatment type.

DATA SOURCE/STUDY SETTING

The 1995 National Survey of Family Growth.

STUDY DESIGN

We use a binomial logit model to estimate the effects of financial access and individual characteristics on the likelihood that a woman pursues infertility treatment. We then use a multinomial logit model to estimate the differential effects of these variables across treatment types.

DATA COLLECTION/EXTRACTION METHOD

This study analyzes the subset of 1,210 women who meet the definition of infertile or subfecund from the 1995 National Survey of Family Growth.

PRINCIPAL FINDINGS

We find that income, insurance coverage, age, and parity (number of previous births) all significantly affect the probability of seeking infertility treatment; however, the effect of these variables on choice of treatment type varies significantly. Neither income nor insurance influences the probability of seeking advice, a relatively low cost, low yield treatment. At the other end of the spectrum, the choice to pursue assisted reproductive technologies (ARTs)-a much more expensive but potentially more productive option-is highly influenced by income, but merely having private insurance has no significant effect. In the middle of the spectrum are treatment options such as testing, surgery, and medications, for which "financial access" increases their probability of selection.

CONCLUSIONS

Our results illustrate that for the sample of infertile of subfecund women of childbearing age studied, and considering their options, financial access to infertility treatment does matter.

Productivity Losses Attributable to Untreated Chlamydial Infection and Associated Pelvic Inflammatory Disease in Reproductive-Aged Women

BACKGROUND AND OBJECTIVES

The productivity losses attributable to disease-related morbidity and mortality impose a burden on society in general and on employers in particular. A reliable assessment of the productivity losses associated with untreated infection with Chlamydia trachomatis (Ct) would complement earlier work on direct medical costs and contribute to an estimate of the full cost of chlamydial disease.

GOAL

The goal of this study was to estimate the discounted lifetime productivity losses attributable to untreated chlamydial infection in reproductive-aged women.

STUDY DESIGN

We developed a cost model using Monte Carlo methods to estimate the lifetime discounted productivity losses attributable to untreated lower genital tract Ct infection among reproductive-aged women. The model considered the impact of disability resulting from acute pelvic inflammatory disease (PID) associated with untreated Ct infection and from the sequelae of acute PID, including chronic pelvic pain, ectopic pregnancy, and infertility. To accommodate disparate Ct infection rates and labor market characteristics across age groups, we matched age-based risk factors for Ct infection with labor market patterns. Data sources included the 2001 National Chlamydia Surveillance Data, the 2001 Current Population Survey, and published literature.

RESULTS

Estimates indicate that the mean weighted productivity losses per untreated Ct infection were approximately US dollars 130 (in year 2001 dollars). Mean weighted productivity losses per case of acute PID were estimated at US dollars 649. Estimated productivity losses were highly correlated with age, reflecting age-dependent differences in labor market characteristics.

CONCLUSIONS

The productivity losses attributable to untreated infection with Ct and to sequelae of this infection form a substantial portion of the total economic burden of disease. Effective programs to prevent chlamydial infection and effective screening, diagnosis, and treatment of Ct-infected women may reduce productivity losses and substantially lessen the economic burden of disease to employers.

Recombinant versus highly-purified, urinary follicle-stimulating hormone (r-FSH vs. HP-uFSH) in ovulation induction: a prospective, randomized study with cost-minimization analysis

BACKGROUND

Both recombinant FSH (r-FSH) and highly-purified, urinary FSH (HP-uFSH) are frequently used in ovulation induction associated with timed sexual intercourse. Their effectiveness is reported to be similar, and therefore the costs of treatment represent a major issue to be considered. Although several studies about costs in IVF have been published, data obtained in low-technology infertility treatments are still scarce.

METHODS

Two hundred and sixty infertile women (184 with unexplained infertility, 76 with CC-resistant polycystic ovary syndrome) at their first treatment cycle were randomized and included in the study. Ovulation induction was accomplished by daily administration of rFSH or HP-uFSH according to a low-dose, step-up regimen aimed to obtain a monofollicular ovulation. A bi- or tri-follicular ovulation was anyway accepted, whereas hCG was withdrawn and the cycle cancelled when more than three follicles greater than or equal to 18 mm diameter were seen at ultrasound. The primary outcome measure was the cost of therapy per delivered baby, estimated according to a cost-minimization analysis. Secondary outcomes were the following: monofollicular ovulation rate, total FSH dose, cycle cancellation rate, length of the follicular phase, number of developing follicles (>12 mm diameter), endometrial thickness at hCG, incidence of twinning and ovarian hyperstimulation syndrome, delivery rate.

RESULTS

The overall FSH dose needed to achieve ovulation was significantly lower with r-FSH, whereas all the other studied variables did not significantly differ with either treatments. However, a trend toward a higher delivery rate with r-FSH was observed in the whole group and also when results were considered subgrouping patients according to the indication to treatment.

CONCLUSION

Considering the significantly lower number of vials/patient and the slight (although non-significant) increase in the delivery rate with r-FSH, the cost-minimization analysis showed a 9.4% reduction in the overall therapy cost per born baby in favor of r-FSH.

Health disparities and infertility: impacts of state-level insurance mandates

OBJECTIVE

To determine whether important racial, ethnic, or socioeconomic status (SES) health disparities exist in infertility, impaired fecundity, or infertility treatment.

DESIGN

Four waves of the National Survey of Family Growth (NSFG) were pooled. Measures were compared across various race/ethnicity, education, and age groups.

PARTICIPANT(S)

Data for 31,047 women 15-44 years old from the NSFG were pooled.

INTERVENTION(S)

Outcomes were compared by whether the women's states of residence had a mandate in place (at least 1 year before the interview) to compel insurers to cover or offer to cover infertility treatment.

MAIN OUTCOME MEASURE(S)

Infertility status, impaired fecundity, ever having sought infertility treatment.

RESULT(S)

Infertility is more common for non-Hispanic black women, non-Hispanic other race women, and Hispanic women than for non-Hispanic white women, and both infertility and impaired fecundity are more common for high school dropouts and high school graduates with no college than for 4-year college graduates, and for older women compared with women 29 and younger. Older women, non-Hispanic white women, and women who are more educated (with at least some college) are more likely to have ever received treatment. No evidence has been found that the racial, ethnic, or education disparities are ameliorated by the health insurance mandates.

CONCLUSION(S)

Racial, ethnic, and educational disparities exist in infertility status and treatment, and educational disparities in impaired fecundity. More study of the impact of infertility treatment mandates on these disparities is needed.

Socioeconomic and racial disparities among infertility patients seeking care

OBJECTIVE

To examine sociodemographic differences based on patient race/ethnicity among infertility patients seeking care in a state with mandated coverage of infertility treatment.

DESIGN

Cross-sectional survey.

SETTING

University-hospital-based fertility center.

PATIENT(S)

A total of 1,500 consecutive women who presented for infertility care.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Self-report questionnaire assessing patient race/ethnicity, diagnosis, income, education level, and duration of infertility before seeking care.

RESULT(S)

African American women experienced a significantly longer duration of infertility before seeking care compared with Caucasian women (4.3 vs. 3.3 years, respectively; P=.03). With regard to infertility diagnosis, a significantly greater proportion of African American and Hispanic women had tubal factor infertility compared with Caucasian women (24.0% and 27.3% vs. 5.3%, respectively; P=.001). Looking at the highest level of education attained by patients, a significantly greater proportion of African American and Hispanic women had less than a 4-year college degree compared with Caucasian women (48% and 40.9% vs. 13.2%, respectively; P<.001). Examining the gross annual household income of patients, a significantly greater proportion of African American and Hispanic women had household incomes below $100,000 compared with Caucasian women (72% and 68.2% vs. 37.3%, respectively; P<.01).

CONCLUSION(S)

African American women are more likely to seek infertility treatment after a longer duration of failed conception compared with Caucasian women. Furthermore, African American, and Hispanic women are more likely to have tubal factor infertility, a lower education level, and a lower household income compared with Caucasian women.

Comparison of assisted reproductive technology utilization and outcomes between Caucasian and African American patients in an equal-access-to-care setting

OBJECTIVE

Racial disparity in assisted reproductive technology (ART) outcomes has been reported but remains controversial. Reasons for the disparity are unclear, and access to care has been suggested as a causative factor. In this study, we sought to examine minority utilization of ART in the Department of Defense (DoD) compared with minority utilization in the U.S. ART population. Outcomes from ART were compared between Caucasian (Cau) and African American (AA) patients, and etiologies of disparity were examined.

DESIGN

Retrospective cohort study.

SETTING

University-based ART program.

PATIENT(S)

A total of 1,457 patients undergoing first-cycle fresh, nondonor ART.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate, live birth rate, implantation rate, spontaneous abortion rate.

RESULT(S)

Within the DoD population, AA women had a fourfold increase in utilization of ART services relative to the U.S. ART population. In this equal-access-to-care setting, AA women experienced a clinically significant decrease in live birth rate that did not reach statistical significance (29.6% vs. 35.8%, risk ratio [RR] 0.83, 95% confidence interval [CI] 0.67-1.02) and a statistically significant increase in spontaneous abortions compared with Cau women (25% vs. 15.9%, RR 1.57, 95% CI 1.05-2.36). This might be explained, in part, by a higher prevalence of uterine leiomyomas in AA women (30.8% AA vs. 10.7% Cau, RR 2.85, 95% CI 2.06-3.95). For both AA and Cau women, the presence of fibroids at baseline ultrasound was associated with reductions in clinical pregnancy rates (35% with leiomyomas vs. 43.2% without leiomyomas, RR 0.74, 95% CI 0.51-0.98), live birth rates (26.2% vs. 36.0%, RR 0.63, 95% CI 0.44-0.90), and implantation rates (25.6% vs. 31.1% RR 0.82, 95% CI 0.69-0.98).

CONCLUSION(S)

Utilization of ART services among AA women increased when access to care was improved. A clinically significant reduction in live birth rate and statistically significant increase in spontaneous abortion rate was observed in AA women compared with Cau women. Leiomyomas were three times more prevalent in AA women and reduced ART success, regardless of race. The persistence of racial differences in an equal-access-to-care environment might be explained, in part, by the increased prevalence of leiomyomas in AA women.

Comparison of outcomes and direct cost between minimal stimulation and conventional protocols on ovarian stimulation in in vitro fertilization

AIM

To determine whether minimal stimulation with clomiphene and gonadotropin provides outcomes and direct costs comparable with those of a conventional GnRHa-gonadotropin stimulation protocol for infertile patients undergoing in vitro fertilization.

METHODS

A non-randomized clinical trial was conducted from 1 July 1996 to 31 March 2003 at the Infertility and Assisted Reproductive Unit, Ramathibodi Hospital, Faculty of Medicine, Mahidol University, Thailand. A total of 192 patients were recruited of whom 96 cases underwent ovarian stimulated cycles with minimal stimulation protocol, and 96 controls underwent ovarian stimulated cycles with GnRHa-gonadotropin protocol, with cases and controls matched for age and infertility cause.

RESULTS

The median patient age was 35 years. Endometriosis was the most frequent infertility cause (28.1%). The conventional GnRHa-gonadotropin protocol could give more oocyte numbers than the minimal stimulation protocol (7.3 +/- 4.9 vs 4.5 +/- 3.3 oocytes). The fertilization rate and cleavage rate were similar (73.4 +/- 31.9 and 84.9 +/- 32.6 in minimal stimulation protocol, 69.3 +/- 29.6 and 88.4 +/- 28.0 in GnRHa-gonadotropin protocol, respectively). The pregnancy rate per oocyte retrieval cycle in the GnRHa-gonadotropin protocol was similar to the minimal stimulation protocol. (13.1%vs 13.0%, P = 1.000). However, the cost per pregnancy of minimal stimulation protocol was less than that of GnRHa-gonadotropin protocol. (6021.95 US dollars for minimal stimulation protocol per pregnancy, 10,785.65 US dollars for GnRHa-gonadotropin protocol per pregnancy, P < 0.000).

CONCLUSION

Minimal stimulation was less effective than conventional GnRHa-gonadotropin on the ovarian stimulation. However, the total costs of minimal stimulation were cheaper than the conventional GnRHa-gonadotropin protocol. The decreased costs of minimal stimulation justifies further evaluation of its role in the treatment of infertility in selected cases.

In vitro fertilization (IVF) versus gonadotropins followed by IVF as treatment for primary infertility: a cost-based decision analysis

OBJECTIVE

To compare the economic consequences of proceeding directly to IVF to those of proceeding with gonadotropins followed by IVF in patients <35 years of age with unexplained infertility.

DESIGN

A decision-tree model. The model incorporated the cost and success of each infertility regimen as well as the pregnancy-associated costs of singleton or multiple gestations and the risk and cost of cerebral palsy.

MAIN OUTCOME MEASURE(S)

Cost per live birth.

RESULT(S)

Both treatment arms resulted in a >80% chance of birth. The gonadotropin arm was over four times more likely to result in a high-order multiple pregnancy (HOMP). Despite this, when the base case estimates were utilized, immediate IVF emerged as more costly per live birth. In sensitivity analysis, immediate IVF became less costly per live birth when IVF was more likely to achieve birth (55.1%) or cheaper (11,432 dollars) than our base case assumptions.

CONCLUSION(S)

After considering the risk and cost of HOMP, immediate IVF is more costly per live birth than a trial of gonadotropins prior to IVF.

Diagnosing infertility in a district general hospital: a case-note and cost analysis

This study aimed to observe diagnostic work-up and cost evaluation of infertile couples to identify opportunities for improvement. One hundred and seventy-four new referrals to the gynaecology clinic in a District General Hospital during 1996 and 1997 provided the cohort for analysis. Data from case notes were transferred on to data collection sheets. Data were inputted into SPSS for analysis. Primary infertility accounted for 62% of couples. One hundred and forty-two couples (81.6%) had a definitive diagnosis, and the analyses relate to these couples only. There was no single investigation performed on the whole cohort studied. Semen analysis was undertaken in 80.3% of the couples; couples with suspected male infertility were over four times more likely to have had more than two semen tests (P = 0.0005); 77.5% of couples had FSH and LH tests; and midluteal progesterone was tested in 76.1%. An increased intensity of FSH-LH hormone testing was associated with couples with anovulation (chi(2) = 6.79, P = 0.03). Serial repeat progesterone tended to be given to women with irregular or prolonged cycles (35 days or more), although this tendency was not statistically significant. The most common test for tubal patency was hysterosalpingography. Higher costs are generally associated with diagnosing endometriosis and tubal factor because of the relatively high cost of laparoscopy. The average cost of diagnosis for each patient was pound 365 and ranged from pound 64 to pound 851. In conclusion, a standard protocol of basic investigative procedures should be offered in secondary centres to all couples. Avoiding duplication and unnecessary investigations (for example, serial progesterone) may reduce costs, although offering all couples a standard protocol of tests would probably offset this observation.

Disparities in access to infertility services in a state with mandated insurance coverage

The objective of our study was to examine the demographic and socioeconomic characteristics of patients accessing infertility services in a state (Massachusetts) with mandated and comprehensive insurance coverage for such services. Even in a state with such insurance coverage, disparities in access to infertility services exist, with the majority of individuals accessing those services being Caucasian, highly educated, and wealthy.

Investigation of the infertile couple: a basic fertility work-up performed within 12 months of trying to conceive generates costs and complications for no particular benefit

The current approach of the basic fertility work-up has been questioned recently in this journal. Based on new data on human fecundity, the authors advocated starting the fertility work-up after just 6 months of trying to conceive instead of the usual 12 months. In women younger than 39 years and with a regular cycle, there are several arguments why the basic fertility work-up should not be done earlier than after 12 months of child wish. Firstly, 50% of couples who have tried to conceive for 6 months without success will conceive in the next 6 months without any treatment. Secondly, the prevalence of fertility diseases is lower in couples who have been trying to conceive for 6 months as compared with those who have been trying for 12 months. Performance of a fertility work-up at this stage will lead to an increase in false-positive diagnoses compared with performing them at 12 months of subfertility. Thirdly, fertility treatment will have fewer additional effects in couples with good spontaneous conception prospects (6-12 months child wish), compared with subfertile couples who have poor prospects. At present, none of the available fertility treatments have success rates comparable with no intervention in these women, and postponement of treatment in such couples will prevent complications such as ovarian hyperstimulation syndrome and multiple pregnancies. We argue that the fertility work-up should not be offered to couples with a duration of child wish of <12 months, except for women with ovulation disorders and women of 39 years and older.

Cost-effectiveness of Chlamydia antibody tests in subfertile women

BACKGROUND

For the evaluation of tubal function, Chlamydia antibody testing (CAT) has been introduced as a screening test. We compared six CAT screening strategies (five CAT tests and one combination of tests), with respect to their cost-effectiveness, by using IVF pregnancy rate as outcome measure.

METHODS

A decision analytic model was developed based on a source population of 1715 subfertile women. The model incorporates hysterosalpingography (HSG), laparoscopy and IVF. To calculate IVF pregnancy rates, costs, effects, cost-effectiveness and incremental costs per effect of the six different CAT screening strategies were determined.

RESULTS

pELISA Medac turned out to be the most cost-effective CAT screening strategy (15 075 per IVF pregnancy), followed by MIF Anilabsystems (15 108). A combination of tests (pELISA Medac and MIF Anilabsystems; 15 127) did not improve the cost-effectiveness of the single strategies. Sensitivity analyses showed that the results are robust for changes in the baseline values of the model parameters.

CONCLUSIONS

Only small differences were found between the screening strategies regarding the cost-effectiveness, although pELISA Medac was the most cost-effective strategy. Before introducing a particular CAT test into clinical practice, one should consider the effects and consequences of the entire screening strategy, instead of only the diagnostic accuracy of the test used.

[In vitro oocyte maturation for safer treatment of infertility. The risk of ovarian overstimulation syndrome is minimized]

Ovarian hyperstimulation syndrome is a well known side effect of hormone stimulation in assisted reproduction. New treatments using minimal amounts of gonadotropins or no hormone supplementation may reduce this risk. In-vitro maturation (IVM) is a treatment where final oocyte maturation is achieved in the laboratory. Results have been acceptable and this method may provide a low-risk and cost-effective alternative to traditional IVF. IVM would thus avoid the high amounts of exogenous gonadotropins required for controlled ovarian hyperstimulation. Currently, only a few teams internationally are pursuing research in this field of human reproduction. IVM is a promising treatment alternative and can be recommended especially for patients at risk of developing ovarian hyperstimulation syndrome.

Inconceivable? Deducting the costs of fertility treatment

This Article considers whether infertile taxpayers can deduct their fertility treatment costs as medical expenses under Internal Revenue Code section 213 and whether they should be able to deduct them. Internal Revenue Code section 213 defines medical expenses as "amounts paid-for the diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body." This definition is interpreted by reference to a baseline of normal biological functioning, which includes reproductive functioning. Most people conceive and bear children without having to incur expenses for fertility treatment. Expenses incurred to approximate the baseline of normal reproductive health are deductible, even if the taxpayer winds up better off, with a child, after the fertility treatment. The medical profession recognizes that infertility is a disease or condition. Infertility is a loss, just as a broken leg is a loss. Fertility treatment costs are thus medical expenses under section 213. In addition, given the existence of the medical expense deduction, taxpayers should be able to deduct the cost of fertility treatments, including IVF, egg donor, and surrogate procedures, under either an "ability-to-pay" or consequentialist normative approach. Reproduction is extremely important to most people. In addition, allowing taxpayers to deduct the costs of fertility treatment will encourage infertile taxpayers to elect the most effective treatment option and reduce the rate of risky multifetal pregnancies. This Article concludes that fertility treatment costs are deductible as medical expenses under current law and should be deductible as medical expenses.

Ovulation induction with urinary FSH or recombinant FSH in polycystic ovary syndrome patients: a prospective randomized analysis of cost-effectiveness

The aim of this prospective, randomized trial was to compare the clinical results and the cost-effectiveness of urinary FSH (uFSH) and recombinant FSH (rFSH) in ovarian stimulation for intrauterine insemination (IUI) cycles in polycystic ovary syndrome (PCOS) patients. One-hundred and seventy PCOS infertile patients undergoing IUI were enrolled, and protocols of ovarian stimulation with uFSH or rFSH were randomly assigned. The total number of cycles performed was 379 (182 and 197, respectively). The main outcome measures were the number of mature follicles, the days of stimulation, the number of ampoules and IU used per cycle, the biochemical/clinical pregnancy rates, the number of multiple pregnancies and the cost-effectiveness. No statistically significant differences were found in the follicular development, length of stimulation, pregnancy rates, delivery rates and multiple pregnancies between the two groups. In the uFSH group, the cost per cycle remained significantly lower (218.51 +/- 88.69 versus 312.22 +/- 118.12; P < 0.0001), even though a significantly higher number of IU of gonadotrophins were used (809.3 +/- 271.9 versus 589.1 +/- 244.7; P < 0.0001). The cost-effectiveness (i. e. within a group, the total cost of all cycles divided by no. of clinical pregnancies) was 1729.08 in the uFSH group and 3075.37 in the rFSH group. In conclusion, uFSH and rFSH demonstrated the same effectiveness in ovarian stimulation in IUI cycles in PCOS patients. The urinary preparation is more cost-effective due to the difference of its cost per IU.

Economic evaluation of infertility treatment for tubal disease

PURPOSE

The number of published studies comparing cost-effectiveness of tubal surgery and IVF treatment is limited, in part because of the difficulties of conducting randomized trials, given that IVF is now a clinically accepted treatment and the decision to offer surgery or IVF is often dictated by the severity of the tubal disease and by the availability of the methods. The aim of this study was to compare the costs of our policy of offering tubal surgery to patients with mild or moderate tubal disease with the cost of offering IVF to these and severe tubal disease.

METHODS

In this retrospective cohort study patients with tubal pathology as the sole reason for their infertility were included: 61 patients in the tubal surgery group and 464 patients in the IVF group. The delivery rates and costs per delivery were compared.

RESULTS

Delivery rates were 28% in the tubal surgery group within 2 years of follow-up and 52% in the IVF group that involved up to three cycles of treatment. This economic evaluation demonstrated only small differences in the average cost when considering the cost per delivery.

CONCLUSIONS

With a policy involving strict selection of patients, tubal surgery will continue to have a role in the treatment of infertility.

A refined estimate of the average lifetime cost of pelvic inflammatory disease

BACKGROUND

The major complications of pelvic inflammatory disease (infertility, ectopic pregnancy, and chronic pelvic pain) are the leading cause of non-HIV sexually transmitted disease morbidity in the United States.

GOAL

The goal of the study was to estimate a plausible range for the average lifetime cost of pelvic inflammatory disease (PID) and its major complications in a cohort of U.S. women of reproductive age.

STUDY DESIGN

We developed a state-transition computer-based model to simulate the natural history of PID, incorporating the severity of infection, number of recurrent episodes, treatment setting, and the risk over time of major complications. Clinical and cost data were from the published literature. Model outcomes included life expectancy, quality-adjusted life expectancy, and lifetime costs.

RESULTS

In a cohort of 100,000 females acquiring PID between 20 and 24 years of age, 8550 ectopic pregnancies, 16,800 cases of infertility, and 18,600 cases of chronic pelvic pain were projected to occur. Assuming a 3% annual discount rate, we found the average per-person lifetime cost to be $2150. Average lifetime costs for women who developed major complications were $6350 for chronic pelvic pain, $6840 for ectopic pregnancy, and $1270 for infertility. The majority of costs (79%) were accrued within 5 years of upper genital tract infection. Results were most sensitive to assumptions about the timing of major complications and the discount rate.

CONCLUSION

The average per-person lifetime cost of PID ranges between $1060 and $3180. Future cost-effectiveness analyses of STD screening programs can include this range as a reasonable upper and lower bound. These findings suggest successful PID prevention efforts may avert substantial costs for care providers such as managed care organizations while providing well documented clinical benefits for women in the United States.

Funding in vitro fertilization treatment for persistent subfertility: the pain and the politics

OBJECTIVE

To consider the arguments for and against funding for in vitro fertilization (IVF) and to explore potential avenues for policy change.

DESIGN

Narrative literature review, policy analysis.

SETTING

University Department of Obstetrics and Gynecology.

PATIENT(S)

Sub-fertile women and men.

INTERVENTION(S)

Fertility treatments, in particular IVF.

RESULT(S)

The two main arguments used against funding for IVF are that [1] subfertility is a social, not a medical problem, and therefore its treatment is not medically indicated or necessary, and [2] the clinical effectiveness of IVF is unproven. These and other major arguments are critiqued.

CONCLUSION(S)

Dismissing IVF as medically unnecessary seems premature because medical necessity has not been operationally defined. Demonstrating IVF effectiveness through a randomized trial has not been done but is feasible: a multicenter trial is currently underway in Canada. Dealing with the concern that subfertility treatment challenges the role of women in society, as well as with questions of cost-effectiveness, are more difficult challenges that deserve further debate. The potential for unethical uses and broader social implications of IVF add to its dubious status and provide a convenient rationale for refusing to pay. However, none of these concerns is unique to IVF: many currently covered health services are susceptible to the same criticisms. For all services, judgments of eligibility for coverage should be consistent and transparent and should explicitly separate the issues of cost from other factors.

Cost effectiveness analysis of a population based screening programme for asymptomatic Chlamydia trachomatis infections in women by means of home obtained urine specimens

OBJECTIVES

To evaluate the cost effectiveness of a systematic screening programme for asymptomatic Chlamydia trachomatis infections in a female inner city population. To determine the sensitivity of the cost effectiveness analysis to variation in the probability of developing sequelae.

METHODS

A decision tree was constructed to evaluate health effects of the programme, such as averted sequelae of chlamydial infection. Cost effectiveness from a societal perspective was estimated for screening by means of a ligase chain reaction on mailed, home obtained urine specimens, in a population with a C trachomatis test prevalence of 2.9%. An extensive sensitivity analysis was performed for the probability of sequelae, the percentage of preventable pelvic inflammatory disease (PID), and the discount rate.

RESULTS

The estimated net cost of curing one woman, aged 15-40 years, of a C trachomatis infection is US$1210. To prevent one major outcome (PID, tubal factor infertility, ectopic pregnancy, chronic pelvic pain, or neonatal pneumonia), 479 women would have to be screened. The net cost of preventing one major outcome is $15 800. Changing the probability of PID after chlamydial infection from 5% to 25% decreases the net cost per major outcome averted from $28 300 to $6380, a reduction of 78%. Results were less sensitive to variations in estimates for other sequelae. The breakeven prevalence of the programme ranges from 6.4% for the scenario with all probabilities for complications set at the maximum value to a prevalence of 100% for probabilities set at the minimum value.

CONCLUSIONS

Systematic screening of all women aged 15-40 years for asymptomatic C trachomatis infections is not cost effective. Although the results of the analyses are sensitive to variation in the assumptions, the costs exceed the benefits, even in the most optimistic scenario.