An estimate of the cost of in vitro fertilization services in the United States in 1995

The cost of infertility evaluation and therapy: findings of a self-insured university healthcare plan

OBJECTIVE

To assess the total costs of infertility coverage, determine the proportion of healthcare costs related to infertility, compare infertility costs to those of other diseases, and calculate a per member per month cost of an infertility benefit.

DESIGN

Historical prospective analysis.

SETTING

A university-based, self-insured, fee-for-service healthcare plan.

PATIENT(S)

Healthcare policy members from January 1993 through December 1995.

INTERVENTION(S)

General and infertility-specific healthcare that included diagnostic tests for infertility, induction of ovulation, artificial insemination, donor gametes, in vitro fertilization, gamete intrafallopian transfer, zygote intrafallopian transfer, microsurgical epididymal sperm aspiration, embryo cryopreservation, and frozen embryo transfer.

MAIN OUTCOME MEASURE(S)

Healthcare costs, as calculated from the International Classification of Diseases, Volume 9 codes.

RESULT(S)

Total healthcare and infertility-specific costs of the university healthcare plan over a 3-year period were $86,445,642 and $680,921, respectively. Therefore, infertility accounted for 0.79% of the total university healthcare costs. The mean total and infertility-specific per member per month healthcare costs were $86.15 and $0.67, respectively.

CONCLUSION(S)

These data reveal that infertility costs account for only a small fraction of the total healthcare costs and can be attained at a nominal monthly fee.

Prospective randomized trial comparing the outcome and cost of in vitro fertilization with that of a traditional treatment algorithm as first-line therapy for couples with infertility

OBJECTIVE

To determine whether IVF or a standard infertility treatment algorithm results in better outcome and/or lower cost when used as first-line therapy for couples with infertility.

DESIGN

Prospective, randomized clinical study.

SETTING

University-affiliated infertility clinic.

PATIENT(S)

Couples with newly diagnosed infertility and no prior treatment.

INTERVENTION(S)

Couples were randomized to undergo either IVF (group 1, n = 46) or a standard infertility treatment algorithm (group 2, n = 50) as initial therapy for infertility.

MAIN OUTCOME MEASURE(S)

Pregnancy rates and costs per couple, per month of treatment, and per pregnancy.

RESULT(S)

Pregnancy rates were higher in group 2 than in group 1. Costs per couple were not statistically different, although a trend toward higher costs was apparent in group 1, reflected by a higher median cost per clinical pregnancy established and a higher cost per month of treatment. Whereas cost differences between the groups diminished over time, pregnancy rates remained the same.

CONCLUSION(S)

In vitro fertilization currently does not represent an appropriate first-line treatment option for couples with infertility. The use of a standard infertility treatment algorithm results in a higher pregnancy rate and lower cost and therefore should be the preferred treatment approach.

Cost-effective treatment of the infertile couple

OBJECTIVE

To review the published literature on the cost-effective approach to infertility treatment.

DESIGN

The literature on the economics and cost-effectiveness of infertility treatments was reviewed. Studies related to this topic were identified through MEDLINE.

RESULT(S)

Few cost-effectiveness studies about infertility treatment have been published. In the absence of tubal blockage and severe male factor, use of IUI and hMG-IUI is more cost-effective than IVF. In vitro fertilization is at least as cost-effective as tubal surgery. Although IVF costs are high, they fall well within the range of other accepted medical treatments and are below the general public's willingness to pay for these treatments.

CONCLUSION(S)

Cost-effectiveness analysis is an important means of improving quality of care while controlling costs. Further work regarding cost-effectiveness of treatments among different diagnostic groups is needed.

The economic cost of infertility-related services: an examination of the Massachusetts infertility insurance mandate

OBJECTIVE

To examine the costs and outcomes of infertility-related services in Massachusetts during a time of expanded use of assisted reproductive technology (ART).

DESIGN

Cost data were obtained from the Massachusetts Department of Insurance Rate-Setting Commission and 9 large group insurance plans for the period 1986-1993. Utilization and success rates of ART were examined, and the cost per live delivery with the use of ART in 1993 was estimated.

SETTING

The state of Massachusetts, in which access to infertility-related services has been mandated by law since 1989.

PATIENT(S)

The study population consisted of 8 large health maintenance organization plans and the Blue Cross/Blue Shield indemnity plan.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Per capita infertility-related expenditures, infertility-related expenditures as a percentage of total expenditures, live deliveries per initiated ART cycle, and cost per live delivery.

RESULT(S)

Expenditures for infertility services increased at a rate similar to or slower than inflation during the years 1988-1992. Increases were slowest in health maintenance organizations, probably as a result of provider arrangements. Infertility services accounted for 0.41% of total expenditures within the indemnity plan in 1993 (approximately $1.71 per contract-month). Examination of ART utilization showed no evidence of overutilization by patients with a low chance of success. The cost per live delivery with the use of ART in 1993 was $59,484.

CONCLUSION(S)

Mandated infertility coverage was associated with increased use of ART but not with excessive increases in consumer cost for infertility insurance coverage.

Profiling assisted reproductive technology: outcomes and quality of infertility management

OBJECTIVE

To critically appraise the content of the American Society for Reproductive Medicine (ASRM)/Society for Reproductive Technology (SART) Registry.

DESIGN

English-language literature review.

PATIENT(S)

Women undergoing treatment with assisted reproductive technology (ART).

INTERVENTION(S)

Current ART treatments, including IVF, GIFT, zygote intrafollopian transfer (ZIFT), oocyte micromanipulation, and cryopreserved embryo transfers.

MAIN OUTCOME MEASURE(S)

Compliance with clinical practice guidelines, and casemix-adjusted rates of live delivery, clinical pregnancy, ectopic pregnancy, miscarriage, birth defects, implantation, fertilization, and retrieval.

RESULT(S)

Outcomes should be adjusted for variation in patient characteristics known to affect prognosis, including maternal age, the duration of infertility, the presumed cause(s) of infertility, the patient's prior history of treatment for infertility, and diethylstilbestrol exposure. Outcome rates should be reported using the patient as the denominator, as well as cycle, retrieval, and transfer. The statistical significance of observed differences in events rates should be indicated. Because widely accepted clinical practice guidelines related to performance of ART procedures are not available, compliance with practice guidelines cannot currently be assessed.

CONCLUSION(S)

Reports based on ASRM/SART Registry data can be enhanced by refined casemix adjustment, assessing outcome rates per patient, as well as per component of ART procedure, and by providing an indication of the statistical significance of observed differences in event rates. In addition, a critical appraisal of available evidence related to particular aspects of infertility management would help clarify the areas in which there is an evidentiary basis for formulation of practice guidelines, as well as topics requiring additional clinical research.

Ethical issues and practical problems in preimplantation genetic diagnosis

Author argues the preimplantation genetic diagnosis is ethically acceptable for currently intended uses, but a variety of ethical and practical issues will arise with further development of this technology.

Association of semen quality and occupational factors: comparison of case-control analysis and analysis of continuous variables

OBJECTIVE

To compare two statistical approaches, case-control and analysis of continuous parameters of semen, in examining the relationship between occupational exposures and male reproductive function.

DESIGN

Case-control study.

SETTING

Males providing semen samples at a university infertility clinic.

PATIENT(S)

Nonvasectomized males who provided at least one semen sample at an infertility clinic.

MAIN OUTCOME MEASURE(S)

Standard clinical semen analysis.

RESULT(S)

Analyses using a dichotomous dependent variable did not uncover significant associations between any occupational factor and infertility case status. However, linear models incorporating continuous variables identified a number of occupational factors that were associated with specific parameters of semen. A reduction in percentage of progressive sperm and an increase in percentage of coiled tail sperm defects in welders, compared with unexposed subjects, were found. Significant dose-response relationships between level of perceived job stress and percentage of progressive sperm, total motile count, morphology, abnormal heads, and coiled tail defects were found.

CONCLUSION(S)

The findings suggest that subtle changes in semen variables, possibly associated with workplace exposure, may be detected only with parametric analyses of continuous variables of semen.

Should health insurance cover IVF? Issues and options

An emotional debate has attended the question of whether health insurance should cover the cost of in vitro fertilization (IVF) for infertile couples. Some private health plans have opted to cover IVF, although most have not. Ten states have mandated that it be included or offered as a standard benefit for private health insurance plans. This article analyzes several key issues in the debate: the impact of insurance coverage; the cost-effectiveness of IVF; valuing the benefit of IVF; and adoption as an alternative. It recommends policy action in several areas: more efficiently allocating resources for IVF (by giving priority to couples with better chances of success, and by making more extensive use of facilities with higher success rates); ensuring that clear and reliable information about the effectiveness of IVF is available; and leveling the playing field between IVF and adoption.

Factors influencing patients' decision not to repeat IVF

Women who did not pursue a second in vitro fertilization cycle after a failed cycle were surveyed. The major reason for not pursuing a second cycle was financial.

Global importance of infertility and its treatment: role of fertility technologies

Understanding the reasons for infertility and the development of new techniques for its treatment is one of the fields within medicine which has undergone a dramatic development during the last two decades. In the past, gynecologists seemed more successful in the treatment of female problems than urologists and andrologists on the male side, while in the last couple of years this scenario has changed due to the development of both operative procedures to harvest spermatozoa from the epididymis and the testis and the ability to micro-inject single spermatozoa (ICSI) or even spermatides directly into metaphase II oocytes. It should, however, be emphasized that the successful development of in vitro fertilization (IVF) and other assisted reproduction technologies (ART), could not have taken place without the development of diagnostic innovations, such as immunoassays of hormones, high resolution ultrasound and various endoscopic techniques. Today, treatment of the infertile couple is less of a medico-technical problem and more a socio-economic dilemma. This communication is an attempt to summarize the more prominent steps in reproductive medicine during the last decades and one more general conclusion of global relevance which can be drawn, is that less money must be spent on diagnosis and more resources transferred to treatment options.

Fertility options after vasectomy: a cost-effectiveness analysis

OBJECTIVE

To evaluate cost per delivery using two different initial approaches to the treatment of postvasectomy infertility.

DESIGN

Model of expected costs and results in the United States in 1994.

SETTING

Men with postvasectomy infertility, evaluated and treated at centers with experience in vasectomy reversal or sperm retrieval and ICSI.

PATIENT(S)

Men with postvasectomy infertility, with a female partner < or = 39 years of age.

INTERVENTION(S)

Initial microsurgical vasectomy reversal was compared with retrieved epididymal or testicular sperm. Actual treatment charges, complication rates, and pregnancy and delivery rates obtained in the United States were used for cost per delivery analysis.

MAIN OUTCOME MEASURE(S)

Cost per delivery, delivery rates.

RESULT(S)

Cost per delivery with an initial approach of vasectomy reversal was only $25,475. (95% confidence interval $19,609 to $31,339), with a delivery rate of 47%. However, the cost per delivery after sperm retrieval and ICSI was $72,521. (95% confidence interval $63,357 to $81,685), with an average of $73,146 for percutaneous or testicular sperm retrieval and $71,896 for surgical epididymal sperm retrieval. The delivery rate after one cycle of sperm retrieval and ICSI was 33%.

CONCLUSION(S)

The most cost-effective approach to treatment of postvasectomy infertility is microsurgical vasectomy reversal. This treatment also has the highest chance of resulting in delivery of a child for a single intervention.

Is assisted reproduction the optimal treatment for varicocele-associated male infertility? A cost-effectiveness analysis

OBJECTIVES

To evaluate the cost-effectiveness of assisted reproduction using in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) as a primary treatment for varicocele-associated infertility.

METHODS

Analysis of cost per delivery using published and contemporary results for treatment with ICSI in the United States for male factor infertility was compared with cost per delivery after surgical varicocelectomy. Only results from controlled trials of varicocelectomy were used for evaluation of pregnancy and delivery rates. Cost estimates were based on prevailing nationwide charges for services in 1994.

RESULTS

The cost per delivery with ICSI was found to be $89,091 (95% confidence interval $78,720 to $99,462), whereas the cost per delivery after varicocelectomy was only $26,268 (95% confidence interval $19,138 to $44,656). Assuming the highest possible published success rate for ICSI resulted in a cost estimate as low as $62,263. The average published U.S. delivery rate after one attempt of ICSI was only 28%. whereas a 30% delivery rate was obtained after varicocelectomy.

CONCLUSIONS

Specific treatment of varicocele-associated male factor infertility with surgical varicocelectomy is more cost-effective than primary treatment with assisted reproduction. Continued evaluation and treatment of the man with infertility is warranted. Despite the apparent success of ICSI for the most severe cases of male factor infertility, application of assisted reproduction for all cases of male factor infertility also does not necessarily provide as high a delivery rate as specific treatment of the cause of male factor infertility.

A cost and outcome model of fertility treatment in a managed care environment

OBJECTIVE

To build a financial model of a fertility practice operating under managed care.

DESIGN

Financial model in Microsoft Excel (Redmond, Washington).

SETTING

University-affiliated infertility practice, assuming primary care referral of patients and total revenue a function of the capitation contract.

PATIENT(S)

Female infertility patients and their partners with assumed mean age of 35 years.

MAIN OUTCOME MEASURE(S)

Breakeven capitation rate.

RESULT(S)

Every other month ovulation induction produced the lowest breakeven capitation rates in the model. Breakeven capitation rates increased from $0.85 up to $4.70 per member per month as utilization increased from 0.1% to 1% of health plan members. Decreasing the cost of an IVF-ET cycle $2,050 decreased breakeven capitation rates from $0.05 up to $0.80 per member per month as utilization of fertility services increases from 0.1% to 1% of health plan members. Decreasing average yearly pregnancy rate from 56% to 41% increased breakeven capitation rate from $0.10 to $0.80 per member per month across similar utilization. The average cost of pregnancy per year ranged from $6,787 to $21,075.

CONCLUSION(S)

As utilization of fertility services increases, cost reductions no longer exist to offset increasing breakeven capitation rates. Financial modeling, using actual data, can evaluate any medical decision in terms of outcome and the cost of that outcome. Modeling is an effective means for physicians to educate themselves concerning the cost of their fertility and medical decisions.

Factors that affect outcome of in-vitro fertilisation treatment

BACKGROUND

The effectiveness of in-vitro fertilisation (IVF) treatment depends both on the overall success rate in the treating clinic and on the characteristics of the couple seeking treatment. Since 1991, the Human Fertilisation and Embryology Authority (HFEA) has been collecting information on all IVF cycles carried out in the UK. This database has been analysed to identify the factors that affect the outcome of treatment.

METHODS

All IVF treatment cycles and outcomes registered between August, 1991, and April, 1994, were identified (52507). Cycles that involved gamete or embryo donation, frozen embryo transfer, or micromanipulation and unstimulated cycles were excluded. Thus, 36961 cycles (70% of those registered) were included in the analysis. The main outcome measure was liverbirth rate per cycle started. The relation between age and outcome was investigated by fitting of different fractional polynomials of age with logistic regression models. All other factors were analysed by logistic regression with age included in the model.

FINDINGS

The overall livebirth rate per cycle of treatment was 13.9%. The highest livebirth rates were in the age-group 25-30 years; younger women had lower rates and there was a sharp decline in older women. At all ages over 30, use of donor eggs was associated with a significantly higher livebirth rate than use of the woman's own eggs, but there was also a downward trend in success rate with age (p = 0.04). After adjustment for age, there was a significant decrease in livebirth rate with increasing duration of infertility from 1 to 12 years (p < 0.001). The medical indication for treatment had no significant effect on the outcome. Previous pregnancy and livebirth significantly increased treatment success. The possibility of success decreased with each IVF treatment cycle.

INTERPRETATION

We were able to identify by logistic regression the factors that significantly affect the outcome of IVF treatment, and to measure the magnitude of that effect. These factors should be taken into account in assessment of IVF results. After allowance for background clinic success rates, these factors can be used to predict outcome in individual cases.

Recanalization of obstructed fallopian tube by selective salpingography and transvaginal bougie dilatation: outcome and cost analysis

OBJECTIVE

To investigate effectiveness and cost of transcervical salpingography and recanalization in the management of infertility caused by tubal occlusion.

DESIGN

Retrospective analysis of patients investigated with transcervical selective salpingography and, in some instances, treated by transcervical recanalization.

SETTING

Four hundred patients with hysterosalpingography diagnosis of obstructed fallopian tubes (clinical environment) are investigated. A repeat hysterosalpingogram after administration of a prostaglandin antagonist demonstrated patency of the tubes in 82 patients and selective transcervical salpingography demonstrated patency in an additional 131 patients.

INTERVENTION

Transcervical tubal recanalization. Of the remaining 187 patients, recanalization by transcervical technique was successful in 145 patients. The underlying etiology for tubal obstruction was salpingitis isthmica nodosa in 62, salpingitis and perisalpingitis in 71, endometriosis in 8, failed surgical anastomosis in 43, and undeterminate cause in 3 patients. Pregnancy was attained in 24 patients, there were 10 minor and 1 major complication.

OUTCOME MEASURE

Attained and maintained patency of tubes, pregnancy, attendant complications.

CONCLUSION

A pregnancy rate of 12.8% was attained after transcervical recanalization of obstructed tubes. An attendant increased rate of pregnancy in patients proven patent after selective salpingography, valuable detailed information about proximal and distal tubes after recanalization of the obstructed proximal tube segment, the low rate of complications, and low cost are factors recommending the use of this technique. Moreover, tubal surgery or IVF treatment are not influenced adversely by prior transcervical tubal recanalization and remain an option for patients who failed to attain pregnancy.