1
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Venson R, Maheshwari A, Nelson SM, Boyd KA. Setting a tariff for IVF and ICSI treatment: a cost analysis. HUM FERTIL 2023; 26:519-526. [PMID: 37300314 DOI: 10.1080/14647273.2023.2204409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 02/17/2023] [Indexed: 06/12/2023]
Abstract
In-vitro fertilisation (IVF) and intra-cytoplasmatic sperm injection (ICSI) are available in Scotland through the National Health Service (NHS) according to specific criteria. There is no standardised NHS tariff for these treatments in Scotland, and variation exists amongst different centres providing NHS services. The aim of this study was to calculate the mean cost of IVF and ICSI cycles for NHS-funded treatment in Scotland. A detailed cost analysis of fresh and frozen cycles was performed, and a breakdown of the various cost components was presented. A deterministic approach was applied using NHS-funded individual cycle data from 2015-2018 and aggregate data. All costs were calculated in UK pounds sterling (£- using 2018 prices). Resource use was assigned to individual cycles based on cycle-level data or expert-informed assumptions; whenever needed, average aggregate costs were assigned to cycles. A total of 9442 NHS-funded cycles were included in the analysis. The average cost of fresh IVF and ICSI cycles was £3247 [£1526-£4215] and £3473 [£1526-£4416], respectively. Frozen cycles averaged £938 [£272-£1085]. This data can be useful to decision-makers, especially where IVF/ICSI is publicly funded, as it delivers a detailed IVF/ICSI cost breakdown. It is an opportunity for other authorities to estimate IVF/ICSI costs, as the methods applied are clear and reproducible.
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Affiliation(s)
- Rafael Venson
- Health Economics and Health Technology Assessment, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
- Wolfson Medical School Building, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Abha Maheshwari
- Aberdeen Maternity Hospital, National Health Service Grampian, Aberdeen, UK
| | - Scott M Nelson
- Glasgow Royal Infirmary, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
- NIHR Biomedical Research Centre, University of Bristol, Bristol, UK
- TFP Oxford Fertility, Institute of Reproductive Sciences, Oxford, UK
| | - Kathleen A Boyd
- Health Economics and Health Technology Assessment, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
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2
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Keller E, Chambers GM. Valuing infertility treatment: Why QALYs are inadequate, and an alternative approach to cost-effectiveness thresholds. FRONTIERS IN MEDICAL TECHNOLOGY 2022; 4:1053719. [PMID: 36619344 PMCID: PMC9822722 DOI: 10.3389/fmedt.2022.1053719] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022] Open
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3
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Sinegubova M, Vorobiev I, Klishin A, Eremin D, Orlova N, Orlova N, Polzikov M. Purification Process of a Recombinant Human Follicle Stimulating Hormone Biosimilar (Primapur ®) to Yield a Pharmaceutical Product with High Batch-to-Batch Consistency. Pharmaceutics 2022; 14:96. [PMID: 35056992 PMCID: PMC8781808 DOI: 10.3390/pharmaceutics14010096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/24/2021] [Accepted: 12/28/2021] [Indexed: 12/30/2022] Open
Abstract
Recombinant human follicle stimulating hormone (r-hFSH) is widely used for infertility treatment and is subject to the development of biosimilars. There are different purification strategies that can yield r-hFSH of pharmaceutical quality from Chinese hamster ovary cell culture broth. We developed a purification process for r-hFSH centered on immunoaffinity chromatography with single-domain recombinant camelid antibodies. The resulting downstream process is simple and devoid of ultrafiltration operations. Studies on chromatography resin resource and ligand leakage showed that the immunoaffinity matrix employed was suitable for industrial use and stable for at least 40 full chromatography cycles, and the leaked single-domain antibody ligand was completely removed by subsequent purification steps. All chromatography resins employed withstood the same 40 cycles of use without significant changes in separation efficiency and product binding capacity. The resulting industrial purification process yielded batches of r-hFSH with consistent levels of purity and bioactivity.
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Affiliation(s)
- Maria Sinegubova
- Laboratory of Mammalian Cell Bioengineering, Institute of Bioengineering, Federal State Institution «Federal Research Centre «Fundamentals of Biotechnology» of the Russian Academy of Sciences», Leninsky Prospect, 33, Build. 2, 119071 Moscow, Russia; (I.V.); (N.O.)
- IVFarma LLC, Nauchnyi Proezd, 20, Build. 2, 117246 Moscow, Russia;
| | - Ivan Vorobiev
- Laboratory of Mammalian Cell Bioengineering, Institute of Bioengineering, Federal State Institution «Federal Research Centre «Fundamentals of Biotechnology» of the Russian Academy of Sciences», Leninsky Prospect, 33, Build. 2, 119071 Moscow, Russia; (I.V.); (N.O.)
| | - Anatoly Klishin
- State Research Institute of Genetics and Selection of Industrial Microorganisms of National Research Center «Kurchatov Institute», Dorozhniy Proezd, 1, 117545 Moscow, Russia; (A.K.); (N.O.)
| | - Dmitry Eremin
- IVFarma LLC, Nauchnyi Proezd, 20, Build. 2, 117246 Moscow, Russia;
| | - Nadezhda Orlova
- Laboratory of Mammalian Cell Bioengineering, Institute of Bioengineering, Federal State Institution «Federal Research Centre «Fundamentals of Biotechnology» of the Russian Academy of Sciences», Leninsky Prospect, 33, Build. 2, 119071 Moscow, Russia; (I.V.); (N.O.)
| | - Natalya Orlova
- State Research Institute of Genetics and Selection of Industrial Microorganisms of National Research Center «Kurchatov Institute», Dorozhniy Proezd, 1, 117545 Moscow, Russia; (A.K.); (N.O.)
| | - Mikhail Polzikov
- IVFarma LLC, Nauchnyi Proezd, 20, Build. 2, 117246 Moscow, Russia;
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4
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JING M, ZHANG R. [Economic studies of in vitro fertilization and embryo transfer]. Zhejiang Da Xue Xue Bao Yi Xue Ban 2019; 48:580-585. [PMID: 31901035 PMCID: PMC8800743 DOI: 10.3785/j.issn.1008-9292.2019.10.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 06/25/2019] [Indexed: 06/10/2023]
Abstract
In vitro fertilization and embryo transplantation (IVF-ET) technology is one of the main treatments for infertility. But IVF-ET is expensive and has not be covered by health insurance in most developing countries. Therefore, how to obtain the maximum success rate with the minimum cost is a common concern of clinicians and patients. At present, the economic studies on IVF-ET mainly focus on different ovulation stimulating drugs, different ovulation stimulating protocols, different transplantation methods and the number of transplants. But the process of IVF-ET is complex, the relevant methods of economic study are diverse, and there are no unified standard for outcome indicators, so there is no unified conclusion for more economical and effective protocol by now. Therefore, to analyze the economic studies of IVF-ET, and to explore appropriate evaluation methods and cost-effective protocols will be helpful for reasonable allocation of medical resources and guidance of clinical selection. It would provide policy reference to include the costs of IVF-ET treatment in health insurance in the future.
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Affiliation(s)
| | - Runju ZHANG
- 张润驹(1978-), 男, 博士, 副主任医师, 硕士生导师, 主要从事生殖内分泌、子宫内膜容受性、胚胎着床研究; E-mail:
;
https://orcid.org/0000-0003-4438-4416
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Benbassat B, Mitov K, Savova A, Tachkov K, Petrova G. Cost-effectiveness of different types of COH protocols for in vitro fertilization at national level. BIOTECHNOL BIOTEC EQ 2016. [DOI: 10.1080/13102818.2016.1261636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Boriana Benbassat
- Department of Social Pharmacy, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
| | - Konstantin Mitov
- Department of Social Pharmacy, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
| | - Alexandra Savova
- Department of Social Pharmacy, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
| | - Konstantin Tachkov
- Department of Social Pharmacy, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
| | - Guenka Petrova
- Department of Social Pharmacy, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
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6
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Petrova G, Benbassat B, Lakic D, Dimitrova M, Mitov K, Dimitrov J. Cost-effectiveness of short COH protocols with GnRH antagonists using different types of gonadotropins for in vitro fertilization. BIOTECHNOL BIOTEC EQ 2016. [DOI: 10.1080/13102818.2016.1160796] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Affiliation(s)
- Guenka Petrova
- Department of Organization and Economy of Pharmacy, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
| | | | - Dragana Lakic
- Department of Organization and Economy of Pharmacy, Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia
| | - Maria Dimitrova
- Department of Organization and Economy of Pharmacy, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
| | - Konstantin Mitov
- Department of Organization and Economy of Pharmacy, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
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Wex J, Abou-Setta AM. Economic evaluation of highly purified human menopausal gonadotropin versus recombinant human follicle-stimulating hormone in fresh and frozen in vitro fertilization/intracytoplasmic sperm-injection cycles in Sweden. CLINICOECONOMICS AND OUTCOMES RESEARCH 2013; 5:381-97. [PMID: 23966798 PMCID: PMC3745292 DOI: 10.2147/ceor.s48994] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Gonadotropin-releasing hormone-analog type, fertilization method, and number of embryos available for cryopreservation should be incorporated into economic evaluations of highly purified human menopausal gonadotropin (HP-hMG) and recombinant human follicle-stimulating hormone (r-hFSH), as they may affect treatment costs. We searched for randomized trials and meta-analyses comparing HP-hMG and r-hFSH. Meta-analysis showed no significant difference in live births (odds ratio 0.82, 95% confidence interval [CI] 0.66–1.01), but a greater number of oocytes with r-hFSH (mean difference [MD] 1.96, 95% CI 1.02–2.90). Using a cost-minimization model for Sweden, accounting for embryo availability, survival following thawing, and patient dropout, we simulated patients individually for up to three cycles. R-hFSH was found to be cost-saving, at 2,767 kr (95% CI 1,580–4,057) per patient (€315 or $411); baseline savings were 6.43% of the total HP-hMG cost. In fresh cycles only, the savings for r-hFSH were 1,752 kr (95% CI 48–3,658) per patient (€200 or $260). In univariate sensitivity analyses, savings were obtained until the price of r-hFSH increased by 30% or the dosage of HP-hMG decreased by 38%–62% of baseline value. In probabilistic sensitivity analysis, r-hFSH was cost-saving in 100% of the simulated cohort per patient and in 85% per live birth; the respective percentages for fresh cycles only were 97.3% and 73.1%. In conclusion, a greater number of oocytes with r-hFSH allows for more frozen embryo transfers, thereby reducing overall treatment cost.
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8
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Ludwig M, Felberbaum RE, Diedrich K, Lunenfeld B. Ovarian stimulation: from basic science to clinical application. Reprod Biomed Online 2013; 5 Suppl 1:73-86. [PMID: 12537786 DOI: 10.1016/s1472-6483(11)60221-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Treatment for infertility, including ovarian stimulation, was first introduced almost 100 years ago. At this time, radiation therapy became an established treatment, and it was only some decades later that the problem of radiation-induced cancer emerged. Non-human gonadotrophins, such as pregnant mare serum gonadotrophin (PMSG), and human pituitary gonadotrophins (HPG), were commonly used for hormonal stimulation procedures. However, use of PMSG led to antibody formation, and it was therefore only useful for the first treatment cycle. HPG produced good results, but its use came to an end in the late 1980s when it was linked to the development of Creutzfeldt-Jakob disease. The first hormonal product from human menopausal urine to be used was human menopausal gonadotrophin (HMG), followed later by purified preparations of this product. All of these preparations contained a high percentage of unknown urinary proteins, which interfered with batch-to-batch consistency. This changed with the introduction of recombinant gonadotrophins, produced from an immortalized/standardized mammalian cell line (CHO). More recent developments include the introduction of long-acting gonadotrophin formulations. The development of gonadotrophin-releasing hormone (GnRH) analogues and more recently the use of GnRH antagonists has helped to improve ovarian stimulation protocols by optimizing their efficacy, and making them easier to administer.
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Affiliation(s)
- Michael Ludwig
- Division of Reproductive Medicine and Gynecologic Endocrinology, Department of Gynecology and Obstetrics, University Clinic, Ratzeburger Allee 160, 23538 Lübeck, Germany.
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9
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Gerli S, Bini V, Favilli A, Di Renzo GC. Clinical efficacy and cost-effectiveness of HP-human FSH (Fostimon®) versus rFSH (Gonal-F®) in IVF-ICSI cycles: a meta-analysis. Gynecol Endocrinol 2013; 29:520-9. [PMID: 23356335 DOI: 10.3109/09513590.2012.758703] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Clinical efficacy of human-derived follicle-stimulating hormone (FSH) versus recombinant FSH (rFSH) in IVF-ICSI cycles has long been compared, but no clear evidence of the superiority of a preparation over the other has been found. Human gonadotropins have been often grouped together, but a different glycosylation may be present in each preparation, therefore influencing the specific bioactivity. To exclude confounding factors, a meta-analysis and a cost-effectiveness analysis were designed to compare effectiveness and cost-effectiveness of a specific highly purified human FSH (HP-hFSH) (Fostimon®) versus rFSH (Gonal-F®) in IVF/ICSI cycles. Research methodology filters were applied in MEDLINE, Current Contents and Web of Science from 1980 to February 2012. Eight randomized trials met selection criteria. The meta-analysis showed no significant differences between rFSH and HP-hFSH treatment in live-birth rate (odds ratio [OR] 0.84, 95% confidence interval [CI] 0.63-1.11), clinical pregnancy rate (OR 0.85, 95% CI 0.68-1.07), number of oocytes retrieved, number of mature oocytes and days of stimulation. The cost-effectiveness ratio was € 7174 in the rFSH group and € 2056 in the HP-hFSH group. HP-hFSH is as effective as rFSH in ovarian stimulation for IVF-ICSI cycles, but the human preparation is more cost-effective.
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Affiliation(s)
- Sandro Gerli
- Department of Obstetrics and Gynecology, University of Perugia, Perugia, Italy.
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10
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Fragoulakis V, Kourlaba G, Tarlatzis B, Mastrominas M, Maniadakis N. Economic evaluation of alternative assisted reproduction techniques in management of infertility in Greece. CLINICOECONOMICS AND OUTCOMES RESEARCH 2012; 4:185-92. [PMID: 22888264 PMCID: PMC3414378 DOI: 10.2147/ceor.s31972] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The purpose of this study was to compare Gonal-F(®), a recombinant follicle-stimulating hormone, with Menopur(®), a highly purified human menopausal gonadotrophin (hpHMG) in assisted reproduction in Greece. METHODS A decision tree in combination with a Markov model was used to assess the clinical and economical impact of comparators for up to three consecutive cycles. Transition probabilities were derived from the literature and validated by clinical experts. Cost components were derived from the electronic databases of selected private and public clinics. A probabilistic sensitivity analysis was performed to deal with uncertainty and to construct a cost-effectiveness acceptability curve. RESULTS There was a statistically significant difference in favor of the recombinant follicle-stimulating hormone arm compared with hpHMG, which was associated with 52 more births (95% uncertainty interval 26-78, P = 0.001) per 1000 patients. The cost per birth was estimated at €16,906 and €17,286 in the recombinant follicle-stimulating hormone and hpHMG arms, respectively. The cost per in vitro fertilization was estimated at €4365 in the recombinant follicle-stimulating hormone arm and €3815 in the hpHMG arm, indicating a difference of €550. The incremental cost per birth for recombinant follicle-stimulating hormone versus hpHMG was estimated at €14,540, while the incremental cost per life-year was estimated at €175.41. CONCLUSION Recombinant follicle-stimulating hormone may represent a cost-effective choice compared with hpHMG when used for ovarian stimulation for a pharmacoeconomic point of view in the Greek public health care setting. However, it must be noted that in clinical practice both agents may be used together to increase the number of follicles, oocytes, embryos, and/or pregnancies in treated patients, an approach which has not been evaluated in Greece or reported in the literature due to obvious limitations.
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Affiliation(s)
- Vassilis Fragoulakis
- Department of Health Services Management, National School of Public Health, Athens
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11
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Ludwig M, Felberbaum RE, Diedrich K, Lunenfeld B. Ovarian stimulation: from basic science to clinical application. Reprod Biomed Online 2011; 22 Suppl 1:S3-16. [PMID: 21575847 DOI: 10.1016/s1472-6483(11)60003-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Treatment for infertility, including ovarian stimulation, was first introduced almost 100 years ago. At this time, radiation therapy became an established treatment, and it was only some decades later that the problem of radiation-induced cancer emerged. Non-human gonadotrophins, such as pregnant mare serum gonadotrophin (PMSG), and human pituitary gonadotrophins (HPG), were commonly used for hormonal stimulation procedures. However, use of PMSG led to antibody formation, and it was therefore only useful for the first treatment cycle. HPG produced good results, but its use came to an end in the late 1980s when it was linked to the development of Creutzfeldt-Jakob disease. The first hormonal product from human menopausal urine to be used was human menopausal gonadotrophin (HMG), followed later by purified preparations of this product. All of these preparations contained a high percentage of unknown urinary proteins, which interfered with batch-to-batch consistency. This changed with the introduction of recombinant gonadotrophins, produced from an immortalized/standardized mammalian cell line (CHO). More recent developments include the introduction of long-acting gonadotrophin formulations. The development of gonadotrophin-releasing hormone (GnRH) analogues and more recently the use of GnRH antagonists has helped to improve ovarian stimulation protocols by optimizing their efficacy, and making them easier to administer.
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Affiliation(s)
- Michael Ludwig
- Division of Reproductive Medicine and Gynecologic Endocrinology, Department of Gynecology and Obstetrics, University Clinic, Lübeck, Germany.
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12
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Wex-Wechowski J, Abou-Setta AM, Kildegaard Nielsen S, Kennedy R. HP-HMG versus rFSH in treatments combining fresh and frozen IVF cycles: success rates and economic evaluation. Reprod Biomed Online 2010; 21:166-78. [PMID: 20541471 DOI: 10.1016/j.rbmo.2010.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2009] [Revised: 02/18/2010] [Accepted: 05/06/2010] [Indexed: 11/30/2022]
Abstract
The economic implications of the choice of gonadotrophin influence decision making but their cost-effectiveness in frozen-embryo transfer cycles has not been adequately studied. An economic evaluation was performed comparing highly purified human menopausal gonadotrophin (HP-HMG) and recombinant FSH (rFSH) using individual patient data (n=986) from two large randomized controlled trials using a long agonist IVF protocol. The simulation model incorporated live birth data and published UK costs of IVF-related medical resources. After treatment for up-to-three cycles (one fresh and up to two subsequent fresh or frozen cycles conditional on availability of cryopreserved embryos), the cumulative live birth rate was 53.7% (95% CI 49.3-58.1%) for HP-HMG and 44.6% (40.2-49.0%) for rFSH (OR 1.44, 95% CI 1.12-1.85; P<0.005). The mean costs per IVF treatment for HP-HMG and rFSH were pound5393 ( pound5341-5449) and pound6269 ( pound6210-6324), respectively (number needed to treat to fund one additional treatment was seven; P<0.001). With maternal and neonatal costs applied, the median cost per IVF baby delivered with HP-HMG was pound11,157 ( pound11,089-11,129) and pound14,227 ( pound14,183-14,222) with rFSH (P<0.001). The cost saving using HP-HMG remained after varying model parameters in a probabilistic sensitivity analysis.
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Affiliation(s)
- Jaro Wex-Wechowski
- PharmArchitecture, Quatro House, Lyon Way, Camberley, Surrey GU167ER, UK.
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13
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Pharmacoeconomy in ART: The importance of the gonadotrophin choice. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2010. [DOI: 10.1016/j.mefs.2010.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Ledger W, Wiebinga C, Anderson P, Irwin D, Holman A, Lloyd A. Costs and outcomes associated with IVF using recombinant FSH. Reprod Biomed Online 2009; 19:337-42. [PMID: 19778478 DOI: 10.1016/s1472-6483(10)60167-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Cost and outcome estimates based on clinical trial data may not reflect usual clinical practice, yet they are often used to inform service provision and budget decisions. To expand understanding of assisted reproduction treatment in clinical practice, an economic evaluation of IVF/intracytoplasmic sperm injection (ICSI) data from a single assisted conception unit (ACU) in England was performed. A total of 1418 IVF/ICSI cycles undertaken there between October 2001 and January 2006 in 1001 women were analysed. The overall live birth rate was 22% (95% CI: 19.7-24.2), with the 30- to 34-year age group achieving the highest rate (28%). The average recombinant FSH (rFSH) dose/cycle prescribed was 1855 IU. Average cost of rFSH/cycle was 646 pound(SD: 219 pound), and average total cost/cycle was 2932 pound (SD: 422 pound). Economic data based on clinical trials informing current UK guidance assumes higher doses of rFSH dose/cycle (1750-2625 IU), higher average cost of drugs/cycle (1179 pound), and higher average total cost/cycle (3266 pound). While the outcomes in this study matched UK averages, total cost/cycle was lower than those cited in UK guidelines. Utilizing the protocols and (lower) rFSH dosages reported in this study may enable other ACU to provide a greater number of IVF/ICSI cycles to patients within given budgets.
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Affiliation(s)
- W Ledger
- Centre for Reproductive Medicine and Fertility, Royal Hallamshire Hospital, Sheffield, UK
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15
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Maheshwari A, Scotland G, Bell J, McTavish A, Hamilton M, Bhattacharya S. Direct health services costs of providing assisted reproduction services in older women. Fertil Steril 2009; 93:527-36. [PMID: 19261279 DOI: 10.1016/j.fertnstert.2009.01.115] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2008] [Revised: 01/16/2009] [Accepted: 01/19/2009] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the total health service costs incurred for each live birth achieved by older women undergoing IVF compared with costs in younger women. DESIGN Retrospective cross-sectional analysis. SETTING In vitro fertilization unit and maternity hospital in a tertiary care setting. PATIENT(S) Women who underwent their first cycle of IVF between 1997 and 2006. INTERVENTION(S) Bottom-up costs were calculated for all interventions in the IVF cycle. Early pregnancy and antenatal care costs were obtained from National Health Service reference costs, Information Services Division Scotland, and local departmental costs. MAIN OUTCOME MEASURE(S) Cost per live birth. RESULT(S) The mean cost per live birth (95% confidence interval [CI]) in women undergoing IVF at the age of > or =40 years was pound 40,320 (pound 27,105- pound 65,036), which is >2.5 times higher than those aged 35-39 years (pound 17,096 [pound 15,635- pound 18,937]). The cost per ongoing pregnancy was almost three times in women aged > or =40 (pound 31,642 [pound 21,241- pound 58,979]) compared with women 35-39 years of age (pound 11,300 [pound 10,006- pound 12,938]). CONCLUSION(S) The cost of a live birth after IVF rises significantly at the age of 40 years owing to lower success rates. Most of the extra cost is due to the low success of IVF treatment, but some of it is due to higher rates of early pregnancy loss.
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Affiliation(s)
- Abha Maheshwari
- Department of Obstetrics and Gynaecology, University of Aberdeen, Aberdeen Maternity Hospital, Foresterhill, Aberdeen, AB25 2ZL, Scotland, UK.
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16
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Nyachieo A, Spiessens C, Mwenda JM, Debrock S, D’Hooghe TM. Improving ovarian stimulation protocols for IVF in baboons: Lessons from humans and rhesus monkeys. Anim Reprod Sci 2009; 110:187-206. [DOI: 10.1016/j.anireprosci.2008.08.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2008] [Revised: 08/18/2008] [Accepted: 08/21/2008] [Indexed: 10/21/2022]
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17
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Wechowski J, Connolly M, Schneider D, McEwan P, Kennedy R. Cost-saving treatment strategies in in vitro fertilization: a combined economic evaluation of two large randomized clinical trials comparing highly purified human menopausal gonadotropin and recombinant follicle-stimulating hormone alpha. Fertil Steril 2008; 91:1067-76. [PMID: 18339384 DOI: 10.1016/j.fertnstert.2008.01.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2007] [Revised: 01/08/2008] [Accepted: 01/08/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To assess the cost-effectiveness of two gonadotropin treatments that are available in the United Kingdom in light of limited public funding and the fundamental role of costs in IVF treatment decisions. DESIGN An economic evaluation based on two large randomized clinical trials in IVF patients using a simulation model. SETTING Fifty-three fertility clinics in 13 European countries and Israel. PATIENT(S) Women indicated for treatment with IVF (N = 986), aged 18-38, participating in double-blind, randomized controlled trials. INTERVENTION(S) Highly purified menotropin (HP-hMG, Menopur) or recombinant follitropin alpha (rFSH, Gonal-F). MAIN OUTCOME MEASURE(S) Cost per IVF cycle and cost per live birth for HP-hMG and rFSH alpha. RESULT(S) HP-hMG was more effective and less costly versus rFSH for both IVF cost per live birth and for IVF cost per baby (incremental cost-effectiveness ratio was negative). The mean costs per IVF treatment for HP-hMG and rFSH were 2408 pounds (95% confidence interval [CI], 2392 pounds, 2421 pounds) and 2660 pounds (95% CI 2644 pounds, 2678 pounds), respectively. The mean cost saving of 253 pounds per cycle using HP-hMG allows one additional cycle to be delivered for every 9.5 cycles. CONCLUSION(S) Treatment with HP-hMG was dominant compared with rFSH in the United Kingdom. Gonadotropin costs should be considered alongside live-birth rates to optimize outcomes using scarce health-care resources.
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18
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Gerli S, Bini V, Di Renzo GC. Cost-effectiveness of recombinant follicle-stimulating hormone (FSH) versus human FSH in intrauterine insemination cycles: a statistical model-derived analysis. Gynecol Endocrinol 2008; 24:18-23. [PMID: 18224540 DOI: 10.1080/09513590701690241] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE Recently we proposed a randomized trial specifically designed to evaluate the cost-effectiveness of two different protocols of stimulation in intrauterine insemination (IUI) cycles. Computer-simulated clinical models have been developed to perform pharmacoeconomic studies, creating a decision tree in which the complex procedure is performed and repeated. The present study was designed to compare the cost-effectiveness of recombinant follicle-stimulating hormone (rFSH) and human-derived FSH (hFSH) in ovarian stimulation and to indicate which protocol should be used in IUI cycles. STUDY DESIGN Two computer-generated decision tree models were constructed to compare the clinical effects and costs of rFSH versus hFSH in IUI cycles. A first decision tree model was built according to the trial previously published. In a second model, 10 000 hypothetical infertile patients were entered in a computer-generated simulation and were stimulated with two different protocols for IUI. IUI was hypothetically performed in both groups of patients with a known pregnancy, cancellation, miscarriage and abandonment rate. The two protocols were compared using a cost-effective analysis: cost-effectiveness ratios (CE) and incremental cost-effectiveness ratios (ICER) were calculated. The cost-effectiveness acceptability curve (CEAC) was constructed. RESULTS The overall estimated costs with each ovarian stimulation strategy in the first model demonstrated that rFSH was a less cost-effective strategy, with an ICER of euro 13,727. The CEAC showed that at a level of euro 0 of willingness to pay, hFSH was cost-effective in 73% of the samples while rFSH was cost-effective in 27% only. Recombinant FSH would be more cost-effective than hFSH at an effectiveness threshold of 0.170 and at a cost per cycle of euro 235. This finding was also confirmed by the acceptability curve obtained with 10,000 Monte Carlo simulations, in which hFSH was cost-effective in about 96-98% of samples at any threshold of willingness to pay. CONCLUSIONS This study represents the first statistical model developed with a computer-generated clinical simulation with the intent to elaborate a pharmacoeconomic comparison between rFSH and hFSH in ovarian stimulation for IUI cycles. Results demonstrated that hFSH is more cost-effective than rFSH.
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Affiliation(s)
- Sandro Gerli
- Department of Medical-Surgical Specialties and Public Health, Obstetrics and Gynecology, University of Perugia, Perugia, Italy.
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19
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Wechowski J, Connolly M, McEwan P, Kennedy R. An economic evaluation of highly purified HMG and recombinant FSH based on a large randomized trial. Reprod Biomed Online 2007; 15:500-6. [DOI: 10.1016/s1472-6483(10)60380-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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20
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Navarro Espigares JL, Martínez Navarro L, Castilla Alcalá JA, Hernández Torres E. Coste de las técnicas de reproducción asistida en un hospital público. GACETA SANITARIA 2006; 20:382-90. [PMID: 17040647 DOI: 10.1157/13093207] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Most studies on the costs of assisted reproductive technologies (ART) identify the total cost of the procedure with the direct cost, without considering important items such as overhead or intermediate costs. The objective of this study was to determine the cost per ART procedure in a public hospital in 2003 and to compare the results with those in the same hospital in 1998. METHODS Data from the Human Reproduction Unit of the Virgen de las Nieves University Hospital in Granada (Spain) from 1998 and 2003 were analyzed. Since the total costs of the unit were known, the cost of the distinct ART procedures performed in the hospital was calculated by means of a methodology for cost distribution. RESULTS Between 1998 and 2003, the activity and costs of the Human Reproduction Unit analyzed evolved differently. Analysis of activity showed that some techniques, such as intracytoplasmic sperm injection, were consolidated while others, such as stimulation without assisted reproduction or intracervical insemination were abandoned. In all procedures, unit costs per cycle and per delivery decreased in the period analyzed. CONCLUSIONS Important changes took place in the structure of costs of ART in the Human Reproduction Unit of the Virgen de las Nieves University Hospital between 1998 and 2003. Some techniques were discontinued, while others gained importance. Technological advances and structural innovations, together with a "learning effect," modified the structure of ART-related costs.
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Affiliation(s)
- José Luis Navarro Espigares
- Subdirección Económico-Administrativa de Control de Gestión, Hospital Universitario Virgen de las Nieves, Granada, Spain.
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21
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Revelli A, Poso F, Gennarelli G, Moffa F, Grassi G, Massobrio M. Recombinant versus highly-purified, urinary follicle-stimulating hormone (r-FSH vs. HP-uFSH) in ovulation induction: a prospective, randomized study with cost-minimization analysis. Reprod Biol Endocrinol 2006; 4:38. [PMID: 16848893 PMCID: PMC1550405 DOI: 10.1186/1477-7827-4-38] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2006] [Accepted: 07/18/2006] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Alberto Revelli
- Reproductive Medicine and IVF Unit, Department of Obstetrical and Gynecological Sciences, University of Torino, S. Anna Hospital, Torino, Italy
| | - Francesca Poso
- Reproductive Medicine and IVF Unit, Department of Obstetrical and Gynecological Sciences, University of Torino, S. Anna Hospital, Torino, Italy
| | - Gianluca Gennarelli
- Reproductive Medicine and IVF Unit, Department of Obstetrical and Gynecological Sciences, University of Torino, S. Anna Hospital, Torino, Italy
| | - Federica Moffa
- Reproductive Medicine and IVF Unit, Department of Obstetrical and Gynecological Sciences, University of Torino, S. Anna Hospital, Torino, Italy
| | - Giuseppina Grassi
- Reproductive Medicine and IVF Unit, Department of Obstetrical and Gynecological Sciences, University of Torino, S. Anna Hospital, Torino, Italy
| | - Marco Massobrio
- Reproductive Medicine and IVF Unit, Department of Obstetrical and Gynecological Sciences, University of Torino, S. Anna Hospital, Torino, Italy
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22
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Macklon NS, Stouffer RL, Giudice LC, Fauser BCJM. The science behind 25 years of ovarian stimulation for in vitro fertilization. Endocr Rev 2006; 27:170-207. [PMID: 16434510 DOI: 10.1210/er.2005-0015] [Citation(s) in RCA: 338] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
To allow selection of embryos for transfer after in vitro fertilization, ovarian stimulation is usually carried out with exogenous gonadotropins. To compensate for changes induced by stimulation, GnRH analog cotreatment, oral contraceptive pretreatment, late follicular phase human chorionic gonadotropin, and luteal phase progesterone supplementation are usually added. These approaches render ovarian stimulation complex and costly. The stimulation of multiple follicular development disrupts the physiology of follicular development, with consequences for the oocyte, embryo, and endometrium. In recent years, recombinant gonadotropin preparations have become available, and novel stimulation protocols with less detrimental effects have been developed. In this article, the scientific background to current approaches to ovarian stimulation for in vitro fertilization is reviewed. After a brief discussion of the relevant aspect of ovarian physiology, the development, application, and consequences of ovarian stimulation strategies are reviewed in detail.
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Affiliation(s)
- Nick S Macklon
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands.
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23
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Al-Inany HG, Abou-Setta AM, Aboulghar MA, Mansour RT, Serour GI. HMG versus rFSH for ovulation induction in developing countries: a cost–effectiveness analysis based on the results of a recent meta-analysis. Reprod Biomed Online 2006; 12:163-9. [PMID: 16478578 DOI: 10.1016/s1472-6483(10)60856-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Both cost and effectiveness should be considered conjointly to aid judgments about drug choice. Therefore, based on the results of a recent published meta-analysis, a Markov model was developed to conduct a cost-effectiveness analysis for estimation of the cost of an ongoing pregnancy in IVF/intracytoplasmic sperm injection (ICSI) cycles. In addition, Monte Carlo micro-simulation was used to examine the potential impact of assumptions and other uncertainties represented in the model. The results of the study reveal that the estimated average cost of an ongoing pregnancy is 13,946 Egyptian pounds (EGP), and 18,721 EGP for a human menopausal gonadotrophin (HMG) and rFSH cycle respectively. On performing a sensitivity analysis on cycle costs, it was demonstrated that the rFSH price should be 0.61 EGP/IU to be as cost-effective as HMG at the price of 0.64 EGP/IU (i.e. around 60% reduction in its current price). The difference in cost between HMG and rFSH in over 100,000 cycles would result in an additional 4565 ongoing pregnancies if HMG was used. Therefore, HMG was clearly more cost-effective than rFSH. The decision to adopt a more expensive, cost-ineffective treatment could result in a lower number of cycles of IVF/ICSI treatment undertaken, especially in the case of most developing countries.
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Affiliation(s)
- Hesham G Al-Inany
- The Egyptian IVF-ET Centre, Maadi, and Cairo University, Department of Obstetrics and Gynecology, Cairo, Egypt.
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24
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Abstract
Follicle-stimulating hormone (FSH), a glycoprotein produced by the anterior pituitary gland, plays an important role in the regulation of fertility in both men and women. FSH is used clinically to treat women with anovulatory infertility, for controlled ovarian stimulation in women being treated with assisted reproductive technologies (ART), and in the treatment of male hypogonadotrophic hypogonadism. Urine-derived gonadotropin preparations containing variable amounts of FSH together with urinary proteins have been available for many years. More recently, FSH preparations produced using recombinant DNA technology have become available. Recombinant FSH has a high specific activity, high purity, and guaranteed consistency among batches. Two recombinant FSH preparations have been available for clinical use for some years: follitropin-alpha and follitropin-beta. The continuing development of recombinant FSH has recently resulted in a new presentation (follitropin-alpha filled by mass [FbM]). This product can be filled by mass (microg) with an activity (IU), reflecting exceptional consistency as a result of refinement and improvement in the manufacturing process, allowing the clinician to deliver a guaranteed dose of FSH. Experience with recombinant FSH in the treatment of male hypogonadotrophic hypogonadism is limited, but the available data suggest that recombinant FSH has a similar efficacy to urine-derived preparations (urofollitropin). In patients with WHO group I anovulatory infertility, the use of recombinant FSH to stimulate follicular development is effective and well tolerated. In patients with WHO group II anovulation, protocols based on recombinant FSH are more effective than conventional protocols using urofollitropin. Comparative studies and a meta-analysis have shown that recombinant FSH is more effective than urofollitropin for controlled ovarian stimulation in women undergoing ART. Pharmacoeconomic modeling indicates that follitropin-alpha is more cost effective than urofollitropin in a range of different healthcare systems. The available evidence from comparative studies of the two recombinant FSH preparations suggests that follitropin-alpha may have an advantage over follitropin-beta in terms of efficacy. Follitropin-alpha is superior to follitropin-beta in terms of local tolerability. Recent preliminary studies suggest an efficacy advantage for follitropin-alpha FbM compared with standard follitropin-alpha. The FbM presentation appears to represent an advance on standard preparations of recombinant FSH in terms of consistency and clinical efficacy.
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Affiliation(s)
- Salim Daya
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada.
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25
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Collins JA. Associate editor’s commentary: Mathematical modelling and clinical prediction. Hum Reprod 2005; 20:2932-4. [PMID: 15980001 DOI: 10.1093/humrep/dei131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- John A Collins
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada.
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26
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Ludwig M, Keck C. Recombinant gonadotrophins in reproductive medicine: gold standard for ovarian stimulation therapy in the 21st century. Reprod Biomed Online 2005; 11:535-6. [PMID: 16409693 DOI: 10.1016/s1472-6483(10)61153-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The clinical use of gonadotrophin preparations started in the 1960s when it was possible to extract human menopausal gonadotrophins from urine of post-menopausal women. Recombinant gonadotrophins became available in 1995. Whereas in other therapeutic areas the introduction of pure, recombinant preparations such as insulin and growth hormone has lead to rapid phasing out of biological extraction-based therapies, this is different for gonadotrophins. It is difficult to understand why even today women are exposed to urinary products although the benefits of recombinant gonadotropohins in terms of safety are obvious.
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Affiliation(s)
- M Ludwig
- Endokrinologikum Hamburg, Zentrum für Hormon- und Stoffwechselerkrankungen, Reproduktionsmedizin und Gynäkologische Endokrinologie
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27
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Abstract
The 20th century witnessed the steady development of knowledge about the reproductive process in animals and humans. These advances led to the identification of higher centres governing the dynamics of ovarian function and to the discovery of gonadotrophic hormones. As the mechanisms of action of these hormones became increasingly understood, they began to be used in the management of infertility during the early 1930s. Hormone extracts were originally prepared from animal pituitaries and pregnant mare serum, as well as from human pituitaries, placenta and urine, with pregnancies reported following their use in the late 1930s. This review traces the constant quest to reduce risks and improve safety and efficacy of hormone preparations for patients. It describes the complex path and perils leading to the pure hormone preparations that are available today, concluding with an optimistic glimpse towards the future. Small molecules that are orally active and specific are currently being investigated, some with the capacity to bypass many parts of the receptor conformation. Here lies the immediate future of this field, utilizing low-cost, small, defined molecules to stimulate follicle growth, ovulation and corpus luteum formation. Perhaps one day the classical gonadotrophins will no longer be required in clinical treatment.
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Affiliation(s)
- Bruno Lunenfeld
- Faculty of Life Sciences, Bar-Ilan University, Ramat Gan 52900, Israel
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28
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Gerli S, Casini ML, Unfer V, Costabile L, Bini V, Di Renzo GC. Recombinant versus urinary follicle-stimulating hormone in intrauterine insemination cycles: A prospective, randomized analysis of cost effectiveness. Fertil Steril 2004; 82:573-8. [PMID: 15374698 DOI: 10.1016/j.fertnstert.2004.04.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2003] [Revised: 04/06/2004] [Accepted: 04/06/2004] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare the clinical results and the cost effectiveness of urinary FSH and recombinant FSH in ovarian stimulation for IUI cycles. DESIGN Prospective, randomized trial. SETTING University Hospital, Perugia, and A.G.UN.CO. Obstetrics and Gynaecology Centre, Rome, Italy. PATIENT(S) IUI cycles were performed in 67 infertile patients. INTERVENTION(S) Protocols of ovarian stimulation with urinary FSH or recombinant FSH were randomly assigned, for a total of 138 cycles performed (67 and 71, respectively). MAIN OUTCOME MEASURE(S) Number of mature follicles, days of stimulation, number of ampules, and IU used per cycle, biochemical/clinical pregnancy rates and cost-effectiveness ratio. RESULT(S) Follicular development, length of stimulation, pregnancy and delivery rates were not statistically different. Although in the urinary FSH group a significantly higher number of IU of gonadotropins were used (815.5 +/- 284.9 vs. 596.0 +/- 253.8), the cost per cycle remained significantly lower (220.73 +/- 94.72 vs. 318.50 +/- 125.21). The cost-effectiveness ratio was 1,848.61 euro in the urinary FSH group and 2,512.61 euro in the recombinant FSH group. CONCLUSION(S) Urinary FSH and recombinant FSH are both effective in ovarian stimulation in IUI cycles. The urinary preparation is more cost effective due to the difference of its cost per IU.
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Affiliation(s)
- Sandro Gerli
- Centre of Reproductive and Perinatal Medicine, Department of Gynecological, Obstetrical and Pediatric Sciences, University of Perugia, Policlinico Monteluce, Perugia 06122, Italy.
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29
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Levi-Setti PE, Cavagna M, Baggiani A, Zannoni E, Colombo GV, Liprandi V. FSH and LH together in ovarian stimulation. Eur J Obstet Gynecol Reprod Biol 2004; 115 Suppl 1:S34-9. [PMID: 15196714 DOI: 10.1016/j.ejogrb.2004.01.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The authors review the physiology of the ovulatory cycle and the role of the gonadotrophins in ovulation induction in patients with anovulatory disorders and in multifollicular development for assisted reproductive technologies. The use of gonadotrophins with luteinizing hormone (LH) activity and the use of recombinant LH associated with follicle stimulating hormone (FSH) are discussed. The authors point out that administration of gonadotrophins with LH activity is essential in hypogonadotropic hypogonadal anovulation, and data available in the medical literature allow the conclusion that recombinant LH may be added to all ovarian stimulation protocols because it is difficult to determine which patients will benefit from LH administration and there is no evidence that LH affects adversely the outcome of ovarian stimulation. The use of recombinant LH in addition to recombinant FSH may be particularly useful when a GnRH antagonist is associated with the ovarian stimulation regimen, by preventing the fall in estradiol and diminishing FSH requirements.
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Affiliation(s)
- Paolo E Levi-Setti
- Unità Operativa di Medicina della Riproduzione--Istituto Clinico Humanitas, Rozzano, Milan, Italy.
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30
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Gerli S, Casini ML, Unfer V, Costabile L, Mignosa M, Di Renzo GC. Ovulation induction with urinary FSH or recombinant FSH in polycystic ovary syndrome patients: a prospective randomized analysis of cost-effectiveness. Reprod Biomed Online 2004; 9:494-9. [PMID: 15588465 DOI: 10.1016/s1472-6483(10)61632-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Sandro Gerli
- Centre of Reproductive and Perinatal Medicine, Department of Gynecological, Obstetrical and Pediatric Sciences, University of Perugia, Italy.
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31
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Lloyd A, Kennedy R, Hutchinson J, Sawyer W. Economic evaluation of highly purified menotropin compared with recombinant follicle-stimulating hormone in assisted reproduction. Fertil Steril 2003; 80:1108-13. [PMID: 14607557 DOI: 10.1016/s0015-0282(03)02185-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To determine the cost of achieving pregnancy with different gonadotropin preparations. DESIGN Cost-minimization analysis of a prospective randomized clinical trial. SETTING Twenty-two centers in six countries. PATIENT(S) Women 18 to 36 years of age with infertility for more than 1 year who were undergoing IVF or ICSI. INTERVENTION(S) Highly purified hMG or recombinant FSH. RESULT(S) Mean cost of achieving an ongoing pregnancy. The mean cost per patient treatment cycle was estimated to be pound 2423 with highly purified hMG (95% CI, pound 2356 to pound 2495) and pound 2745 with recombinant FSH (95% CI, pound 2658 to pound 2830). The ongoing pregnancy rate was 22% with highly purified hMG and 19% with recombinant FSH. The cost per ongoing pregnancy was pound 10781 with highly purified hMG (95% CI, pound 9056 to pound 12919) and pound 14284 with recombinant FSH (95% CI, pound 11883 to pound 17891). CONCLUSION(S) Highly purified hMG and recombinant FSH are equally effective, but highly purified hMG is less expensive per cycle. Using highly purified hMG instead of recombinant FSH would translate into a 13% increase in the number of cycles that could be offered.
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Affiliation(s)
- Adam Lloyd
- Fourth Hurdle Consulting Ltd, London, United Kingdom.
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32
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Goldfarb JM, Desai N. Follitropin-α versus human menopausal gonadotropin in an in vitro fertilization program. Fertil Steril 2003; 80:1094-9. [PMID: 14607554 DOI: 10.1016/s0015-0282(03)02188-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To compare the efficacy of recombinant FSH and urinary-derived hMG for ovarian stimulation during IVF. DESIGN Retrospective analysis of data from IVF cycles conducted over 15 months. SETTING University hospital IVF unit. PATIENT(S) Three hundred twenty-four women undergoing their first to sixth IVF cycle. INTERVENTION(S) After pituitary down-regulation, patients received recombinant FSH or hMG, according to personal choice. After hCG administration, patients underwent oocyte retrieval, oocyte fertilization, and embryo transfer. MAIN OUTCOME MEASURE(S) Implantation rate and clinical ongoing pregnancy rate per oocyte retrieval. RESULT(S) Patients who chose recombinant FSH were slightly younger than those who chose hMG (34.1 vs. 35.1 years, respectively). Although more embryos were transferred in the hMG group (3.6 vs. 3.2), the ongoing pregnancy and implantation rates were significantly higher in the recombinant FSH group (ongoing pregnancy rate, 50.0% vs. 36.2%). CONCLUSION(S) Recombinant FSH is more effective than hMG for ovarian stimulation in IVF cycles. This increased efficacy, which is achieved with fewer ampoules, is likely to offset the higher acquisition costs of recombinant FSH.
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Affiliation(s)
- James M Goldfarb
- Department of Reproductive Biology, Case Western Reserve University, Cleveland, Ohio 44122, USA.
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33
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Romeu A, Balasch J, Balda JAR, Barri PN, Daya S, Auray JP, Duru G, Beresniak A, Peinado JA. Cost-effectiveness of recombinant versus urinary follicle-stimulating hormone in assisted reproduction techniques in the Spanish public health care system. J Assist Reprod Genet 2003; 20:294-300. [PMID: 12948090 PMCID: PMC3455272 DOI: 10.1023/a:1024899806149] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To evaluate the relative cost-effectiveness of recombinant and urinary follicle-stimulating hormone (FSH) in assisted reproduction techniques in the Spanish National Health Service. METHODS Markov modelling was used to compare costs and outcomes of three complete treatment cycles using recombinant or urinary FSH for controlled ovarian stimulation. Cost and effectiveness estimates were obtained from the literature and from Spanish clinicians. A Monte Carlo technique was used to randomise the distribution of outcomes at each stage. The analysis was performed by passing a virtual population of 100,000 patients through the computer simulation in each of 5000 Monte Carlo simulations. RESULTS The cost per pregnancy was Euro12,791+/-1202 ($11,346+/-1066) with recombinant and Euro13,007+/-1319 ($11,537+/-1170) with urinary FSH (p < 0.0001). The mean number of cycles per pregnancy was 4.69 and 5.21, respectively. CONCLUSIONS Recombinant FSH is more cost-effective than urinary FSH in the Spanish public health care system.
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Affiliation(s)
- Alberto Romeu
- Department of Gynecology (Human Reproduction), Hospital Universitario La Fe, Valencia, Spain
| | - Juan Balasch
- Institut Clinic of Gynecology, Obstetrics and Neonatology, Hospital Clinic, Institut d'Investigacions biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | | | - Pedro N. Barri
- Department of Obstetrics and Gynaecology, Institut Universitari Dexeus, Barcelona, Spain
| | - Salim Daya
- Department of Obstetrics & Gynecology and Clinical Epidemiology & Biostatistics, McMaster University, 1200 Main Street West, Hamilton, Ontario Canada L8N 3Z5
| | - Jean P. Auray
- National Center of Scientific Research (CNRS), Villeurbanne, Lyon, France
| | - Gerald Duru
- National Center of Scientific Research (CNRS), Villeurbanne, Lyon, France
| | | | - José A. Peinado
- Medical Department of Reproductive Health, Laboratorios Serono, S.A., Madrid, Spain
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Hugues JN, Barlow DH, Rosenwaks Z, Cédrin-Durnerin I, Robson S, Pidoux L, Loumaye E. Improvement in consistency of response to ovarian stimulation with recombinant human follicle stimulating hormone resulting from a new method for calibrating the therapeutic preparation. Reprod Biomed Online 2003; 6:185-90. [PMID: 12675998 DOI: 10.1016/s1472-6483(10)61709-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Traditionally, therapeutic preparations of gonadotrophins are quantified with a rat in-vivo bioassay in biological international units (IU). This method was developed to cope with variability of production batch quality. The bioassay, however, presents some limitations, and differences in clinical responses when using different batches of urine-derived gonadotrophins have been reported. The production of human FSH by recombinant technology now allows the use of advanced physicochemical methods for quantifying FSH, which can be measured in microg of FSH proteins (in mass). The study reported here was designed and conducted to assess the clinical relevance of this new method for quantifying therapeutic preparation of FSH. Four bulk lots of recombinant human FSH (r-hFSH) were used to prepare batches filled by IU (FbIU) and four batches filled by mass (FbM). These eight batches were compared in a double-blind, randomized study in patients undergoing assisted reproductive technology. One hundred and thirty-one patients were enrolled in this study and met protocol criteria (66 in the FbM group and 65 in the FbIU group). The starting dose of recombinant human FSH (r-hFSH) was either 150 IU or 11 microg/day. Both preparations induced multiple follicular development and all patients underwent oocyte retrieval. The number of follicles >/= 11mm was 14.85 and 14.91, serum oestradiol concentration on day of human chorionic gonadotrophin (HCG) administration was 6524 and 6350 pmol/l, number of oocytes retrieved was 10.76 and 11.28, number of two-pronuclear (2 PN) oocytes was 5.2 and 5.00, number of viable embryos (replaced or cryopreserved) was 4.15 and 3.72, and clinical pregnancy rate was 30.3 and 26.2% respectively in the FbM and FbIU groups. Overall, the patients' response consistency was found to be superior with FbM (P = 0.039), and in particular for clinical pregnancy rates (P < 0.001). This new method for quantifying r-hFSH delivers an improved consistency in clinical outcome.
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Affiliation(s)
- Jean-Noel Hugues
- Assistance publique Hopitaux de Paris, Hopital Jean Verdier, Avenue du 14 Juillet, F-93143 Bondy, France.
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Felberbaum RE, Diedrich K. Gonadotrophin-releasing hormone antagonists: will they replace the agonists? Reprod Biomed Online 2003; 6:43-53. [PMID: 12626142 DOI: 10.1016/s1472-6483(10)62054-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Modern gonadotrophin-releasing hormone (GnRH) antagonists such as cetrorelix and ganirelix reliably prevent premature LH surges in controlled ovarian hyperstimulation for assisted reproductive technologies. Cetrorelix and ganirelix are safe and effective compounds. Because of their distinct pharmacological mode of action, it has been possible to achieve a significant reduction of treatment time. Fertilization and pregnancy rates are comparable to those obtained in agonist protocols for ovarian stimulation. No allergic or hyperergic reactions have been reported, and patient compliance is excellent. The fact that GnRH antagonists allow an immediate suppression of gonadotrophin concentrations while preserving pituitary responsiveness to endogenous GnRH provides enormous flexibility in treatment. GnRH antagonists have helped to overcome some major disadvantages of GnRH agonists, especially of the long protocol, which is currently the standard protocol for ovarian stimulation. The mistaken administration of antagonists during early pregnancy is not possible, since they are only administered during ovarian stimulation when a premature LH surge may be imminent. They are used in the spontaneous cycle or after pretreatment with oral contraceptives. Pregnancy can easily be ruled out by testing for human gonadotrophic hormone before onset of gonadotrophin stimulation on the second or third day of the cycle. Since flare-up effects are absent, there is no risk of cyst formation. Hormonal withdrawal symptoms are eliminated, since no period of pituitary suppression occurs, and therefore exogenous gonadotrophins are not required. Overall, the duration of the stimulation cycle is as short as a normal menstrual cycle. The procedure seems to be safer than the long protocol, since the most serious complication, the occurrence of severe cases of OHSS, is reduced. It is also safe with respect to the course of pregnancies and the health of offspring. Both protocols developed so far, the single dose and multiple dose antagonist protocol, are comparable, utilizing data from the large prospective phase IIIb studies. Although several studies have indicated a slight reduction in pregnancy rate with GnRH antagonists as compared with agonists, this problem may be rectified by developing flexible antagonist regimens designed for individual patients. Introducing flexible GnRH antagonist regimens should be the area of research in the near future.
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Affiliation(s)
- Ricardo E Felberbaum
- Department of Obstetrics and Gynaecology, Medical University of Lübeck, Ratzeburger Allee 160, 23 538 Lübeck, Germany.
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Silverberg K, Schertz J, Falk B, Beresniak A. Impact of urinary FSH price: a cost-effectiveness analysis of recombinant and urinary FSH in assisted reproduction techniques in the USA. Reprod Biomed Online 2002; 5:265-9. [PMID: 12470524 DOI: 10.1016/s1472-6483(10)61830-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
This study compares the cost-effectiveness of recombinant human FSH (r(h)FSH, Gonal-F) and urinary FSH (uFSH) in assisted reproduction techniques in the USA, using several hypothetical prices for uFSH. A specifically designed Markov model and Monte-Carlo simulation techniques were used to model the possible outcomes during three treatment cycles. Data included in the model were derived from randomized clinical trials and databases. An expert panel determined probability distributions for each decision point throughout each virtual treatment cycle. The assumed unit cost of r(h)FSH was $58.52 (based on the average retail cost) and three unit prices ($49, $45, $40) were used for uFSH. A total of 5000 simulations was performed on a virtual cohort of 100,000 patients. The mean number of assisted reproduction treatment cycles/success (ongoing pregnancy at 12 weeks) was 4.34 with r(h)FSH and 4.75 with uFSH. The total number of pregnancies achieved was 40,665 and 37,890, respectively. The mean cost per successful pregnancy with r(h)FSH was $40 688. For uFSH at unit costs of $40, $45 and $49, the mean costs per successful pregnancy were $43,500, $44,400 and $45,000, respectively (each P < 0.0001 versus r(h)FSH). Thus, despite its greater cost per unit dose, r(h)FSH is more cost-effective than uFSH over a wide range of uFSH prices, reflecting the greater clinical efficacy of r(h)FSH.
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De Sutter P, Gerris J, Dhont M. A health-economic decision-analytic model comparing double with single embryo transfer in IVF/ICSI. Hum Reprod 2002; 17:2891-6. [PMID: 12407045 DOI: 10.1093/humrep/17.11.2891] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Single embryo transfer (SET) is the sole strategy with which to reduce the incidence of twins following assisted reproductive technology (ART), but SET may increase the number of ART cycles needed per live-born child. Its cost-effectiveness compared with double embryo transfer (DET) is therefore unknown. METHODS A decision-analytic model comparing SET with DET was developed. Estimates were obtained from literature, national pregnancy registers and local hospital records. A sensitivity analysis was performed, using pregnancy rates from four published studies. The outcome measure was the cost per child born, calculated from IVF procedure-related, pregnancy-related and neonatal care costs. Neonatal mortality and long-term morbidity costs were not taken into account. RESULTS Independently of the pregnancy rates used, the SET cost per child born was in all instances the same as with DET, varying from EURO= 9520 (SET) versus EURO= 9511 (DET) to EURO= 12254 (SET) versus EURO= 12934 (DET). CONCLUSIONS More ART cycles are required to obtain the same numbers of children born following SET compared with DET. Because SET allows the avoidance of twins and thus diminishes pregnancy-related and neonatal care costs, there is no difference in the cost per child born between SET and DET. The real advantage of SET is the avoidance of the very high long-term costs resulting from the increased morbidity of twins after birth.
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Affiliation(s)
- Paul De Sutter
- Infertility Centre, University Hospital Gent, Middelheim Hospital, Antwerpen, Belgium.
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Balen A. Is there a risk of prion disease after the administration of urinary-derived gonadotrophins? Hum Reprod 2002; 17:1676-80. [PMID: 12093821 DOI: 10.1093/humrep/17.7.1676-a] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Concern has been raised recently about the possibility of prion proteins appearing in the urine of animals and, possibly, humans affected by prion disease [scrapie, bovine spongiform encephalopathy (BSE) and Creutzfeldt Jakob disease (CJD)]. A debate has started in which the suggestion has been made that the purification of human urine for the provision of gonadotrophins should be discontinued. The alternative would be to use recombinantly-derived gonadotrophin preparations. The recombinant products, however, rely upon bovine serum during the cell culture process and could potentially also be exposed to abnormal prion proteins. It is reassuring that the different types of gonadotrophin preparations that are currently available are produced with either urine or bovine serum that is sourced from countries that at the present time appear to be free of BSE and new variant CJD. We can therefore be reassured that the gonadotrophins that we use therapeutically appear to be equally safe.
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Affiliation(s)
- Adam Balen
- Department of Reproductive Medicine, The General Infirmary, Leeds LS2 9NS, UK.
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Al-Inany H, Afnan M. Models of cost-effectiveness of recombinant FSH versus urinary FSH. Hum Reprod 2002; 17:1671-3; author reply 1673-4. [PMID: 12042297 DOI: 10.1093/humrep/17.6.1671-b] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Daya S. Models of cost-effectiveness of recombinant FSH versus urinary FSH. Hum Reprod 2002. [DOI: 10.1093/humrep/17.6.1673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Daya S. Updated meta-analysis of recombinant follicle-stimulating hormone (FSH) versus urinary FSH for ovarian stimulation in assisted reproduction. Fertil Steril 2002; 77:711-4. [PMID: 11937121 DOI: 10.1016/s0015-0282(01)03246-0] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To determine the relative efficacy of recombinant FSH (rFSH) and urinary FSH (uFSH) for ovarian stimulation in assisted reproductive techniques (ART). DESIGN Systematic review and meta-analysis of randomized, controlled trials comparing rFSH and uFSH. SETTING Infertility centers providing treatment with ART. PATIENT(S) Patients undergoing IVF with or without ICSI. INTERVENTION(S) Controlled ovarian stimulation using uFSH or rFSH (follitropin alpha or follitropin beta). MAIN OUTCOME MEASURE(S) Primary: rate of clinical pregnancy per cycle. Secondary: rates of spontaneous abortion, multiple pregnancy, and severe ovarian hyperstimulation syndrome (OHSS); total gonadotropin dose; serum E(2) level and number of follicles at hCG administration; number of oocytes retrieved. RESULT(S) Eighteen trials were included in the meta-analysis. Subgroup analyses demonstrated higher pregnancy rates with both follitropins compared with uFSH. However, statistical significance was reached only in the follitropin alpha versus uFSH comparison in IVF cycles, with an additional pregnancy for every 19 patients treated. Fewer units of rFSH than uFSH achieved the same E(2) level and oocyte yield. No differences were found between treatments in rates of spontaneous abortion, OHSS, and multiple gestation. CONCLUSION(S) rFSH produced higher pregnancy rates per cycle than uFSH when follitropin alpha was used in IVF, and the total gonadotropin dose required was lower.
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Affiliation(s)
- Salim Daya
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada L8N 3Z5.
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