Cost-effectiveness of medically assisted reproduction or expectant management for unexplained subfertility: when to start treatment?

What Do the General Public Know about Infertility and Its Treatment?

Rates of infertility are rising, and informed decision making is an essential part of reproductive life planning with the knowledge that ART success decreases dramatically while a woman's age increases and that high costs can often be incurred during fertility treatment. We aimed to determine the current knowledge of infertility and its treatments in the general public through an online survey. We received 360 complete responses. The average age of respondents was 35 years with most respondents being female (90%), heterosexual (88%), white (85%) and university educated (79%). Of the total, 49% had children and 23% had a condition that affects their fertility; 41% had concerns about future fertility and 78% knew someone who had had fertility treatment. Participants' understanding of basic reproductive biology and causes of infertility varied with correct responses to questions ranging from 44% to 93%. Understanding of IVF outcomes was poorer with only 32% to 55% of responses being correct, and 76% of respondents felt that their education in fertility was inadequate. This survey highlights the inconsistencies in the general public's understanding of infertility in this relatively educated population. With increasing demands on fertility services and limited public funds, better education is essential to ensure patients are fully informed with regard to their reproductive life planning.

Current state and practical recommendations on reproductive mental health: a narrative review

Emotional disorders (EDs) are highly prevalent during the reproductive period, including pregnancy, postpartum, and women undergoing fertility treatments. International guidelines are increasingly suggesting the need to evaluate, prevent, and treat EDs in those women. The main aim of this narrative review is to summarize current practice in the field of EDs management during fertility treatments, pregnancy, and the postpartum and to propose a new technology-based model of care that helps to provide psychological care to all women who are in these periods. Four different databases (Pubmed, Scopus, Science Direct, Web of Science) were consulted. Selected keywords were related with infertility, pregnancy, postpartum, EDs, assessment, prevention, treatment, and technologies. We identified 1603 studies and 43 were included in this review. According to these studies, different face-to-face protocols already exist to manage EDs in women undergoing fertility treatments, pregnant or at the postpartum. We noticed an increased interest in developing technology-based solutions to overcome the limitations of traditional mental healthcare services. However, we also detected some issues in the use of technologies (i.e. increased attention to the postpartum or the lack of transdiagnostic approaches). Our results evidenced that there is still a need to develop modern, well-designed, and conceptually-relevant ICT-based programs to be used in women undergoing fertility treatments, pregnant or at the postpartum.

Economic evaluations of assisted reproductive technologies in high-income countries: a systematic review

STUDY QUESTION

Which assited reproductive technology (ART) interventions in high-income countries are cost-effective and which are not?

SUMMARY ANSWER

Among all ART interventions assessed in economic evaluations, most high-cost interventions, including preimplantation genetic testing for aneuploidy (PGT-A) for a general population and ICSI for unexplained infertility, are unlikely to be cost-effective owing to minimal or no increase in effectiveness.

WHAT IS KNOWN ALREADY

Approaches to reduce costs in order to increase access have been identified as a research priority for future infertility research. There has been an increasing number of ART interventions implemented in routine clinical practice globally, before robust assessments of evidence on economic evaluations. The extent of clinical effectiveness of some studied comparisons has been evaluated in high-quality research, allowing more informative decision making around cost-effectiveness.

STUDY DESIGN, SIZE, DURATION

We performed a systematic review and searched seven databases (MEDLINE, PUBMED, EMBASE, COCHRANE, ECONLIT, SCOPUS, and CINAHL) for studies examining ART interventions for infertility together with an economic evaluation component (cost-effectiveness, cost-benefit, cost-utility, or cost-minimization assessment), in high-income countries, published since January 2011. The last search was 22 June 2022.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Two independent reviewers assessed publications and included those fulfilling the eligibility criteria. Studies were examined to assess the cost-effectiveness of the studied intervention, as well as the reporting quality of the study. The chosen outcome measure and payer perspective were also noted. Completeness of reporting was assessed against the Consolidated Health Economic Evaluation Reporting Standard. Results are presented and summarized based on the intervention studied.

MAIN RESULTS AND THE ROLE OF CHANCE

The review included 40 studies which were conducted in 11 high-income countries. Most studies (n = 34) included a cost-effectiveness analysis. ART interventions included medication or strategies for controlled ovarian stimulation (n = 15), IVF (n = 9), PGT-A (n = 7), single embryo transfer (n = 5), ICSI (n = 3), and freeze-all embryo transfer (n = 1). Live birth was the mostly commonly reported primary outcome (n = 27), and quality-adjusted life years was reported in three studies. The health funder perspective was used in 85% (n = 34) of studies. None of the included studies measured patient preference for treatment. It remains uncertain whether PGT-A improves pregnancy rates compared to IVF cycles managed without PGT-A, and therefore cost-effectiveness could not be demonstrated for this intervention. Similarly, ICSI in non-male factor infertility appears not to be clinically effective compared to standard fertilization in an IVF cycle and is therefore not cost-effective. Interventions such as use of biosimilars or HMG for ovarian stimulation are cheaper but compromise clinical effectiveness.

LIMITATIONS, REASONS FOR CAUTION

Lack of both preference-based and standardized outcomes limits the comparability of results across studies. The selection of efficacy evidence offered for some interventions for economic evaluations is not always based on high-quality randomized trials and systematic reviews. In addition, there is insufficient knowledge of the willingness to pay thresholds of individuals and state funders for treatment of infertility. There is variable quality of reporting scores, which might increase uncertainty around the cost-effectiveness results.

WIDER IMPLICATIONS OF THE FINDINGS

Investment in strategies to help infertile people who utilize ART is justifiable at both personal and population levels. This systematic review may assist ART funders decide how to best invest to maximize the likelihood of delivery of a healthy child.

STUDY FUNDING/COMPETING INTEREST(S)

There was no funding for this study. E.C. and R.W. receive salary support from the National Health and Medical Research Council (NHMRC) through their fellowship scheme (EC GNT1159536, RW 2021/GNT2009767). M.D.-T. reports consulting fees from King Fahad Medical School. All other authors have no competing interests to declare.

REGISTRATION NUMBER

Prospero CRD42021261537.

Economic Evaluation of Medically Assisted Reproduction: A Methodological Systematic Review

BACKGROUND

Medically assisted reproduction (MAR) is a challenging application area for health economic evaluations, entailing a broad range of costs and outcomes, stretching out long-term and accruing to several parties.

PURPOSE

To systematically review which costs and outcomes are included in published economic evaluations of MAR and to compare these with health technology assessment (HTA) prescriptions about which cost and outcomes should be considered for different evaluation objectives.

DATA SOURCES

HTA guidelines and systematic searches of PubMed Central, Embase, WOS CC, CINAHL, Cochrane (CENTRAL), HTA, and NHS EED.

STUDY SELECTION

All economic evaluations of MAR published from 2010 to 2022.

DATA EXTRACTION

A predetermined data collection form summarized study characteristics. Essential costs and outcomes of MAR were listed based on HTA and treatment guidelines for different evaluation objectives. For each study, included costs and outcomes were reviewed.

DATA SYNTHESIS

The review identified 93 cost-effectiveness estimates, of which 57% were expressed as cost-per-(healthy)-live-birth, 19% as cost-per-pregnancy, and 47% adopted a clinic perspective. Few adopted societal perspectives and only 2% used quality-adjusted life-years (QALYs). Broader evaluations omitted various relevant costs and outcomes related to MAR. There are several cost and outcome categories for which available HTA guidelines do not provide conclusive directions regarding inclusion or exclusion.

LIMITATIONS

Studies published before 2010 and of interventions not clearly labeled as MAR were excluded. We focus on methods rather than which MAR treatments are cost-effective.

CONCLUSIONS

Economic evaluations of MAR typically calculate a short-term cost-per-live-birth from a clinic perspective. Broader analyses, using cost-per-QALY or BCRs from societal perspectives, considering the full scope of reproduction-related costs and outcomes, are scarce and often incomplete. We provide a summary of costs and outcomes for future research guidance and identify areas requiring HTA methodological development.

HIGHLIGHTS

The cost-effectiveness of MAR procedures can be exceptionally complex to estimate as there is a broad range of costs and outcomes involved, in principle stretching out over multiple generations and over many stakeholders.We list 21 key areas of costs and outcomes of MAR. Which of these needs to be accounted for alters for different evaluation objectives (determined by the type of economic evaluation, time horizon considered, and perspective).Published studies mostly investigate cost-effectiveness in the very short-term, from a clinic perspective, expressed as cost-per-live-birth. There is a lack of comprehensive economic evaluations that adopt a broader perspective with a longer time horizon. The broader the evaluation objective, the more relevant costs and outcomes were excluded.For several costs and outcomes, particularly those relevant for broader, societal evaluations of MAR, the inclusion or exclusion is theoretically ambiguous, and HTA guidelines do not offer sufficient guidance.

Alternatives to in vitro fertilization

There have been concerns on the potential overuse of in vitro fertilization (IVF) in view of the lack of evidence on effectiveness in certain populations, potential short and long-term safety risks, and economic considerations. On the other hand, the use of alternatives to IVF seems to be underappreciated in clinical practice as well as research. In this review, we summarized the up-to-date evidence on the effectiveness, safety as well as cost-effectiveness of different alternatives to IVF, including expectant management, intrauterine insemination, tubal flushing, in vitro maturation as well as intravaginal culture. We also discussed the trend of IVF use over the last decade and the available tiers of service because of intravaginal culture, and revisited the roles of different alternatives to IVF in modern reproductive medicine from both clinical and research perspectives.

The cost-effectiveness of using a prognosis-tailored strategy model to triage couples with idiopathic infertility for assisted reproduction technology

OBJECTIVES

To evaluate whether a prognosis-tailored triage of ART for couples with idiopathic infertility by using the Hunault prognostic model can decrease the cost of treatment without compromising the chance of live birth.

STUDY DESIGN

This is a retrospective study conducted in an Australian fertility clinic. Couples seeking infertility consultation who were subsequently found to have idiopathic infertility after evaluation were included. We compared the costs per conception leading to live birth of the prognosis-tailored strategy with the immediate ART strategy, which generally reflects the current practice in Australian fertility clinics, over a 24-month period. In the prognosis-tailored strategy, for each couple, the prognosis for natural conception was assessed using the well-established Hunault model. Total cost of treatments were calculated as the sum of typical out-of-pocket and Australian Medicare cost (Australian national insurance scheme).

RESULTS

We studied 261 couples. In the prognosis-tailored strategy, the total cost was $2,766,781 and the live birth rate was 63.9%. In contrast, the immediate ART strategy yielded a live birth rate of 64.4% with a total cost of $3,176,845. Implementing the prognosis-tailored strategy using the Hunault model saved $410,064 in total and $1,571 per couple. The incremental cost-effectiveness ratio (ICER) was $341,720 per live birth.

CONCLUSION

In couples with idiopathic infertility, assessment of prognosis for natural conception using the Hunault model and delaying ART for 12 months in couples with favourable prognoses can considerably reduce costs without significantly compromising live birth rates.

Live birth is not the only relevant outcome in research assessing assisted reproductive technology

In assisted reproductive technology (ART) research, live birth has been generally accepted as an important outcome, if not the most important one. However, it has been reported inconsistently in the literature and solely focusing on live birth can lead to misinterpretation of research findings. In this review, we provide an overview on the definitions of live birth, including various denominators and numerators use. We present a series of real clinical examples in ART research to demonstrate the impact of variations in live birth on research findings and the importance of other outcomes, including multiple pregnancy, pregnancy loss, time to pregnancy leading to live birth, other short and long term maternal and offspring health outcomes and cost effectiveness measures. We suggest that outcome choices in ART research should be tailored for the research questions. A holistic outcome assessment beyond live birth would provide a full picture to address research questions in ART in terms of effectiveness and safety, and thus facilitate evidence-based decision making.

The economic burden of infertility treatment and distribution of expenditures overtime in France: a self-controlled pre-post study

Background

Recent cost studies related to infertility treatment have focused on assisted reproductive technologies. None has examined lower-intensity infertility treatments or analyzed the distribution of infertility treatment expenditures over time.

The Purpose of the study was to analyse the size and distribution of infertility treatment expenditures over time, and estimate the economic burden of infertility treatment per 10,000 women aged 18 − 50 in France from a societal perspective.

Methods

We used French National individual medico-administrative database to conduct a self-controlled before-after analytic cohort analysis with 556 incidental women treated for infertility in 2014 matched with 9,903 controls using the exact matching method. Infertility-associated expenditures per woman and per 10,000 women over the 3.5-year follow-up period derived as a difference-in-differences.

Results

The average infertility related expenditure per woman is estimated at 6,996 (95% CI: 5,755–8,237) euros, the economic burden for 10,000 women at 70.0 million (IC95%: 57.6–82.4) euros. The infertility related expenditures increased from 235 (IC95%: 98–373) euros in semester 0, i.e. before treatment, to 1,509 (IC95%: 1,277–1,741) euros in semester 1, mainly due to ovulation stimulation treatment (47% of expenditure), to reach a plateau in semesters 2 (1,416 (IC95%: 1,161–1,670)) and 3 (1,319 (IC95%: 943–1,694)), where the share of expenses is mainly related to hospitalizations for assisted reproductive technologies (44% of expenditure), and then decrease until semester 6 (577 (IC95%: 316–839) euros).

Conclusion

This study informs public policy about the economic burden of infertility estimated at 70.0 million (IC95%: 57.6–82.4) euros for 10,000 women aged between 18 and 50. It also highlights the importance of the share of drugs in infertility treatment expenditures. If nothing is done, the increasing use of infertility treatment will lead to increased expenditure. Prevention campaigns against the preventable causes of infertility should be promoted to limit the use of infertility treatments and related costs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07725-9.

The (decision) tree of fertility: an innovative decision-making algorithm in assisted reproduction technique

PURPOSE

Several mathematical models have been developed to estimate individualized chances of assisted reproduction techniques (ART) success, although with limited clinical application. Our study aimed to develop a decisional algorithm able to predict pregnancy and live birth rates after controlled ovarian stimulation (COS) phase, helping the physician to decide whether to perform oocytes pick-up continuing the ongoing ART path.

METHODS

A single-center retrospective analysis of real-world data was carried out including all fresh ART cycles performed in 1998-2020. Baseline characteristics, ART parameters and biochemical/clinical pregnancies and live birth rates were collected. A seven-steps systematic approach for model development, combining linear regression analyses and decision trees (DT), was applied for biochemical, clinical pregnancy, and live birth rates.

RESULTS

Of fresh ART cycles, 12,275 were included. Linear regression analyses highlighted a relationship between number of ovarian follicles > 17 mm detected at ultrasound before pick-up (OF17), embryos number and fertilization rate, and biochemical and clinical pregnancy rates (p < 0.001), but not live birth rate. DT were created for biochemical pregnancy (statistical power-SP:80.8%), clinical pregnancy (SP:85.4%), and live birth (SP:87.2%). Thresholds for OF17 entered in all DT, while sperm motility entered the biochemical pregnancy's model, and female age entered the clinical pregnancy and live birth DT. In case of OF17 < 3, the chance of conceiving was < 6% for all DT.

CONCLUSION

A systematic approach allows to identify OF17, female age, and sperm motility as pre-retrieval predictors of ART outcome, possibly reducing the socio-economic burden of ART failure, allowing the clinician to perform or not the oocytes pick-up.

Expectant Management Before In vitro Fertilization in Women Aged 39 or Above and Unexplained Infertility Does Not Decrease Live Birth Rates Compared to Immediate Treatment

Unexplained infertile couples can have further expectant management before starting assisted reproductive treatments. However, ovarian reserve and in vitro fertilization (IVF) outcomes rapidly decline after 39 years or more. It is thus important to clarify whether a waiting policy is also appropriate for women of advanced age. Couples who had access to a waiting list for approximately 1 year before receiving reimbursed public IVF were compared with those paying for access to immediate treatment. To allow for comparisons between these two strategies, we followed up couples who opted to pay for 1 year after the last embryo transfer from their first cycle. We calculated the proportion of live births in both groups and compared these using logistic regression models and a two-sample Z test for equality of proportions. Six hundred thirty-five couples were evaluated. Out of 359 couples in the immediate group, 70 (19.5%) had a live birth of which 11 after natural conception and 59 after IVF. Out of 276 couples in the waiting group, 57 (20.7%) had a live birth of which 37 after natural conception and 20 after IVF. There was no statistically significant difference between the two strategies in terms of the crude cumulative live birth rate (cLBR). The adjusted odds ratio of 0.69 (95%CI:0.39–1.22) did not change this conclusion as our sensitivity analyses. The cLBR for the ‘waiting before IVF’ and the ‘immediate’ strategies were similar. Further studies are needed to better characterize couples affected by unexplained infertility in order to individualize treatment strategies.

Economic perspective of evaluating fertility treatment in obese and overweight infertile women

OBJECTIVES

To evaluate direct cost of in-vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) cycle and reproductive outcomes among infertile women with different body mass index (BMI).

METHODS

A retrospective study of 826 subfertility patients who had IVF or IVF-ICSI in 2017 to 2018 were reviewed. The patients were divided into 4 groups bestowing to BMI to normal weight (18.5-24.9 kg/m2), underweight (<18.5 kg/m2), overweight(25-29.9 kg/m2), and obese(≥30 kg/m2). Data on treatment costs of IVF/ICSI and reproductive outcomes were collected and analyzed. A total of 338 patients (40.9%) were overweight, and 300 (36.3%) patients were obese. A bottom-up methodology was used to measure the resource utilization. The capital inputs needed for individual procedures were defined and calculated by consulting with appropriate clinicians and priced using market prices for 2017-2018.

RESULTS

There was no statistical significant difference for live birth rate (LBR) among the BMI groups, with the occurrence of LBR in 23 women with normal BMI (13.1%), in 48 (14.2%) women who were overweight, in 48 (16%) in women who were obese (p=0.7). The median cost for IVF/ICSI treatment cycle did not differ across BMI groups; the cost was 10,380 SAR for women of normal weight, 10,440 SAR for women who are overweight and obese (p=0.6).

CONCLUSION

Our results suggest that costs of IVF/IVF-ICSI is not significantly affected in women who are overweight or obese.

Treatment Strategies for Unexplained Infertility

Unexplained infertility is a common diagnosis among couples with infertility. Pragmatic treatment options in these couples are directed at trying to improve chances to conceive, and consequently intrauterine insemination (IUI) with ovarian stimulation and in vitro fertilization (IVF) are standard clinical practice, while expectant management remains an important alternative. While evidence on IVF or IUI with ovarian stimulation versus expectant management was inconclusive, these interventions seem more effective in couples with a poor prognosis of natural conception. Strategies such as strict cancellation criteria and single-embryo transfer aim to reduce multiple pregnancies without compromising cumulative live birth. We propose a prognosis-based approach to manage couples with unexplained infertility so as to expose less couples to unnecessary interventions and less mothers and children to the potential adverse effects of ovarian stimulation or laboratory procedures.