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Si Y, Tan T, Pu K. Systematic review of the economic evaluation model of assisted reproductive technology. HEALTH ECONOMICS REVIEW 2024; 14:34. [PMID: 38767759 PMCID: PMC11103951 DOI: 10.1186/s13561-024-00509-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 04/26/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND With the increasing demand for fertility services, it is urgent to select the most cost-effective assisted reproductive technology (ART) treatment plan and include it in medical insurance. Economic evaluation reports are an important reference for medical insurance negotiation. The aim of this study is to systematically evaluate the economic evaluation research of ART, analyze the existing shortcomings, and provide a reference for the economic evaluation of ART. METHODS PubMed, EMbase, Web of Science, Cochrane Library and ScienceDirect databases were searched for relevant articles on the economic evaluation of ART. These articles were screened, and their quality was evaluated based on the Comprehensive Health Economics Evaluation Report Standard (CHEERS 2022), and the data on the basic characteristics, model characteristics and other aspects of the included studies were summarized. RESULTS One hundred and two related articles were obtained in the preliminary search, but based on the inclusion criteria, 12 studies were used for the analysis, of which nine used the decision tree model. The model parameters were mainly derived from published literature and included retrospective clinical data of patients. Only two studies included direct non-medical and indirect costs in the cost measurement. Live birth rate was used as an outcome indicator in half of the studies. CONCLUSION Suggesting the setting of the threshold range in the field of fertility should be actively discussed, and the monetary value of each live birth is assumed to be in a certain range when the WTP threshold for fertility is uncertain. The range of the parameter sources should be expanded. Direct non-medical and indirect costs should be included in the calculation of costs, and the analysis should be carried out from the perspective of the whole society. In the evaluation of clinical effect, the effectiveness and safety indexes should be selected for a comprehensive evaluation, thereby making the evaluation more comprehensive and reliable. At least subgroup analysis based on age stratification should be considered in the relevant economic evaluation.
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Affiliation(s)
- Yuxin Si
- School of Medical Informatics, Chongqing Medical University, Chongqing, 400016, China
| | - Tao Tan
- Chongqing Health Statistics Information Center, Chongqing, 401120, China.
| | - Kexue Pu
- School of Medical Informatics, Chongqing Medical University, Chongqing, 400016, China.
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Olive E, Bull C, Gordon A, Davies-Tuck M, Wang R, Callander E. Economic evaluations of assisted reproductive technologies in high-income countries: a systematic review. Hum Reprod 2024; 39:981-991. [PMID: 38438132 PMCID: PMC11063548 DOI: 10.1093/humrep/deae039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 01/10/2024] [Indexed: 03/06/2024] Open
Abstract
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.
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Affiliation(s)
- Emily Olive
- Discipline of Obstetrics, Gynaecology and Neonatology, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Claudia Bull
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Adrienne Gordon
- Discipline of Obstetrics, Gynaecology and Neonatology, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Miranda Davies-Tuck
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Rui Wang
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Emily Callander
- School of Public Health, University of Technology Sydney, Sydney, NSW, Australia
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Ji J, Ling X, Zhou Q, Zhou L, Ji H, Wu X, Zhang J, Cao S. Prioritized single vitrified blastocyst to be warmed between grades 3 or 4 blastocyst on day 5 transfer cycles. Arch Gynecol Obstet 2024; 309:1629-1641. [PMID: 38315199 DOI: 10.1007/s00404-023-07336-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 12/05/2023] [Indexed: 02/07/2024]
Abstract
PURPOSE Selecting the optimal blastocyst to implant during cryopreservation and warming is critial for in vitro fertilization success. Therefore, the aim of this study was to explore which blastocyst should be prioritized to be thawed when facing a single vitrified blastocyst on day 5 transfer. METHODS A retrospective study including 1,976 single vitrified-warmed blastocyst transfer cycles was conducted from January 2016 to December 2020. RESULTS We found that grade 4 vitrified blastocyst had a higher clinical pregnancy (60.64% vs. 49.48%, P < 0.001) and live birth rates (50.12% vs 39.59%, P < 0.001) than the grade 3 vitrified blastocyst. However, no statistical difference was found between groups in miscarriage rate, birth weight, or gestational age. Besides, the grade 4 vitrified-thawed blastocyst had significant potential to develop into grade 6 blastocyst after further culturing for 16 h (73.68% vs. 48.60%, P < 0.001). The grade 6 transferred blastocyst was markedly higher in both clinical pregnancy rate (61.88% vs. 51.53%, P < 0.001) and live birth rate (50.91% vs. 40.46%, P < 0.001) compared to grade 5 transferred blastocyst. CONCLUSIONS Grade 4 vitrified blastocyst is recommended when facing single vitrified blastocyst on day 5 transfer. More importantly, the "embryonic escape hypothesis" was firstly proposed to reveal the findings.
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Affiliation(s)
- Juan Ji
- Department of Reproductive Medicine, Women's Hospital of Nanjing Medical University, Nanjing Women and Children's Healthcare Hospital, 123 Tianfeixiang, Mochou Road, Nanjing, 210004, Jiangsu, China
| | - Xiufeng Ling
- Department of Reproductive Medicine, Women's Hospital of Nanjing Medical University, Nanjing Women and Children's Healthcare Hospital, 123 Tianfeixiang, Mochou Road, Nanjing, 210004, Jiangsu, China
| | - Qiao Zhou
- Department of Reproductive Medicine, Women's Hospital of Nanjing Medical University, Nanjing Women and Children's Healthcare Hospital, 123 Tianfeixiang, Mochou Road, Nanjing, 210004, Jiangsu, China
| | - Lin Zhou
- Department of Reproductive Medicine, Women's Hospital of Nanjing Medical University, Nanjing Women and Children's Healthcare Hospital, 123 Tianfeixiang, Mochou Road, Nanjing, 210004, Jiangsu, China
| | - Hui Ji
- Department of Reproductive Medicine, Women's Hospital of Nanjing Medical University, Nanjing Women and Children's Healthcare Hospital, 123 Tianfeixiang, Mochou Road, Nanjing, 210004, Jiangsu, China
| | - Xun Wu
- Department of Reproductive Medicine, Women's Hospital of Nanjing Medical University, Nanjing Women and Children's Healthcare Hospital, 123 Tianfeixiang, Mochou Road, Nanjing, 210004, Jiangsu, China
| | - Juanqiang Zhang
- Department of Reproductive Medicine, Women's Hospital of Nanjing Medical University, Nanjing Women and Children's Healthcare Hospital, 123 Tianfeixiang, Mochou Road, Nanjing, 210004, Jiangsu, China
| | - Shanren Cao
- Department of Reproductive Medicine, Women's Hospital of Nanjing Medical University, Nanjing Women and Children's Healthcare Hospital, 123 Tianfeixiang, Mochou Road, Nanjing, 210004, Jiangsu, China.
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Xue X, Li W, Li M. Optimal number of high-quality cleavage-stage embryos for extended culture to blastocyst-stage for transfer in women 38 years and older. Gynecol Endocrinol 2023; 39:2181642. [PMID: 36822231 DOI: 10.1080/09513590.2023.2181642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
PURPOSE We aimed to evaluate the pregnancy outcomes of cleavage-stage embryo transfers (ETs) for the first time and explore optimal number of high-quality cleavage-stage embryos for extended culture to blastocyst-stage in women of advanced maternal age (AMA). METHODS We retrospectively identified 1646 AMA women ≥ age 38 years for the first fresh ETs between January 2014 and December 2020 at our hospital. Double ETs were divided into three groups as follows: DET-HH (two high-quality embryos), DET-HL (one high-quality and one low-quality embryo), and DET-LL (two low-quality embryos) groups. We mainly analyzed the pregnancy outcomes of double cleavage-stage ETs with different embryo grades and blastocyst-stage ETs with different number of high-quality cleavage-stage embryos on day 3. RESULTS Our data indicated that the DET-HH group had significantly higher clinical pregnancy, ongoing pregnancy, and live birth rates than DET-HL and DET-LL groups (p < .05). For extended culture to blastocyst-stage with 2 (D3-2H), 3 (D3-3H), and 4 (D3-≥4H) high-quality cleavage-stage embryos, the D3-≥ 4H group had significantly higher ongoing pregnancy and live birth rates than D3-2H and D3-3H groups (p < .05). We observed that the number of high-quality embryos on day 3 was independently associated with live birth rate for blastocyst transfers (OR: 1.133, 95% CI 1.023-1.256, p = .017). There were no significant differences in the clinical pregnancy, ongoing pregnancy and live birth rates among DET-HH, D3-2H and D3-3H groups (p > .05). CONCLUSIONS Extended culture to blastocyst-stage for transfer was safe and recommended for AMA women with ≥ 4 high-quality embryos on day 3.
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Affiliation(s)
- Xia Xue
- The ART Center, Northwest Women's and Children's Hospital, Xi'an, PR China
| | - Wei Li
- The ART Center, Northwest Women's and Children's Hospital, Xi'an, PR China
| | - Mingzhao Li
- The ART Center, Northwest Women's and Children's Hospital, Xi'an, PR China
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Van Muylder A, D'Hooghe T, Luyten J. Economic Evaluation of Medically Assisted Reproduction: A Methodological Systematic Review. Med Decis Making 2023; 43:973-991. [PMID: 37621143 DOI: 10.1177/0272989x231188129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
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.
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Affiliation(s)
- Astrid Van Muylder
- Department Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium (AVM, JL); Research Group Reproductive Medicine, Department of Development and Regeneration, Organ Systems, Group Biomedical Sciences, KU Leuven (University of Leuven), Belgium (TD); Department of Obstetrics, Gynecology and Reproductive Sciences Yale School of Medicine, New Haven, CT, USA (TD); Global Medical Affairs Fertility, Research and Development, Merck Healthcare KGaA, Darmstadt, Germany (TD). The review was written at the Leuven Institute for Healthcare Policy. It was presented at the ESHRE 38th Annual Meeting (Milan 2022). The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Astrid Van Muylder and Jeroen Luyten have no conflicting interests to declare. The participation of Thomas D'Hooghe to this publication is part of his academic work; he does not see a conflict of interest as Merck KGaA was not involved in writing this article. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We acknowledge an internal funding from KU Leuven for this study. The funding agreement ensured the authors' independence in designing the study, interpreting the data, writing, and publishing the report. The following authors are employed by the sponsor: Astrid Van Muylder and Jeroen Luyten
| | - Thomas D'Hooghe
- Department Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium (AVM, JL); Research Group Reproductive Medicine, Department of Development and Regeneration, Organ Systems, Group Biomedical Sciences, KU Leuven (University of Leuven), Belgium (TD); Department of Obstetrics, Gynecology and Reproductive Sciences Yale School of Medicine, New Haven, CT, USA (TD); Global Medical Affairs Fertility, Research and Development, Merck Healthcare KGaA, Darmstadt, Germany (TD). The review was written at the Leuven Institute for Healthcare Policy. It was presented at the ESHRE 38th Annual Meeting (Milan 2022). The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Astrid Van Muylder and Jeroen Luyten have no conflicting interests to declare. The participation of Thomas D'Hooghe to this publication is part of his academic work; he does not see a conflict of interest as Merck KGaA was not involved in writing this article. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We acknowledge an internal funding from KU Leuven for this study. The funding agreement ensured the authors' independence in designing the study, interpreting the data, writing, and publishing the report. The following authors are employed by the sponsor: Astrid Van Muylder and Jeroen Luyten
| | - Jeroen Luyten
- Department Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium (AVM, JL); Research Group Reproductive Medicine, Department of Development and Regeneration, Organ Systems, Group Biomedical Sciences, KU Leuven (University of Leuven), Belgium (TD); Department of Obstetrics, Gynecology and Reproductive Sciences Yale School of Medicine, New Haven, CT, USA (TD); Global Medical Affairs Fertility, Research and Development, Merck Healthcare KGaA, Darmstadt, Germany (TD). The review was written at the Leuven Institute for Healthcare Policy. It was presented at the ESHRE 38th Annual Meeting (Milan 2022). The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Astrid Van Muylder and Jeroen Luyten have no conflicting interests to declare. The participation of Thomas D'Hooghe to this publication is part of his academic work; he does not see a conflict of interest as Merck KGaA was not involved in writing this article. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We acknowledge an internal funding from KU Leuven for this study. The funding agreement ensured the authors' independence in designing the study, interpreting the data, writing, and publishing the report. The following authors are employed by the sponsor: Astrid Van Muylder and Jeroen Luyten
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Majangara Karaga R, Archary P, Gwet Bell E, Khrouf M, Loto O, Wada I, Dyer S. The status of ART in the public health sector in Africa: a multi-country survey. Reprod Biomed Online 2023; 47:103213. [PMID: 37236886 DOI: 10.1016/j.rbmo.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 04/02/2023] [Accepted: 04/06/2023] [Indexed: 05/28/2023]
Abstract
RESEARCH QUESTION What is the current availability of treatment with assisted reproductive technology (ART) in the public sector in Africa, and what are the facilitators and barriers towards its provision? DESIGN Cross-sectional quantitative and qualitative data were collected in two phases from February 2020 to October 2021. Key informants were identified from countries known to provide ART in Africa based on data from the African Network and Registry for Assisted Reproductive Technology and the 2019 Surveillance from the International Federation of Fertility Societies. Quantitative data were collected via a structured questionnaire (Phase 1); public centre-specific quantitative and qualitative data were then collected via a semi-structured questionnaire followed by a virtual interview (Phase 2). Data were analysed descriptively. RESULTS Informants from 18 countries reported the existence of 185 ART centres in 16 countries. Twenty-four centres (13.0%) in 10 of 16 countries (62.5%) were public. The majority of public centres (20/22 [90.9%]) reporting on ART performed <500 ART cycles per annum. Although public institutions covered most of the cost for ART, copayments from patients were universally required. The number of ART cycles per annum was inversely correlated to the copayment. Lack of policy and legislation, high costs and bureaucratic obstacles were identified by participants as the leading challenges in the delivery of public service ART. CONCLUSION Lack of public ART services leads to chronic and profound health inequities. Enablers of public service ART in the region are the same known to support ART services in general, namely policy and legislation, appropriate funding and good health service infrastructure. Addressing these requires the collated efforts of many stakeholders.
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Affiliation(s)
- Rumbidzai Majangara Karaga
- Department of Obstetrics and Gynaecology, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Paversan Archary
- Department of Obstetrics and Gynaecology, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; African Network and Registry for Assisted Reproductive Technology, Cape Town, South Africa
| | - Ernestine Gwet Bell
- Groupe Interafricain d'Etude, de Recherche et d'Application sur la Fertilité, Lome, Togo
| | - Mohamed Khrouf
- Groupe d'Etude de la Fertilité de la Société Tunisienne de Gynécologie Obstétrique, Tunis, Tunisia
| | - Olabisi Loto
- Department of Obstetrics and Gynaecology, Obafemi Awolowo University, Ile-Ife, Nigeria; Association for Fertility and Reproductive Health, Lagos, Nigeria
| | - Ibrahim Wada
- Association for Fertility and Reproductive Health, Lagos, Nigeria
| | - Silke Dyer
- Department of Obstetrics and Gynaecology, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; African Network and Registry for Assisted Reproductive Technology, Cape Town, South Africa
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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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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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Luyten J, Connolly MP, Verbeke E, Buhler K, Scotland G, Lispi M, Revelli A, Borget I, Cedrin-Durnerin I, D'Hooghe T. Economic evaluation of Medically Assisted Reproduction: An educational overview of methods and applications for healthcare professionals. Best Pract Res Clin Obstet Gynaecol 2022; 85:217-228. [PMID: 35219590 DOI: 10.1016/j.bpobgyn.2022.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 01/11/2022] [Indexed: 12/14/2022]
Abstract
Economic evaluations of the value-for-money of Medically Assisted Reproduction (MAR) interventions are increasingly important due to growing pressure on healthcare budgets. Although such evaluations are commonplace in the published literature, the number/methodological complexity of different evaluations available, and the challenges specific to MAR interventions, can complicate the interpretation of such analyses for fertility treatments. This article aims to serve as an educational resource and provide context on the design/interpretation of economic analyses for MAR interventions. Several areas are relevant for first-line providers and decision makers: scope of analysis, comparator used, perspective/time horizon considered, outcomes used to measure success, and how results from cost-effectiveness studies can be summarised and used in clinical practice. We aim to help clinicians better understand the strengths/weaknesses of economic analyses, to enable the best use of the evidence in practice, so resources available for MAR interventions can provide maximum value to patients and society.
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Affiliation(s)
- Jeroen Luyten
- Leuven Institute for Healthcare Policy, KU Leuven, Kapucijnenvoer 35, B-3000, Leuven, Belgium.
| | - Mark P Connolly
- Global Market Access Solutions Sarl, Route de Buchillon, 65 St-Prex 1162, Switzerland; Unit of Pharmacoepidemiology and Pharmacoeconomics, Department of Pharmacy, University of Groningen, 9713, AV, Groningen, the Netherlands.
| | - Evelyn Verbeke
- Leuven Institute for Healthcare Policy, KU Leuven, Kapucijnenvoer 35, B-3000, Leuven, Belgium.
| | - Klaus Buhler
- Scientific Clinical Centre for Endometriosis, University Hospitals of Saarland, Saarbrüken, Germany; Department of Gynaecology, Jena-University Hospital-Friedrich Schiller University, 07737, Jena, Germany.
| | - Graham Scotland
- Health Services Research Unit, University of Aberdeen, 3rd Floor, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK; Health Economics Research Unit, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, AB25 2ZD, UK.
| | - Monica Lispi
- Merck Healthcare KGaA, Frankfurter Str. 250, 64293, Darmstadt, Germany; School of Clinical and Experimental Medicine, Unit of Endocrinology, University of Modena and Reggio Emilia, Via Campi N. 287, 41125, Modena, Italy.
| | - Alberto Revelli
- SCDU2 Obstetrics and Gynecology, Department of Surgical Sciences, S. Anna Hospital, University of Turin, Via Ventimiglia 1, 10126, Turin, Italy.
| | - Isabelle Borget
- Department of Biostatistics and Epidemiology, Oncostat U1018, Inserm, Labeled Ligue Contre le Cancer Gustave Roussy, University Paris-Saclay, 114, rue Édouard-Vaillant, Villejuif Cedex, 94805, France; EA GRADES, University Paris-Saclay, Bâtiment B, 5 ue Jean-Baptiste Clément, 92296, Châtenay-Malabry Cedex, France.
| | - Isabelle Cedrin-Durnerin
- AP-HP- Department of Reproductive Medicine and Fertility Preservation, Jean Verdier Hospital, July 14th Avenue, 93140, Bondy, France.
| | - Thomas D'Hooghe
- Merck Healthcare KGaA, Frankfurter Str. 250, 64293, Darmstadt, Germany; Department of Development and Regeneration, Laboratory of Endometrium, Endometriosis & Reproductive Medicine, KU Leuven, B-3000, Leuven, Belgium; Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University Medical School, New Haven, CT, 06510, USA.
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10
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Yakin K, Urman B, Balaban B. Dynamic view of assisted reproduction in Turkey from 1996 to 2020. Reprod Biomed Online 2021; 44:747-754. [DOI: 10.1016/j.rbmo.2021.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 10/28/2021] [Accepted: 12/10/2021] [Indexed: 10/19/2022]
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11
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Maleki A, Khalid N, Rajesh Patel C, El-Mahdi E. The rising incidence of heterotopic pregnancy: Current perspectives and associations with in-vitro fertilization. Eur J Obstet Gynecol Reprod Biol 2021; 266:138-144. [PMID: 34653918 DOI: 10.1016/j.ejogrb.2021.09.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 07/18/2021] [Accepted: 09/26/2021] [Indexed: 12/27/2022]
Abstract
Heterotopic pregnancy is the simultaneous occurrence of an intrauterine and ectopic pregnancy. This study aims to review the current literature regarding heterotopic pregnancy with a focus on its diagnosis and associations with in-vitro fertilization (IVF). Studies have shown that ovarian hyperstimulation syndrome and multiple embryo transfer during IVF are associated with an increased risk of heterotopic pregnancy. Tubal abnormalities such as pelvic inflammatory disease and previous tubal or abdomino-pelvic surgery have also been identified as risk factors. Diagnosis is challenging as the falsely reassuring presence of an intrauterine fetus frequently delays early intervention. Treatment should be individualised, but is often prompt surgical intervention, and focuses on terminating the ectopic pregnancy while minimizing harm to the mother and intrauterine fetus.
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Affiliation(s)
- Aryan Maleki
- Queen Mary University of London, Barts and The London School of Medicine and Dentistry, London, UK
| | - Noorulain Khalid
- Queen Mary University of London, Barts and The London School of Medicine and Dentistry, London, UK
| | - Chandni Rajesh Patel
- Queen Mary University of London, Barts and The London School of Medicine and Dentistry, London, UK
| | - Essam El-Mahdi
- Department of Obstetrics and Gynaecology, Newham University Hospital, Barts Health NHS Trust, London, UK
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12
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Reimundo P, Gutiérrez Romero JM, Rodríguez Pérez T, Veiga E. Single-embryo transfer: a key strategy to reduce the risk for multiple pregnancy in assisted human reproduction. ADVANCES IN LABORATORY MEDICINE 2021; 2:179-198. [PMID: 37363329 PMCID: PMC10197809 DOI: 10.1515/almed-2021-0013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 12/05/2020] [Indexed: 06/28/2023]
Abstract
In the early days of assisted reproductive technology (ART), the main target was achieving gestation. Success rates were low, and multiple embryo transfers became common practice, with multiple pregnancies being 20 times higher than in natural conception. Multiple pregnancy is associated with a higher risk of complications for the mother and the baby than a singleton pregnancy. Added to healthcare costs, multiple pregnancy also involves other costs and psychosocial risks, with a high social and health costs. At present, success rates of assisted human reproduction (AHR) have improved dramatically, partially due to advances in laboratory techniques such as culture of blastocyst-stage embryos and vitrification. Additionally, there is a wide range of counseling, health and economic policies that have demonstrated being effective in increasing single-embryo transfer (SET) practices and reducing multiple pregnancies, which ensures satisfactory success rates. Therefore, single-embryo transfer emerges as the approach of choice for AHR to result in a full-term healthy newborn.
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Affiliation(s)
- Pilar Reimundo
- Laboratory of Assisted Reproduction and Andrology, Area of Clinical Biochemistry, Vall d’Hebron Clinical Laboratories, Vall d’Hebron University Hospital, Barcelona, Spain
| | | | - Tamara Rodríguez Pérez
- Laboratory of Andrology and Assisted Reproduction Techniques, Service of Clinical Biochemistry, La Paz University Hospital, Madrid, Spain
| | - Ernesto Veiga
- Unit of Assisted Human Reproduction, Complejo Hospitalario Universitario de Santiago de Compostela (CHUS), SERGAS, Santiago de Compostela, Spain
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13
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Wang N, Zhao X, Ma M, Zhu Q, Wang Y. Effect of Day 3 and Day 5/6 Embryo Quality on the Reproductive Outcomes in the Single Vitrified Embryo Transfer Cycles. Front Endocrinol (Lausanne) 2021; 12:641623. [PMID: 34046010 PMCID: PMC8147686 DOI: 10.3389/fendo.2021.641623] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 04/06/2021] [Indexed: 11/16/2022] Open
Abstract
Objective To explore the live birth rate and neonatal outcome after single vitrified blastocyst transfer versus single vitrified cleavage-stage embryo transfer at different grades of embryo quality. Methods A retrospective cohort study including 6077 single vitrified-thawed embryo transfer cycles was performed in the time-period from January 2013 to December 2018. Results After controlling for potential confounding variables, there are 161% increased odds of a live birth after transfer of single good quality embryo at day 5, 152% increased odds of a live birth after transfer of single poor quality embryo at day 5, 60% increased odds of a live birth after transfer of single good quality embryo at day 6 compared with transfer of single good quality embryo at day 3. Results from the generalized estimated equation regression showed significant relationship of unadjusted birth weight with development stage of embryo and embryo quality (good quality embryo on day 5 vs. Good quality embryo on day 3:β=108.55, SE=34.89, P=0.002; good quality embryo on day 6 vs. Good quality embryo on day 3:β=68.80, SE=33.75, P=0.041). However, no significant differences were seen in birth weight between transfer single poor quality embryo on day 5, 6 and transfer single good quality embryo on day 3. Conclusion A significant increase in live birth rate and birth weight after transfer of single good quality embryo on day 5 and day 6 compared with transfer of single good quality embryo on day 3 in the vitrified embryo transfer cycles.
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Affiliation(s)
| | | | | | - Qianqian Zhu
- Department of Assisted Reproduction, Shanghai Ninth People’s Hospital, School of Medicine, JiaoTong University, Shanghai, China
| | - Yao Wang
- Department of Assisted Reproduction, Shanghai Ninth People’s Hospital, School of Medicine, JiaoTong University, Shanghai, China
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14
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Cheng PJ, Kim J, Craig JR, Alukal J, Pastuszak AW, Walsh TJ, Hotaling JM. "The Back-up Vasectomy Reversal." Simultaneous Sperm Retrieval and Vasectomy Reversal in the Couple With Advanced Maternal Age: A Cost-Effectiveness Analysis. Urology 2021; 153:175-180. [PMID: 33812879 DOI: 10.1016/j.urology.2021.03.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/21/2021] [Accepted: 03/21/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To determine the cost-effectiveness of different fertility options in men who have undergone vasectomy in couples with a female of advanced maternal age (AMA). The options include vasectomy reversal (VR), sperm retrieval (SR) with in vitro fertilization (IVF), and the combination of VR and SR with IVF, which is a treatment pathway that has been understudied. MATERIALS AND METHODS Using TreeAge software, a model-based cost-utility analysis was performed estimating the cost per quality-adjusted life years (QALY) in couples with infertility due to vasectomy and advanced female age over a period of one year. The model stratified for female age (35-37, 38-40, >40) and evaluated four strategies: VR followed by natural conception (NC), SR with IVF, VR and SR followed by failed NC and then IVF, and VR and SR followed by failed IVF and then NC. QALY estimates and outcome probabilities were obtained from the literature and average patient charges were calculated from high-volume centers. RESULTS The most cost-effective fertility strategy was to undergo VR and try for NC (cost-per-QALY: $7,150 (35-37 y), $7,203 (38-40 y), and $7,367 (>40 y)). The second most cost-effective strategy was the "back-up vasectomy reversal": undergo VR and SR, attempt IVF and switch to NC if IVF fails. CONCLUSION In couples with a history of vasectomy and female of AMA, it is most cost-effective to undergo a VR. If the couple opts for SR for IVF, it is more cost-effective to undergo a concomitant VR than SR alone.
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Affiliation(s)
- Philip J Cheng
- Reproductive Medicine Associates of New Jersey, Basking Ridge, NJ, Rutgers Robert Wood Johnson Medical School, Department of Obstetrics, Gynecology, and Reproductive Sciences.
| | - Jaewhan Kim
- Department of Health and Kinesiology, University of Utah, Salt Lake City, UT
| | - James R Craig
- Fontana Medical Center, Kaiser Permanente, Fontana, CA
| | - Joseph Alukal
- Department of Urology, Columbia University Medical Center, New York, NY
| | | | - Thomas J Walsh
- Department of Urology, University of Washington, Seattle, WA
| | - James M Hotaling
- Division of Urology, University of Utah, Salt Lake City, UT, Reproductive Medicine Associates of New Jersey
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15
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Webb JA, Fabreau G, Spackman E, Vaughan S, McBrien K. The cost-effectiveness of schistosomiasis screening and treatment among recently resettled refugees to Canada: an economic evaluation. CMAJ Open 2021; 9:E125-E133. [PMID: 33622765 PMCID: PMC8034375 DOI: 10.9778/cmajo.20190057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Many refugees and asylum seekers from countries where schistosomiasis is endemic are infected with the Schistosoma parasite when they arrive in Canada. We assessed, from a systemic perspective, which of the following management strategies by health care providers is cost-effective: testing for schistosomiasis and treating if the individual is infected, treating presumptively or waiting for symptoms to emerge. METHODS We constructed a decision-tree model to examine the cost-effectiveness of 3 management strategies: watchful waiting, screening and treatment, and presumptive treatment. We obtained data for the model from the literature and other sources, to predict deaths and chronic complications caused by schistosomiasis, as well as costs and net monetary benefit. RESULTS Presumptive treatment was cost-saving if the prevalence of schistosomiasis in the target population was greater than 2.1%. In our baseline analysis, presumptive treatment was associated with an increase of 0.156 quality-adjusted life years and a cost saving of $405 per person, compared with watchful waiting. It was also more effective and less costly than screening and treatment. INTERPRETATION Among recently resettled refugees and asylum claimants in Canada, from countries where schistosomiasis is endemic, presumptive treatment was predicted to be less costly and more effective than watchful waiting or screening and treatment. Our results support a revision of the current Canadian recommendations.
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Affiliation(s)
- John A Webb
- South Zone Medical Affairs, Alberta Health Services (Webb); Department of Community Health Sciences (Fabreau, Spackman, McBrien), O'Brien Institute for Public Health (Fabreau, Spackman, McBrien), Department of Medicine (Fabreau, Vaughan), Division of Infectious Diseases (Vaughan) and Department of Family Medicine (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Gabriel Fabreau
- South Zone Medical Affairs, Alberta Health Services (Webb); Department of Community Health Sciences (Fabreau, Spackman, McBrien), O'Brien Institute for Public Health (Fabreau, Spackman, McBrien), Department of Medicine (Fabreau, Vaughan), Division of Infectious Diseases (Vaughan) and Department of Family Medicine (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Eldon Spackman
- South Zone Medical Affairs, Alberta Health Services (Webb); Department of Community Health Sciences (Fabreau, Spackman, McBrien), O'Brien Institute for Public Health (Fabreau, Spackman, McBrien), Department of Medicine (Fabreau, Vaughan), Division of Infectious Diseases (Vaughan) and Department of Family Medicine (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Stephen Vaughan
- South Zone Medical Affairs, Alberta Health Services (Webb); Department of Community Health Sciences (Fabreau, Spackman, McBrien), O'Brien Institute for Public Health (Fabreau, Spackman, McBrien), Department of Medicine (Fabreau, Vaughan), Division of Infectious Diseases (Vaughan) and Department of Family Medicine (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Kerry McBrien
- South Zone Medical Affairs, Alberta Health Services (Webb); Department of Community Health Sciences (Fabreau, Spackman, McBrien), O'Brien Institute for Public Health (Fabreau, Spackman, McBrien), Department of Medicine (Fabreau, Vaughan), Division of Infectious Diseases (Vaughan) and Department of Family Medicine (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta
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16
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Adamson GD, Norman RJ. Why are multiple pregnancy rates and single embryo transfer rates so different globally, and what do we do about it? Fertil Steril 2020; 114:680-689. [PMID: 33010940 DOI: 10.1016/j.fertnstert.2020.09.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 09/02/2020] [Indexed: 12/18/2022]
Abstract
In the early years of in vitro fertilization, overall pregnancy rates were low, and it was considered necessary to transfer more than one embryo to increase the chances of pregnancy. It was not until advances in assisted reproductive technologies resulting in increased pregnancy rates that the concept of transferring just one embryo was considered possible. A consequence of improvements in implantation rates was also an increase in multiple pregnancies when more than one embryo was transferred. Although some countries have reduced the number of embryos transferred, international data show that in many parts of the world high twin and higher order multiple pregnancy rates still exist. Even in developed countries these problems persist depending on clinical practice, funding of health services, and patient demands. Perinatal and other outcomes are significantly worse with twins compared with singleton pregnancies and there is an urgent need to reduce multiple pregnancy rates to at least 10%. This has been achieved in several countries and clinics by introducing single embryo transfer but there are many barriers to the introduction of this technique in most clinics worldwide. We discuss the background to the high multiple rate in assisted reproduction and the factors that contribute to its persistence even in excellent clinics and in high-quality health services. Practices that may promote single embryo transfer are discussed.
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Affiliation(s)
| | - Robert J Norman
- Robinson Research Institute, University of Adelaide, Adelaide, Australia
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17
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Faye AS, Oh A, Kumble LD, Kiran RP, Wen T, Lawlor G, Lichtiger S, Abreu MT, Hur C. Fertility Impact of Initial Operation Type for Female Ulcerative Colitis Patients. Inflamm Bowel Dis 2020; 26:1368-1376. [PMID: 31880776 PMCID: PMC7534416 DOI: 10.1093/ibd/izz307] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ileal pouch-anal anastomosis (IPAA) is the mainstay of surgical treatment for patients with ulcerative colitis (UC) but is associated with an increased risk of infertility. We developed a simulation model examining the impact of initial surgical procedure on quality-adjusted life-years (QALYs) and fertility end points. METHODS A patient-level state transition model was used to analyze outcomes by surgical approach strategy for females of childbearing age. Initial surgical options included IPAA, rectal-sparing colectomy with end ileostomy (RCEI), and ileorectal anastomosis (IRA). The primary outcome examined was QALYs, whereas secondary outcomes included UC and fertility-associated end points. RESULTS IPAA resulted in higher QALYs for patients aged 20-30 years, as compared with RCEI. For patients aged 35 years, RCEI resulted in higher QALYs (7.54 RCEI vs 7.53 IPAA) and was associated with a 28% higher rate of childbirth, a 14-month decrease in time to childbirth, and a 77% reduction in in vitro fertilization utilization. When accounting for the decreased infertility risk associated with laparoscopic IPAA, IPAA resulted in higher QALYs (7.57) even for patients aged 35 years. CONCLUSIONS Despite an increased risk of infertility, our model results suggest that IPAA may be the optimal surgical strategy for female UC patients aged 20-30 years who desire children. For patients aged 35 years, RCEI should additionally be considered, as QALYs for RCEI and IPAA were similar. These quantitative data can be used by patients and providers to help develop an individualized approach to surgical management choice.
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Affiliation(s)
- Adam S Faye
- Division of Digestive and Liver Diseases, Department of Medicine, New York, New York, USA
| | - Aaron Oh
- Division of Digestive and Liver Diseases, Department of Medicine, New York, New York, USA
| | - Lindsay D Kumble
- Division of Digestive and Liver Diseases, Department of Medicine, New York, New York, USA
| | - Ravi P Kiran
- Department of Colorectal Surgery, New York, New York, USA
| | - Timothy Wen
- Department of Obstetrics and Gynecology, New York Presbyterian Columbia University Medical Center, New York, New York, USA
| | - Garrett Lawlor
- Division of Digestive and Liver Diseases, Department of Medicine, New York, New York, USA
| | - Simon Lichtiger
- Division of Digestive and Liver Diseases, Department of Medicine, New York, New York, USA
| | - Maria T Abreu
- Division of Gastroenterology, Department of Medicine, University of Miami, Miami, Florida, USA
| | - Chin Hur
- Division of Digestive and Liver Diseases, Department of Medicine, New York, New York, USA
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18
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Huang X, Liu R, Shen W, Cai Y, Ding M, Sun H, Zhou J. An elective single cleavage embryo transfer strategy to minimize twin live birth rate based on a prediction model from double cleavage embryos transfer patients. J Matern Fetal Neonatal Med 2020; 35:1775-1782. [PMID: 32746666 DOI: 10.1080/14767058.2020.1770215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To minimize twin birth rate by establishing an elective single cleavage embryo transfer strategy based on a twin live birth prediction model from fresh double cleavage embryos transfer (cleavage DET) patients. METHODS A total of 2478 patients underwent fresh cleavage DET in Nanjing Tower Hospital were enrolled to establish the twin live birth prediction model by logistic regression analysis and the cutoff value was calculated by ROC curve. Another 300 fresh cleavage DET patients and 550 cleavage single-embryo transfer (SET) patients were selected to testify the sensitivity, specificity and usefulness of this model. RESULTS The twin live birth probability (TLBP) = eX /(eX + 1), e is a natural logarithm, X = -1.763 - (0.319 × female age) + (0.329 × endometrial thickness) + (0.282 × the number of transferred top embryos) - (0.314 × previous transfer times), and the cutoff value of TLBP was 24.2%. The sensitivity of this model for predicting twin live birth was 75.6%, while the specificity was 52.5% in the external validation of 300 DET patients. Furthermore, the validation of 550 SET patients showed that the live birth rate of TLBP value positive patients was significantly higher than that in negative patients (54.3% vs. 35.5%, p < .001). When adopted an elective single cleavage embryo transfer strategy, the patients with a positive TLBP value choose SET, while still undergo DET who with a negative TLBP value, the live birth rate would maintain as 56.7%; however, the twin birth rate would significantly decline to 7.4%. CONCLUSION Female age, endometrial thickness, the number of transferred top embryos and previous embryo transfer times were critical variables for the twin live birth prediction model. An elective single cleavage embryo transfer strategy according to this model can maintain the relatively high live birth rate, meanwhile get the acceptable low twin birth rate.
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Affiliation(s)
- Xiaomin Huang
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Rong Liu
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Wenjuan Shen
- Department of Obstetrics and Gynecology, Suqian People's Hospital of Nanjing Drum Tower Hospital Group, Suqian, China
| | - Yunni Cai
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Min Ding
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Haixiang Sun
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Jianjun Zhou
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
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19
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Schofield D, Zeppel M, Staffieri S, Shrestha R, Jelovic D, Lee E, Jamieson R. Preimplantation genetic diagnosis for retinoblastoma survivors: a cost-effectiveness study. REPRODUCTIVE BIOMEDICINE & SOCIETY ONLINE 2020; 10:37-45. [PMID: 32577540 PMCID: PMC7301166 DOI: 10.1016/j.rbms.2020.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 02/17/2020] [Accepted: 03/16/2020] [Indexed: 06/11/2023]
Abstract
This study aimed to investigate the cost-effectiveness of preimplantation genetic diagnosis (PGD) for the reproductive choices of patients with heritable retinoblastoma. The study modelled the costs of three cycles of in-vitro fertilization (IVF) and PGD across all uptake rates of PGD, number of children affected with retinoblastoma at each uptake rate and the estimated quality-adjusted life years (QALYs) gained. Cost-effectiveness analysis was conducted from the Australian public healthcare perspective. The intervention was the use of three cycles (one fresh and two frozen) of IVF and PGD with the aim of live births unaffected by the retinoblastoma phenotype. Compared with the standard care pathway (i.e. natural pregnancy), IVF and PGD resulted in a cost-saving to 18 years of age of AUD$2,747,294 for a base case of 100 couples with an uptake rate of 50%. IVF and PGD resulted in fewer affected (n = 56) and unaffected (n = 78) live births compared with standard care (71 affected and 83 unaffected live births), and an additional 0.03 QALYs per live birth. This modelling suggests that the use of IVF and PGD to achieve an unaffected child for patients with heritable retinoblastoma resulted in an overall cost-saving. There was an increase in QALYs per baby across all uptake rates. However, in total, fewer babies were born following the IVF and PGD pathway.
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Affiliation(s)
- D. Schofield
- GenIMPACT, Centre for Economic Impacts of Genomic Medicine, Faculty of Business and Economics, Macquarie University, Sydney, Australia
| | - M.J.B. Zeppel
- GenIMPACT, Centre for Economic Impacts of Genomic Medicine, Faculty of Business and Economics, Macquarie University, Sydney, Australia
| | - S. Staffieri
- Department of Ophthalmology, Royal Children's Hospital, Parkville, Australia
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
- Ophthalmology, University of Melbourne, Department of Surgery, East Melbourne, Australia
| | - R.N. Shrestha
- GenIMPACT, Centre for Economic Impacts of Genomic Medicine, Faculty of Business and Economics, Macquarie University, Sydney, Australia
| | - D. Jelovic
- Eye Genetics Research Unit, The Children’s Hospital at Westmead, Children’s Medical Research Institute, Save Sight Institute, University of Sydney, Sydney, Australia
- Discipline of Genomic Medicine, The Children’s Hospital at Westmead Clinical School, University of Sydney, Sydney, Australia
- Department of Clinical Genetics, Western Sydney Genetics Program, The Children’s Hospital at Westmead, Sydney Children’s Hospitals Network, Sydney, Australia
| | - E. Lee
- GenIMPACT, Centre for Economic Impacts of Genomic Medicine, Faculty of Business and Economics, Macquarie University, Sydney, Australia
| | - R.V. Jamieson
- Eye Genetics Research Unit, The Children’s Hospital at Westmead, Children’s Medical Research Institute, Save Sight Institute, University of Sydney, Sydney, Australia
- Discipline of Genomic Medicine, The Children’s Hospital at Westmead Clinical School, University of Sydney, Sydney, Australia
- Department of Clinical Genetics, Western Sydney Genetics Program, The Children’s Hospital at Westmead, Sydney Children’s Hospitals Network, Sydney, Australia
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20
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Maheshwari A, Bhattacharya S, Bowler U, Brison D, Child T, Cole C, Coomarasamy A, Cutting R, Harbottle S, Hardy P, Juszczak E, Khalaf Y, Kurinczuk JJ, Lavery S, Lewis-Jones C, Macklon N, Raine-Fenning NJ, Rajkohwa M, Scotland G, Troup S. Study protocol: E-freeze - freezing of embryos in assisted conception: a randomised controlled trial evaluating the clinical and cost effectiveness of a policy of freezing embryos followed by thawed frozen embryo transfer compared with a policy of fresh embryo transfer, in women undergoing in vitro fertilisation. Reprod Health 2019; 16:81. [PMID: 31196113 PMCID: PMC6567605 DOI: 10.1186/s12978-019-0737-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 05/13/2019] [Indexed: 11/16/2022] Open
Abstract
Background Infertility affects one in seven couples; many of these need in vitro fertilisation (IVF). IVF involves external hormones to stimulate a woman’s ovaries to produce eggs which are harvested surgically. Embryos, created in the laboratory by mixing eggs with sperm, are grown in culture for a few days before being replaced within the uterus (fresh embryo transfer). Spare embryos are usually frozen with a view to transfer at a later point in time – especially if the initial fresh transfer does not result in a pregnancy. Despite improvements in technology, IVF success rates remain low with an overall live birth rate of 25–30% per treatment. Additionally, there are concerns about health outcomes for mothers and babies conceived through IVF, particularly after fresh embryo transfer, including maternal ovarian hyperstimulation syndrome (OHSS) and preterm delivery. It is believed that high levels of hormones during ovarian stimulation could create a relatively hostile environment for embryo implantation whilst increasing the risk of OHSS. It has been suggested that freezing all embryos with the intention of thawing and replacing them within the uterus at a later stage (thawed frozen embryo transfer) instead of fresh embryo transfer, may lead to improved pregnancy rates and fewer complications. We aim to compare the clinical and cost effectiveness of fresh and thawed frozen embryo transfer, with the primary aim of identifying any difference in the chance of having a healthy baby. Methods E-Freeze is a pragmatic, multicentre two-arm parallel group randomised controlled trial where women aged ≥18 and < 42 years, with at least three good quality embryos are randomly allocated to receive either a fresh or thawed frozen embryo transfer. The primary outcome is a healthy baby, defined as a term, singleton, live birth with appropriate weight for gestation. Cost effectiveness will be calculated from a healthcare and societal perspective. Discussion E-Freeze will determine the relative benefits of fresh and thawed frozen embryo transfer in terms of improving the chance of having a healthy baby. The results of this pragmatic study have the potential to be directly transferred to clinical practice. Trial registration ISRCTN registry: ISRCTN61225414. Date assigned 29/12/2015.
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21
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Abstract
Many countries tightly ration access to publicly funded fertility treatments such as in vitro fertilisation (IVF). One basis for excluding people from access to IVF is their body mass index. In this paper, I consider a number of potential justifications for such a policy, based on claims about effectiveness and cost-efficiency, and reject these as unsupported by available evidence. I consider an alternative justification: that those whose subfertility results from avoidable behaviours for which they are responsible are less deserving of treatment. I ultimately stop short of endorsing or rejecting such a justification, though highlight some reasons for thinking it is unlikely to be practicable.
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Affiliation(s)
- Rebecca C H Brown
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Suite 8 Littlegate House, 16-17 St Ebbes Street, OX1 1PT, Oxford, UK.
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Cutting R. Single embryo transfer for all. Best Pract Res Clin Obstet Gynaecol 2018; 53:30-37. [DOI: 10.1016/j.bpobgyn.2018.07.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 06/28/2018] [Accepted: 07/10/2018] [Indexed: 10/28/2022]
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Stark Z, Schofield D, Martyn M, Rynehart L, Shrestha R, Alam K, Lunke S, Tan TY, Gaff CL, White SM. Does genomic sequencing early in the diagnostic trajectory make a difference? A follow-up study of clinical outcomes and cost-effectiveness. Genet Med 2018; 21:173-180. [DOI: 10.1038/s41436-018-0006-8] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 03/20/2018] [Indexed: 01/09/2023] Open
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Botha W, Donnolley N, Shanahan M, Chambers GM. Assessment of the societal and individual preferences for fertility treatment in Australia: study protocol for stated preference discrete choice experiments. BMJ Open 2018; 8:e020509. [PMID: 29444788 PMCID: PMC5829889 DOI: 10.1136/bmjopen-2017-020509] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION In Australia, societal and individual preferences for funding fertility treatment remain largely unknown. This has resulted in a lack of evidence about willingness to pay (WTP) for fertility treatment by either the general population (the funders) or infertile individuals (who directly benefit). Using a stated preference discrete choice experiment (SPDCE) approach has been suggested as a more appropriate method to inform economic evaluations of fertility treatment. We outline the protocol for an ongoing study which aims to assess fertility treatment preferences of both the general population and infertile individuals, and indirectly estimate their WTP for fertility treatment. METHODS AND ANALYSIS Two separate but related SPDCEs will be conducted for two population samples-the general population and infertile individuals-to elicit preferences for fertility treatment to indirectly estimate WTP. We describe the qualitative work to be undertaken to design the SPDCEs. We will use D-efficient fractional experimental designs informed by prior coefficients from the pilot surveys. The mode of administration for the SPDCE is also discussed. The final results will be analysed using mixed logit or latent class model. ETHICS AND DISSEMINATION This study is being funded by the Australian National Health and Medical Research Council (NHMRC) project grant AP1104543 and has been approved by the University of New South Wales Human Research Ethics Committee (HEC 17255) and a fertility clinic's ethics committee. Findings of the study will be disseminated in peer-reviewed journals and presented at various conferences. A lay summary of the results will be made publicly available on the University of New South Wales National Perinatal Epidemiology and Statistics Unit website. Our results will contribute to the development of an evidence-based policy framework for the provision of cost-effective and patient-centred fertility treatment in Australia.
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Affiliation(s)
- Willings Botha
- The National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health, University of New South Wales-Randwick Campus, Sydney, New South Wales, Australia
| | - Natasha Donnolley
- The National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health, University of New South Wales-Randwick Campus, Sydney, New South Wales, Australia
| | - Marian Shanahan
- National Drug and Alcohol Research Centre, University of New South Wales-Randwick Campus, Sydney, New South Wales, Australia
| | - Georgina M Chambers
- The National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health, University of New South Wales-Randwick Campus, Sydney, New South Wales, Australia
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Kawahara S, Ueda A, Nakahori T, Honda T. Treatment period and medical care costs to achieve the first live birth by assisted reproductive technology are lower in the single embryo transfer period than in the double embryo transfer period: a retrospective analysis of women younger than 40 years of age. Reprod Med Biol 2017; 16:139-142. [PMID: 29259461 PMCID: PMC5661805 DOI: 10.1002/rmb2.12018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 12/16/2016] [Indexed: 11/10/2022] Open
Abstract
Aim It was examined whether the single embryo transfer policy makes the treatment period longer for couples to achieve their first live birth by assisted reproductive technology. Methods This study retrospectively analyzed women who started assisted reproductive technology at younger than 40 years of age in the authors’ organization. The treatment periods for couples to achieve the first live birth by assisted reproductive technology, between the women who started assisted reproductive technology from 2004 to 2009 (the double embryo transfer period group, n=250), in which the double embryo transfer was predominant, and the women who started assisted reproductive technology from 2010 to 2015 (the single embryo transfer period group, n=298), in which the single embryo transfer was predominant, were compared. Results The age at the start of assisted reproductive technology, pregnancy rate per embryo transfer, and rate of women who achieved a live birth by assisted reproductive technology per number of women who tried assisted reproductive technology were all significantly higher in the single embryo transfer period group. Among the women who achieved a live birth by assisted reproductive technology, the incidence of multiple births and severe ovarian hyperstimulation syndrome, the treatment period, and medical care costs needed to achieve the first live birth were all significantly lower in the single embryo transfer period group. Conclusion In the single embryo transfer period group, those women who were younger than 40 years of age achieved their first live birth by assisted reproductive technology more safely, quickly, and reasonably.
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Affiliation(s)
- Shunsuke Kawahara
- Department of Obstetrics and Gynecology Kurashiki Central Hospital Kurashiki Japan
| | - Akane Ueda
- Department of Obstetrics and Gynecology Kurashiki Central Hospital Kurashiki Japan
| | - Takashi Nakahori
- Department of Obstetrics and Gynecology Kurashiki Central Hospital Kurashiki Japan
| | - Tetsuro Honda
- Department of Obstetrics and Gynecology Kurashiki Central Hospital Kurashiki Japan
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van Heesch MMJ, van Asselt ADI, Evers JLH, van der Hoeven MAHBM, Dumoulin JCM, van Beijsterveldt CEM, Bonsel GJ, Dykgraaf RHM, van Goudoever JB, Koopman-Esseboom C, Nelen WLDM, Steiner K, Tamminga P, Tonch N, Torrance HL, Dirksen CD. Cost-effectiveness of embryo transfer strategies: a decision analytic model using long-term costs and consequences of singletons and multiples born as a consequence of IVF. Hum Reprod 2016; 31:2527-2540. [PMID: 27907897 DOI: 10.1093/humrep/dew229] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 05/21/2016] [Accepted: 06/10/2016] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION What is the cost-effectiveness of elective single embryo transfer (eSET) versus double embryo transfer (DET) strategies from a societal perspective, when applying a time horizon of 1, 5 and 18 years? SUMMARY ANSWER From a short-term perspective (1 year) it is cost-effective to replace DET with single embryo transfer; however when intermediate- (5 years) and long-term (18 years) costs and consequences are incorporated, DET becomes the most cost-effective strategy, given a ceiling ratio of €20 000 per quality-adjusted life years (QALY) gained. WHAT IS ALREADY KNOWN According to previous cost-effectiveness research into embryo transfer strategies, DET is considered cost-effective if society is willing to pay around €20 000 for an extra live birth. However, interpretation of those studies is complicated, as those studies fail to incorporate long-term costs and outcomes and used live birth as a measure of effectiveness instead of QALYs. With this outcome, both multiple and singletons were valued as one live birth, whereas costs of all children of a multiple were incorporated. STUDY DESIGN, SIZE, DURATION A Markov model (cycle length: 1 year; time horizon: 1, 5 and 18 years) was developed comparing a maximum of: (i) three cycles of eSET in all patients; (ii) four cycles of eSET in all patients; (iii) five cycles of eSET in all patients; (iv) three cycles of standard treatment policy (STP), i.e. eSET in women <38 years with a good quality embryo, and DET in all other women; and (v) three cycles of DET in all patients. PARTICIPANTS/MATERIALS, SETTING, METHODS Expected life years (LYs), child QALYs and costs were estimated for all comparators. Input parameters were derived from a retrospective cohort study, in which hospital resource data were collected (n=580) and a parental questionnaire was sent out (431 respondents). Probabilistic sensitivity analysis (5000 iterations) was performed. MAIN RESULTS AND THE ROLE OF CHANCE With a time horizon of 18 years, DETx3 is most effective (0.54 live births, 10.2 LYs and 9.8 QALYs) and expensive (€37 871) per couple starting IVF. Three cycles of eSET are least effective (0.43 live births, 7.1 LYs and 6.8 QALYs) and expensive (€25 563). We assumed that society is willing to pay €20 000 per QALY gained. With a time horizon of 1 year, eSETx3 was the most cost-effective embryo transfer strategy with a probability of being cost-effective of 99.9%. With a time horizon of 5 or 18 years, DETx3 was most cost-effective, with probabilities of being cost-effective of 77.3 and 93.2%, respectively. LIMITATIONS, REASONS FOR CAUTION This is the first study to use QALYs generated by the children in the economic evaluation of embryo transfer strategies. There remains some disagreement on whether QALYs generated by new life should be used in economic evaluations of fertility treatment. A further limitation is that treatment ends when it results in live birth and that only child QALYs were considered as measure of effectiveness. The results for the time horizon of 18 years might be less solid, as the data beyond the age of 8 years are based on extrapolation. WIDER IMPLICATIONS OF THE FINDINGS The current Markov model indicates that when child QALYs are used as measure of outcome it is not cost-effective on the long term to replace DET with single embryo transfer strategies. However, for a balanced approach, a family-planning perspective would be preferable, including additional treatment cycles for couples who wish to have another child. Furthermore, the analysis should be extended to include QALYs of family members. STUDY FUNDING/COMPETING INTERESTS This study was supported by a research grant (grant number 80-82310-98-09094) from the Netherlands Organization for Health Research and Development (ZonMw). There are no conflicts of interest in connection with this article. TRIAL REGISTRATION NUMBER Not applicable.
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Affiliation(s)
- M M J van Heesch
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The Netherlands
| | - A D I van Asselt
- Department of Pharmacy, University of Groningen, Deusinglaan 1, 9713 AV Groningen, The Netherlands.,Department of Epidemiology, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - J L H Evers
- Department of Obstetrics and Gynecology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The Netherlands.,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The Netherlands
| | - M A H B M van der Hoeven
- Department of Neonatology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The Netherlands
| | - J C M Dumoulin
- Department of Obstetrics and Gynecology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The Netherlands.,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The Netherlands
| | - C E M van Beijsterveldt
- Department of Biological Psychology, VU University, Van der Boechorststraat 1, 1081 BT Amsterdam, The Netherlands
| | - G J Bonsel
- Department of Public Health, Erasmus Medical Center, PO Box 2040, 3000 CA Rotterdam, The Netherlands.,Division of Woman and Baby, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - R H M Dykgraaf
- Department of Obstetrics and Gynecology, Erasmus Medical Center, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - J B van Goudoever
- Department of Pediatrics, Emma Children's Hospital, Academic Medical Center, PO Box 22660, 1100 DD Amsterdam, The Netherlands.,Department of Pediatrics, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, The Netherlands
| | - C Koopman-Esseboom
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, PO Box 85090, 3508 AB Utrecht, The Netherlands
| | - W L D M Nelen
- Department of Obstetrics and Gynecology, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - K Steiner
- Department of Neonatology, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - P Tamminga
- Department of Neonatology, Emma Children's Hospital, Academic Medical Center, PO Box 22660, 1100 DD Amsterdam, The Netherlands
| | - N Tonch
- Academic Medical Center, Center of Reproductive Medicine, PO Box 22660, 1100 DD Amsterdam, The Netherlands
| | - H L Torrance
- Department of Reproductive Medicine, University Medical Center Utrecht, PO Box 85090, 3508 AB Utrecht, The Netherlands
| | - C D Dirksen
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The Netherlands
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Zhang N, Chen H, Xu Z, Wang B, Sun H, Hu Y. Pregnancy, Delivery, and Neonatal Outcomes of In Vitro Fertilization-Embryo Transfer in Patient with Previous Cesarean Scar. Med Sci Monit 2016; 22:3288-95. [PMID: 27636504 PMCID: PMC5027857 DOI: 10.12659/msm.900581] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background What role should previous cesarean section play in affecting clinical pregnancy outcomes and avoiding the complications of in vitro fertilization? In this article, we focus on elective single-embryo transfer (eSET) versus double-embryo transfer (DET) and assess the clinical efficacy and safety of eSET in patients who have a previous cesarean scar. Material/Methods The pregnancy, delivery, and neonatal outcomes of 130 patients who had a previous cesarean scar and received in vitro fertilization-embryo transfer (IVF-ET) were retrospectively analyzed. The number of transferred embryos was chosen depending on patients’ desire after acknowledging all benefits and risks, including eSET (eSET group, n=56) and DET (DET group, n=74). A total of 101 patients with previous vaginal delivery receiving IVF-ET in the same period were included as a control group. Results The pregnancy rates, multiple birth rates, abortion rates, ectopic pregnancy rates, gestational age at delivery, preterm birth rates, neonatal birth weight, and take-home baby rates were similar between the previous cesarean section group and the previous vaginal delivery group. A previous cesarean section scar did not affect embryo implantation and pregnancy outcomes in IVF. In the eSET and DET groups of previous cesarean section patients, the embryo implantation rates, pregnancy rates, abortion rates, and take-home baby rates were similar. However, the rate of multiple pregnancies reached 50% in the DET group, which led to more preterm births and lower birth weight. Conclusions Elective single-embryo transfer is a well-accepted strategy to avoid multiple pregnancies and improve the obstetric and neonatal outcomes of singleton pregnancy in IVF patients with a previous cesarean section.
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Affiliation(s)
- Ningyuan Zhang
- Reproductive Medicine Center, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China (mainland)
| | - Hua Chen
- Reproductive Medicine Center, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China (mainland)
| | - Zhipeng Xu
- Reproductive Medicine Center, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China (mainland)
| | - Bin Wang
- Reproductive Medicine Center, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China (mainland)
| | - Haixiang Sun
- Reproductive Medicine Center, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China (mainland)
| | - Yali Hu
- Reproductive Medicine Center, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China (mainland)
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Hummel SR, Sadler S, Whitaker MJ, Ara RM, Dixon S, Ross RJ. A model for measuring the health burden of classic congenital adrenal hyperplasia in adults. Clin Endocrinol (Oxf) 2016; 85:361-98. [PMID: 26991412 DOI: 10.1111/cen.13060] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 02/03/2016] [Accepted: 03/15/2016] [Indexed: 11/30/2022]
Abstract
AIM Patients with classic congenital adrenal hyperplasia (CAH) have poor health outcomes. In the absence of a comprehensive observational study, this manuscript provides a model to estimate the lifetime disease burden of adults with classic CAH. METHODS The model, built in Excel, comprises subdomains addressing the health consequences of CAH and synthesises evidence from clinical and epidemiological studies on health outcomes. RESULTS The model estimates that adults with classic CAH will implement 'sick day rules' (doubling or tripling glucocorticoid and/or use of parenteral therapy) 171 times over their lifetime and attend hospital for adrenal crisis on 11 occasions. In a population of 1000, over 200 will die of a condition complicated by adrenal crisis resulting, on average, in a loss of 7 years of life. Patients with CAH may also suffer from excess CVD events. Treatment with glucocorticoids almost doubles the risk of bone fractures in patients with CAH compared to the general population, leading on average to an additional 0·8 fractures per patient with CAH over their lifetime. CONCLUSIONS The disease burden model highlights gaps in evidence, particularly regarding intensity of care and adrenal crisis, and the relationship between control of CAH and risks of CVD, osteoporosis, diabetes and infertility. The model can be used for research on the impact of new clinical pathways and therapeutic interventions in terms of clinical events and cost.
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Ferrari S, Paffoni A, Filippi F, Busnelli A, Vegetti W, Somigliana E. Sperm cryopreservation and reproductive outcome in male cancer patients: a systematic review. Reprod Biomed Online 2016; 33:29-38. [DOI: 10.1016/j.rbmo.2016.04.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 04/01/2016] [Accepted: 04/04/2016] [Indexed: 10/24/2022]
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Miller LM, Hodgson R, Wong TY, Merrilees M, Norman RJ, Johnson NP. Single embryo transfer for all? Aust N Z J Obstet Gynaecol 2016; 56:514-517. [DOI: 10.1111/ajo.12478] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 04/16/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Laura M. Miller
- Fertility Plus; Reproductive Endocrinology and Fertility Unit of National Women's; Greenlane Clinical Centre; Auckland New Zealand
| | - Ruth Hodgson
- Fertility Plus; Reproductive Endocrinology and Fertility Unit of National Women's; Greenlane Clinical Centre; Auckland New Zealand
| | - Tze Yoong Wong
- Fertility Plus; Reproductive Endocrinology and Fertility Unit of National Women's; Greenlane Clinical Centre; Auckland New Zealand
| | - Margaret Merrilees
- Fertility Plus; Reproductive Endocrinology and Fertility Unit of National Women's; Greenlane Clinical Centre; Auckland New Zealand
| | - Robert J. Norman
- Robinson Research Institute; University of Adelaide; Adelaide Australia
| | - Neil P. Johnson
- Fertility Plus; Reproductive Endocrinology and Fertility Unit of National Women's; Greenlane Clinical Centre; Auckland New Zealand
- Robinson Research Institute; University of Adelaide; Adelaide Australia
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The effect on pregnancy and multiples of transferring 1-3 embryos in women at least 40 years old. J Assist Reprod Genet 2016; 33:1195-202. [PMID: 27245848 DOI: 10.1007/s10815-016-0749-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 05/23/2016] [Indexed: 12/16/2022] Open
Abstract
UNLABELLED PURPOSE "CAPSULE" IS MANDATORY. PLEASE PROVIDE.SINGLE EMRBYO TRANSFER (SET) IN WOMEN ≥40 YEARS OLD APPEARS TO LOWER THE CHANCE OF A PREGNANCY. HOWEVER, IT MINIMIZES THE RISK OF MULTIPLE PREGNANCIES EVEN IN WOMEN OF ADVANCED MATERNAL AGE. THEREFORE, WOMEN 40 YEARS OF AGE OR OLDER SHOULD BE OFFERED (SET).: This study was performed to investigate the multiple pregnancies and live birth rates when 1-3 embryos are transferred at this age in women at least 40 years of age. METHOD A retrospective analysis of data which included 631 women aged 40 to 46 years, who underwent 901 cycles of IVF, from August 2010 to June 2012 was undertaken. These women underwent embryo transfer of 1-3 non-donor fresh embryo(s). RESULTS Results suggested that the average pregnancy rate when up to three embryos were transferred was 25 % for women 40 years old, 20 % for women 41 years old, 16 % for women 42 years old, 17 % for women 43 years old, 8 % for women 44 years old, 6 % for women 45 years old, and 0 % for women 46 years old. No live births occurred in women treated after their 44th birthday, and only patients younger than 42 years of age receiving double embryo transfer had a live birth of twins. Live birth rates increased as more embryos were transferred for 40- and 42-year-old subjects (p = 0.01 and 0.05, respectively). CONCLUSIONS From these results, it was concluded that SET in women ≥40 years old appears to lower the chance of a pregnancy. However, it minimizes the risk of multiple pregnancies even in women of advanced maternal age. Women 40 years of age or older should be offered single-embryo transfer. Further studies are needed to determine risk of multiple pregnancies in women 42 years of age or older when few embryos are transferred. Decisions on the number of embryos to transfer should be on a case by case basis, in discussion with the patient.
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Styer AK, Luke B, Vitek W, Christianson MS, Baker VL, Christy AY, Polotsky AJ. Factors associated with the use of elective single-embryo transfer and pregnancy outcomes in the United States, 2004-2012. Fertil Steril 2016; 106:80-89. [PMID: 26997248 DOI: 10.1016/j.fertnstert.2016.02.034] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Revised: 02/09/2016] [Accepted: 02/25/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate factors associated with elective single-embryo transfer (eSET) utilization and its effect on assisted reproductive technology outcomes in the United States. DESIGN Historical cohort. SETTING Not applicable. PATIENT(S) Fresh IVF cycles of women aged 18-37 years using autologous oocytes with either one (SET) or two (double-embryo transfer [DET]) embryos transferred and reported to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System between 2004 and 2012. Cycles were categorized into four groups with ([+]) or without ([-]) supernumerary embryos cryopreserved. The SET group with embryos cryopreserved was designated as eSET. INTERVENTION(S) None. MAIN OUTCOMES MEASURE(S) The likelihood of eSET utilization, live birth, and singleton non-low birth weight term live birth, modeled using logistic regression. Presented as adjusted odds ratios (aORs) and 95% confidence intervals (CIs). RESULT(S) The study included 263,375 cycles (21,917 SET[-]cryopreservation, 20,996 SET[+]cryopreservation, 103,371 DET[-]cryopreservation, and 117,091 DET[+]cryopreservation). The utilization of eSET (SET[+]cryopreservation) increased from 1.8% in 2004 to 14.9% in 2012 (aOR 7.66, 95% CI 6.87-8.53) and was more likely with assisted reproductive technology insurance coverage (aOR 1.60, 95% CI 1.54-1.66), Asian race (aOR 1.26, 95% CI 1.20-1.33), uterine factor diagnosis (aOR 1.48, 95% CI 1.37-1.59), retrieval of ≥16 oocytes (aOR 2.85, 95% CI 2.55-3.19), and the transfer of day 5-6 embryos (aOR 4.23, 95% CI 4.06-4.40); eSET was less likely in women aged 35-37 years (aOR 0.76, 95% CI 0.73-0.80). Compared with DET cycles, the likelihood of the ideal outcome, term non-low birth weight singleton live birth, was increased 45%-52% with eSET. CONCLUSION(S) Expanding insurance coverage for IVF would facilitate the broader use of eSET and may reduce the morbidity and healthcare costs associated with multiple pregnancies.
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Affiliation(s)
- Aaron K Styer
- Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, Massachusetts.
| | - Barbara Luke
- Department of Obstetrics, Gynecology, and Reproductive Biology, Michigan State University College of Human Medicine, East Lansing, Michigan
| | - Wendy Vitek
- Department of Obstetrics and Gynecology, University of Rochester School of Medicine, Rochester, New York
| | - Mindy S Christianson
- Department of Obstetrics and Gynecology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Valerie L Baker
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, California
| | - Alicia Y Christy
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Alex J Polotsky
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado
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Tremellen K, Wilkinson D, Savulescu J. Is mandating elective single embryo transfer ethically justifiable in young women? REPRODUCTIVE BIOMEDICINE & SOCIETY ONLINE 2015; 1:81-87. [PMID: 29911189 PMCID: PMC6001354 DOI: 10.1016/j.rbms.2016.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 01/21/2016] [Accepted: 02/02/2016] [Indexed: 06/08/2023]
Abstract
Compared with natural conception, IVF is an effective form of fertility treatment associated with higher rates of obstetric complications and poorer neonatal outcomes. While some increased risk is intrinsic to the infertile population requiring treatment, the practice of multiple embryo transfer contributes to these complications and outcomes, especially concerning its role in higher order pregnancies. As a result, several jurisdictions (e.g. Sweden, Belgium, Turkey, and Quebec) have legally mandated elective single-embryo transfer (eSET) for young women. We accept that in very high-risk scenarios (e.g. past history of preterm delivery and poor maternal health), double-embryo transfer (DET) should be prohibited due to unacceptably high risks. However, we argue that mandating eSET for all young women can be considered an unacceptable breach of patient autonomy, especially since DET offers certain women financial and social advantages. We also show that mandated eSET is inconsistent with other practices (e.g. ovulation induction and intrauterine insemination-ovulation induction) that can expose women and their offspring to risks associated with multiple pregnancies. While defending the option of DET for certain women, some recommendations are offered regarding IVF practice (e.g. preimplantation genetic screening and better support of IVF and maternity leave) to incentivise patients to choose eSET.
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Affiliation(s)
- Kelton Tremellen
- Department of Obstetrics Gynaecology and Reproductive Medicine, Flinders University, Sturt Road, Bedford Park, South Australia 5042, Australia
| | - Dominic Wilkinson
- Oxford Uehiro Centre for Practice Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK
- Department of Neonatology, John Radcliffe Hospital, Oxford, UK
| | - Julian Savulescu
- Oxford Uehiro Centre for Practice Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK
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Harbottle S, Hughes CI, Cutting R, Roberts S, Brison D. Elective Single Embryo Transfer: an update to UK Best Practice Guidelines. HUM FERTIL 2015; 18:165-83. [DOI: 10.3109/14647273.2015.1083144] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Niinimäki M, Veleva Z, Martikainen H. Embryo quality is the main factor affecting cumulative live birth rate after elective single embryo transfer in fresh stimulation cycles. Eur J Obstet Gynecol Reprod Biol 2015; 194:131-5. [PMID: 26366790 DOI: 10.1016/j.ejogrb.2015.08.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 08/13/2015] [Accepted: 08/19/2015] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The study was aimed to evaluate which factors affect the cumulative live birth rate after elective single embryo transfer in women younger than 36 years. Additionally, number of children in women with more than one delivery per ovum pick-up after fresh elective single embryo transfer and subsequent frozen embryo transfers was assessed. STUDY DESIGN Retrospective cohort study analysing data of a university hospital's infertility clinic in 2001-2010. A total of 739 IVF/ICSI cycles with elective single embryo transfer were included. Analyses were made per ovum pick-up including fresh and subsequent frozen embryo transfers. Factors affecting cumulative live birth rates were examined in uni- and multivariate analyses. A secondary endpoint was the number of children born after all treatments. RESULTS In the fresh cycles, the live birth rate was 29.2% and the cumulative live birth rate was 51.3%, with a twin rate of 3.4%. In the multivariate analysis, having two (odds ratio (OR) 1.73; 95% confidence interval (CI) 1.12-2.67) or ≥3 top embryos (OR 2.66; 95% CI 1.79-3.95) was associated with higher odds for live birth after fresh and frozen embryo cycles. Age, body mass index, duration of infertility, diagnosis or total gonadotropin dose were not associated with the cumulative live birth rate. In cycles with one top embryo, the cumulative live birth rate was 40.2%, whereas it was 64.1% in those with at least three top embryos. Of women who had a live birth in the fresh cycle, 20.4% had more than one child after all frozen embryo transfers. Among women with three or more top embryos after ovum pick-up, 16.1% gave birth to more than one child. CONCLUSION The cumulative live birth rate in this age group varies from 40% to 64% and is dependent on the quality of embryos. Women with three or more top embryos have good chance of having more than one child per ovum pick-up without elevated risk of multiple pregnancies.
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Affiliation(s)
- Maarit Niinimäki
- Department of Obstetrics and Gynecology, Oulu University Hospital, 90029 Oulu, Finland; University of Oulu, PEDEGO Research Unit, Oulu and Medical Research Center, Oulu, Finland.
| | - Zdravka Veleva
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Central Hospital, 00029 Helsinki, Finland
| | - Hannu Martikainen
- Department of Obstetrics and Gynecology, Oulu University Hospital, 90029 Oulu, Finland; University of Oulu, PEDEGO Research Unit, Oulu and Medical Research Center, Oulu, Finland
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Ubaldi FM, Capalbo A, Colamaria S, Ferrero S, Maggiulli R, Vajta G, Sapienza F, Cimadomo D, Giuliani M, Gravotta E, Vaiarelli A, Rienzi L. Reduction of multiple pregnancies in the advanced maternal age population after implementation of an elective single embryo transfer policy coupled with enhanced embryo selection: pre- and post-intervention study. Hum Reprod 2015; 30:2097-106. [PMID: 26150408 PMCID: PMC4542718 DOI: 10.1093/humrep/dev159] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 06/09/2015] [Indexed: 12/31/2022] Open
Abstract
STUDY QUESTION Is an elective single-embryo transfer (eSET) policy an efficient approach for women aged >35 years when embryo selection is enhanced via blastocyst culture and preimplantation genetic screening (PGS)? SUMMARY ANSWER Elective SET coupled with enhanced embryo selection using PGS in women older than 35 years reduced the multiple pregnancy rates while maintaining the cumulative success rate of the IVF programme. WHAT IS KNOWN ALREADY Multiple pregnancies mean an increased risk of premature birth and perinatal death and occur mainly in older patients when multiple embryos are transferred to increase the chance of pregnancy. A SET policy is usually recommended in cases of good prognosis patients, but no general consensus has been reached for SET application in the advanced maternal age (AMA) population, defined as women older than 35 years. Our objective was to evaluate the results in terms of efficacy, efficiency and safety of an eSET policy coupled with increased application of blastocyst culture and PGS for this population of patients in our IVF programme. STUDY DESIGN, SIZE, DURATION In January 2013, a multidisciplinary intervention involving optimization of embryo selection procedure and introduction of an eSET policy in an AMA population of women was implemented. This is a retrospective 4-year (January 2010–December 2013) pre- and post-intervention analysis, including 1161 and 499 patients in the pre- and post-intervention period, respectively. The primary outcome measures were the cumulative delivery rate (DR) per oocyte retrieval cycle and multiple DR. PARTICIPANTS/MATERIALS, SETTING, METHODS Surplus oocytes and/or embryos were vitrified during the entire study period. In the post-intervention period, all couples with good quality embryos and less than two previous implantation failures were offered eSET. Embryo selection was enhanced by blastocyst culture and PGS (blastocyst stage biopsy and 24-chromosomal screening). Elective SET was also applied in cryopreservation cycles. MAIN RESULTS AND THE ROLE OF CHANCE Patient and cycle characteristics were similar in the pre- and post-intervention groups [mean (SD) female age: 39.6 ± 2.1 and 39.4 ± 2.2 years; range 36–44] as assessed by logistic regression. A total of 1609 versus 574 oocyte retrievals, 937 versus 350 embryo warming and 138 versus 27 oocyte warming cycles were performed in the pre- and post-intervention periods, respectively, resulting in 1854 and 508 embryo transfers, respectively. In the post-intervention period, 289 cycles were blastocyst stage with (n = 182) or without PGS (n = 107). A mean (SD) number of 2.9 ± 1.1 (range 1–4) and 1.4 ± 0.8 (range 1–3) embryos were transferred pre- and post-intervention, respectively (P < 0.01) and similar cumulative clinical pregnancy rates per transfer and per cycle were obtained: 26.8, 30.9% and 29.7, 26.3%, respectively. The total DR per oocyte retrieval cycle (21.0 and 20.4% pre- and post-intervention, respectively) defined as efficacy was not affected by the intervention [odds ratio (OR) = 0.8, 95% confidence interval (CI) = 0.7–1.1; P = 0.23]. However, a significantly increased live birth rate per transferred embryo (defined as efficiency) was observed in the post-intervention group 17.0 versus 10.6% (P < 0.01). Multiple DRs decreased from 21.0 in the preintervention to 6.8% in the post-intervention group (OR = 0.3. 95% CI = 0.1–0.7; P < 0.01). LIMITATIONS, REASONS FOR CAUTION In this study, the suitability of SET was assessed in individual women on the basis of both clinical and embryological prognostic factors and was not standardized. For the described eSET strategy coupled with an enhanced embryo selection policy, an optimized culture system, cryopreservation and aneuploidy screening programme is necessary. WIDER IMPLICATIONS OF THE FINDINGS Owing to the increased maternal morbidity and perinatal complications related to multiple pregnancies, it is recommended to extend the eSET policy to the AMA population. As shown in this study, enhanced embryo selection procedures might allow a reduction in the number of embryos transferred and the number of transfers to be performed without affecting the total efficacy of the treatment but increasing efficiency and safety. STUDY FUNDING/COMPETING INTEREST(S) None. TRIAL REGISTRATION NUMBER None.
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Affiliation(s)
- Filippo Maria Ubaldi
- G.EN.E.R.A. Centre for Reproductive Medicine, Clinica Valle Giulia, Via G. De Notaris 2b, 00197 Rome, Italy
| | - Antonio Capalbo
- G.EN.E.R.A. Centre for Reproductive Medicine, Clinica Valle Giulia, Via G. De Notaris 2b, 00197 Rome, Italy GENETYX, Molecular Genetics Laboratory, E. Fermi, 1 36063 Marostica, Vicenza, Italy
| | - Silvia Colamaria
- G.EN.E.R.A. Centre for Reproductive Medicine, Clinica Valle Giulia, Via G. De Notaris 2b, 00197 Rome, Italy
| | - Susanna Ferrero
- G.EN.E.R.A. Centre for Reproductive Medicine, Clinica Valle Giulia, Via G. De Notaris 2b, 00197 Rome, Italy
| | - Roberta Maggiulli
- G.EN.E.R.A. Centre for Reproductive Medicine, Clinica Valle Giulia, Via G. De Notaris 2b, 00197 Rome, Italy
| | - Gábor Vajta
- Beishan Industrial Zone, BGI Shenzhen, Yantian District Shenzhen 518083, China
| | - Fabio Sapienza
- G.EN.E.R.A. Centre for Reproductive Medicine, Clinica Valle Giulia, Via G. De Notaris 2b, 00197 Rome, Italy
| | - Danilo Cimadomo
- G.EN.E.R.A. Centre for Reproductive Medicine, Clinica Valle Giulia, Via G. De Notaris 2b, 00197 Rome, Italy GENETYX, Molecular Genetics Laboratory, E. Fermi, 1 36063 Marostica, Vicenza, Italy
| | - Maddalena Giuliani
- G.EN.E.R.A. Centre for Reproductive Medicine, Clinica Valle Giulia, Via G. De Notaris 2b, 00197 Rome, Italy
| | - Enrica Gravotta
- G.EN.E.R.A. Centre for Reproductive Medicine, Clinica Valle Giulia, Via G. De Notaris 2b, 00197 Rome, Italy
| | - Alberto Vaiarelli
- G.EN.E.R.A. Centre for Reproductive Medicine, Clinica Valle Giulia, Via G. De Notaris 2b, 00197 Rome, Italy
| | - Laura Rienzi
- G.EN.E.R.A. Centre for Reproductive Medicine, Clinica Valle Giulia, Via G. De Notaris 2b, 00197 Rome, Italy
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Economic aspects of infertility care: a challenge for researchers and clinicians: Figure 1. Hum Reprod 2015; 30:2243-8. [DOI: 10.1093/humrep/dev163] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 06/11/2015] [Indexed: 11/14/2022] Open
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Goldhaber-Fiebert JD, Brandeau ML. Evaluating Cost-effectiveness of Interventions That Affect Fertility and Childbearing: How Health Effects Are Measured Matters. Med Decis Making 2015; 35:818-46. [PMID: 25926281 DOI: 10.1177/0272989x15583845] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 04/01/2015] [Indexed: 01/26/2023]
Abstract
BACKGROUND Current guidelines for economic evaluations of health interventions define relevant outcomes as those accruing to individuals receiving interventions. Little consensus exists on counting health impacts on current and future fertility and childbearing. Our objective was to characterize current practices for counting such health outcomes. METHODS We developed a framework characterizing health interventions with direct and/or indirect effects on fertility and childbearing and how such outcomes are reported. We identified interventions spanning the framework and performed a targeted literature review for economic evaluations of these interventions. For each article, we characterized how the potential health outcomes from each intervention were considered, focusing on quality-adjusted life-years (QALYs) associated with fertility and childbearing. RESULTS We reviewed 108 studies, identifying 7 themes: 1) Studies were heterogeneous in reporting outcomes. 2) Studies often selected outcomes for inclusion that tend to bias toward finding the intervention to be cost-effective. 3) Studies often avoided the challenges of assigning QALYs for pregnancy and fertility by instead considering cost per intermediate outcome. 4) Even for the same intervention, studies took heterogeneous approaches to outcome evaluation. 5) Studies used multiple, competing rationales for whether and how to include fertility-related QALYs and whose QALYs to include. 6) Studies examining interventions with indirect effects on fertility typically ignored such QALYs. 7) Even recent studies had these shortcomings. Limitations include that the review was targeted rather than systematic. CONCLUSIONS Economic evaluations inconsistently consider QALYs from current and future fertility and childbearing in ways that frequently appear biased toward the interventions considered. As the Panel on Cost-Effectiveness in Health and Medicine updates its guidelines, making the practice of cost-effectiveness analysis more consistent is a priority. Our study contributes to harmonizing methods in this respect.
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Affiliation(s)
- Jeremy D Goldhaber-Fiebert
- Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA (JDGF)
| | - Margaret L Brandeau
- Department of Management Science and Engineering, Stanford University, Stanford, CA (MLB)
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Wilkinson D, Schaefer GO, Tremellen K, Savulescu J. Double trouble: should double embryo transfer be banned? THEORETICAL MEDICINE AND BIOETHICS 2015; 36:121-139. [PMID: 25813034 DOI: 10.1007/s11017-015-9324-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
What role should legislation or policy play in avoiding the complications of in-vitro fertilization? In this article, we focus on single versus double embryo transfer, and assess three arguments in favour of mandatory single embryo transfer: risks to the mother, risks to resultant children, and costs to society. We highlight significant ethical concerns about each of these. Reproductive autonomy and non-paternalism are strong enough to outweigh the health concerns for the woman. Complications due to non-identity cast doubt on the extent to which children are harmed. Twinning may offer an overall benefit rather than burden to society. Finally, including the future health costs for children (not yet born) in reproductive policy is inconsistent with other decisions. We conclude that mandatory single embryo transfer is not justified and that a number of countries should reconsider their current embryo transfer policy.
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Affiliation(s)
- Dominic Wilkinson
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Suite 8, Littlegate House, St Ebbes St, Oxford, OX1 1PT, UK,
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Busnelli A, Papaleo E, Del Prato D, La Vecchia I, Iachini E, Paffoni A, Candiani M, Somigliana E. A retrospective evaluation of prognosis and cost-effectiveness of IVF in poor responders according to the Bologna criteria. Hum Reprod 2014; 30:315-22. [DOI: 10.1093/humrep/deu319] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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Okun N, Sierra S, Douglas Wilson R, Audibert F, Brock JA, Campagnolo C, Carroll J, Cartier L, Chitayat D, Gagnon A, Johnson JA, Langlois S, Murphy-Kaulbeck L, Kim MacDonald W, Okun N, Pastuck M, Tan LY, Poplak V, Robson H. Pregnancy Outcomes After Assisted Human Reproduction. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2014; 36:64-83. [DOI: 10.1016/s1701-2163(15)30685-x] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Caserta D, Bordi G, Stegagno M, Filippini F, Podagrosi M, Roselli D, Moscarini M. Maternal and perinatal outcomes in spontaneous versus assisted conception twin pregnancies. Eur J Obstet Gynecol Reprod Biol 2013; 174:64-9. [PMID: 24405729 DOI: 10.1016/j.ejogrb.2013.12.011] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Revised: 10/01/2013] [Accepted: 12/05/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To compare maternal and perinatal outcomes in twin pregnancies conceived via assisted reproductive techniques (ART) compared with spontaneous twin pregnancies. STUDY DESIGN This retrospective study examined 345 dichorionic, di-amniotic twin pregnancies (207 conceived spontaneously and 138 conceived via ART), delivered between January 2007 and June 2011 at the San Pietro Fatebenefratelli Hospital, Rome, a tertiary medical centre. Maternal and perinatal outcomes were compared. A multiple logistic regression analysis was performed to calculate risk estimates as odds ratios (OR) adjusted for maternal age, parity and systemic diseases. Patient data were obtained from a computerized database and analyzed using Statistical Package for the Social Sciences Version 17. RESULTS Gestational age and birth weight were lower in the ART group, and preterm delivery, gestational diabetes and placental abruption were higher in the ART group compared with the spontaneous conception group. The incidence rates of respiratory complications, patent ductus arteriosus and admission to the neonatal intensive care unit were higher among ART newborns. Length of hospital stay for mothers and newborns was longer in the ART group. No differences in mode of delivery, Apgar score at 5min, congenital anomalies, perinatal mortality, and other considered pregnancy and neonatal complications were found between the two groups. Multivariate analysis adjusted for maternal age, parity and systemic diseases revealed that only the rates of placental abruption [OR 7.45, 95% confidence interval (CI) 2.05-26.98] and patent ductus arteriosus (OR 3.39, 95% CI 1.01-11.46) were significantly higher for the ART group. CONCLUSIONS Twin pregnancies conceived via ART are at greater risk of poorer outcomes than spontaneous twin pregnancies. This may be related to the type of conception and specific negative features of subfertile patients undergoing infertility treatment.
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Affiliation(s)
- D Caserta
- Department of Gynaecologic-Obstetrical Sciences and Urological Sciences, University of Rome Sapienza, S. Andrea Hospital, Rome, Italy.
| | - G Bordi
- Department of Gynaecologic-Obstetrical Sciences and Urological Sciences, University of Rome Sapienza, S. Andrea Hospital, Rome, Italy
| | - M Stegagno
- Department of Gynaecologic-Obstetrical Sciences and Urological Sciences, University of Rome Sapienza, S. Andrea Hospital, Rome, Italy; Neonatal Unit of S. Pietro Fatebenefratelli Hospital, Rome, Italy
| | - F Filippini
- Neonatal Unit of S. Pietro Fatebenefratelli Hospital, Rome, Italy
| | - M Podagrosi
- Neonatal Unit of S. Pietro Fatebenefratelli Hospital, Rome, Italy
| | - D Roselli
- Department of Obstetrics and Gynaecology, S. Pietro Fatebenefratelli Hospital, Rome, Italy
| | - M Moscarini
- Department of Gynaecologic-Obstetrical Sciences and Urological Sciences, University of Rome Sapienza, S. Andrea Hospital, Rome, Italy
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Groen H, Tonch N, Simons AHM, van der Veen F, Hoek A, Land JA. Modified natural cycle versus controlled ovarian hyperstimulation IVF: a cost-effectiveness evaluation of three simulated treatment scenarios. Hum Reprod 2013; 28:3236-46. [DOI: 10.1093/humrep/det386] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Kessler LM, Craig BM, Plosker SM, Reed DR, Quinn GP. Infertility evaluation and treatment among women in the United States. Fertil Steril 2013; 100:1025-32. [PMID: 23849845 DOI: 10.1016/j.fertnstert.2013.05.040] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Revised: 05/14/2013] [Accepted: 05/24/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To examine the characteristics of women seeking infertility evaluation and treatment. DESIGN Cross-sectional survey based on in-person interviews, followed by two-step hurdle analysis. SETTING Not applicable. PATIENT(S) 4,558 married or cohabitating women ages 25 to 44 years. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Likelihood of seeking a preliminary infertility evaluation and of seeking infertility treatment once evaluated, and the treatment type provided. RESULT(S) Of 623 women (13.7%) who reported seeking an infertility evaluation, 328 reported undergoing subsequent infertility treatment. Age at marriage, marital status, education, health insurance status, race/ethnicity, and religion were associated with the likelihood of seeking infertility evaluation. For example, the predicted probability that a non-white woman who married at age 25 will seek evaluation was 12%. This probability increased to 34% for white women with a graduate degree who had married at age 30. Among women who were evaluated, income, employment status, and ethnicity correlated strongly with the likelihood of seeking infertility treatment. Infertility drug therapy was the most frequent treatment used, and reproductive surgery and in vitro fertilization (IVF) were used the least often. CONCLUSION(S) The use of infertility services is not random. Understanding the sociodemographic factors correlated with use may assist new couples with family planning. Roughly 50% of the women evaluated for infertility progressed to treatment, and only a small proportion were treated with more advanced assisted reproductive technologies such as in vitro fertilization. Future research aimed at improving access to effective health-care treatments within the boundaries of affordability is warranted.
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Affiliation(s)
- Lawrence M Kessler
- Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, University of South Florida, Tampa, Florida; Department of Economics, College of Arts and Sciences, University of South Florida, Tampa, Florida.
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Yilmaz N, Engin-Üstün Y, Inal H, Gorkem U, Bardakci Y, Gulerman C. The impact of single embryo transfer policy on pregnancy outcomes after legislative change. Gynecol Endocrinol 2013; 29:600-2. [PMID: 23656390 DOI: 10.3109/09513590.2013.788629] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We evaluated the effect of mandatory single embryo transfer (SET) on live birth rates and pregnancy outcomes in Turkey. A retrospective study was conducted in Zekai Tahir Burak Women's Health Education and Research Hospital. Four hundred and four patients undergoing intracytoplasmic sperm injection (ICSI) cycles were included in the study. In Turkey, the number of embryos to be transferred in an assisted cycle was limited to three under normal circumstances until 6 March 2010. After that, new legislation was introduced to promote the application of SET. Outcomes were compared in periods of 1 year before and after the new law. We compared pregnancy outcomes of all assisted reproductive cycles in SET cycles (group 1: n = 281) with double embryo transfer (DET) cycles (group 2: n = 123). There were significant differences in oocyte number, multiple pregnancy, gestational age, birth weight and perinatal fetal morbidity between the groups (p = 0.023, 0.001, 0.001, 0.001, 0.001, respectively). But there were no differences in age, baseline FSH, infertility period, stimulation protocol, stimulation day, gonadotrophin dose, clinical pregnancy rate, abortion rate, live birth rate and cesarean rate (p > 0.05). These results suggest that under the new legislation multiple pregnancy rates and perinatal complications are significantly reduced without causing a significant decline in the pregnancy rates.
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Affiliation(s)
- Nafiye Yilmaz
- Zekai Tahir Burak Women's Health Education and Research Hospital, Reproductive Endocrinology Department, Ankara, Turkey.
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Ganz ML, Shah D, Gidwani R, Filonenko A, Su W, Pocoski J, Law A. The cost-effectiveness of the levonorgestrel-releasing intrauterine system for the treatment of idiopathic heavy menstrual bleeding in the United States. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2013; 16:325-333. [PMID: 23538185 DOI: 10.1016/j.jval.2012.11.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2011] [Revised: 11/02/2012] [Accepted: 11/25/2012] [Indexed: 06/02/2023]
Abstract
OBJECTIVES Heavy menstrual bleeding negatively impacts the health and quality of life of about 18 million women in the United States. Although some studies have established the clinical effectiveness of heavy menstrual bleeding treatments, few have evaluated their cost-effectiveness. Our objective was to evaluate the cost-effectiveness of the levonorgestrel-releasing intrauterine system (LNG-IUS) compared with other therapies for idiopathic heavy menstrual bleeding. METHODS We developed a model comparing the clinical and economic outcomes (from a US payer perspective) of three broad initial treatment strategies over 5 years: LNG-IUS, oral agents, or surgery. Up to three nonsurgical treatment lines, followed by up to two surgical lines, were allowed; unintended pregnancy was possible, and women could discontinue any time during nonsurgical treatments. Menstrual blood loss of 80 ml or more per cycle determined treatment failure. RESULTS Initiating treatment with LNG-IUS resulted in the fewest hysterectomies (6 per 1000 women), the most quality-adjusted life-years (3.78), and the lowest costs ($1137) among all the nonsurgical strategies. Initiating treatment with LNG-IUS was also less costly than surgery, resulted in fewer hysterectomies (vs. 9 per 1000 for ablation) but was associated with fewer quality-adjusted life-years gained per patient (vs. 3.80 and 3.88 for ablation and hysterectomy, respectively). Sensitivity analyses confirmed these results. CONCLUSIONS LNG-IUS resulted in the lowest treatment costs and the fewest number of hysterectomies performed over 5 years compared with all other initial strategies and resulted in the most quality-adjusted life-years gained among nonsurgical options. Initial treatment with LNG-IUS is the least costly and most effective option for women desiring to preserve their fertility.
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Verhoeve HR, Moolenaar LM, Hompes P, van der Veen F, Mol BWJ. Cost-effectiveness of tubal patency tests. BJOG 2013; 120:583-93. [DOI: 10.1111/1471-0528.12121] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2012] [Indexed: 01/27/2023]
Affiliation(s)
- HR Verhoeve
- Department of Obstetrics & Gynaecology; Onze Lieve Vrouwe Gasthuis; Amsterdam; the Netherlands
| | | | - P Hompes
- Department of Obstetrics & Gynaecology; Vrije Universiteit Medical Centre; Amsterdam; the Netherlands
| | - F van der Veen
- Centre for Reproductive Medicine; Academic Medical Centre; Amsterdam; the Netherlands
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Niinimäki M, Suikkari AM, Mäkinen S, Söderström-Anttila V, Martikainen H. Elective single-embryo transfer in women aged 40-44 years. Hum Reprod 2012; 28:331-5. [PMID: 23175499 DOI: 10.1093/humrep/des399] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY QUESTION Is an elective single-embryo transfer (eSET) policy feasible for women aged 40 or older? SUMMARY ANSWER For older women (aged 40-44 years) with a good prognosis, an eSET policy can be applied with acceptable cumulative clinical pregnancy rates and live birth rates. WHAT IS KNOWN ALREADY Various studies have shown the effectiveness of eSET in women aged <35 years with high cumulative pregnancy rates and low rates of multiple births. STUDY DESIGN, SIZE, DURATION This retrospective cohort study included 628 women treated between 2000 and 2009. PARTICIPANTS, SETTING, METHODS Women aged 40-44 years underwent a fresh cycle of IVF or ICSI treatment with eSET (n = 264) or double-embryo transfer (DET) (n = 364). In the subsequent frozen-thawed embryo transfer cycles, SET/DET was performed in both groups according to the number of embryos available and the opinion of the couple. The study was performed at the Family Federation of Finland Helsinki Fertility Clinic. MAIN RESULTS AND THE ROLE OF CHANCE In the fresh cycles, the clinical pregnancy rates were 23.5 and 19.5% in the eSET and DET groups, respectively, and live birth rates were 13.6 and 11.0%, respectively. In the fresh cycles with eSET, there were no twin pregnancies, but in the DET group, there were three sets of twins (7.5%). The cumulative clinical pregnancy rates per oocyte retrieval were 37.1 and 24.2% in the eSET and DET groups, respectively (P < 0.001), and the cumulative live birth rates were 22.7 and 13.2%, respectively (P = 0.002). Cumulative twin rates were 6.7% (n = 4) in the eSET group and 8.3% (n = 4) in the DET group (P = 0.726). All of the twin pregnancies in the eSET group resulted from frozen and thawed DET embryo transfer cycles. LIMITATIONS The characteristics of the two patients groups are not comparable because the suitability of eSET was individually assessed by a clinician based on both clinical prognostic factors and the outcome of IVF or ICSI, i.e. the number and quality of embryos. WIDER IMPLICATIONS OF THE FINDINGS This study may be generalized to IVF units having experience in eSET and cryopreservation.
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Affiliation(s)
- M Niinimäki
- Department of Obstetrics and Gynecology, University Hospital of Oulu, Oulu, Finland.
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Abstract
In this issue of the journal, Niinimäki et al., colleagues from a pioneering Finnish center in the development of elective single-embryo transfer (eSET), propose the expansion of eSET to suitable women at ages of 40-44 years. This paper offers not only a critique of their proposal but also of eSET in general.
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Affiliation(s)
- Norbert Gleicher
- The Center for Human Reproduction (CHR), New York and Foundation for Reproductive Medicine, New York, NY 10021, USA.
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Theoretical model of the relationship between single embryo transfer rate and multiple pregnancy rate in Japan. J Pregnancy 2012; 2012:620753. [PMID: 22900185 PMCID: PMC3413953 DOI: 10.1155/2012/620753] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Accepted: 04/24/2012] [Indexed: 11/20/2022] Open
Abstract
The purpose of the present study was to examine the effect of single embryo transfer (SET) in assisted reproductive technology (ART) on the reduction of the multiple pregnancy rate. We also estimated the monozygotic (MZ) twinning rates according to the SET diffusion indirectly. A reverse sigmoid curve was assumed and examined using nationwide data of SET from 2007 to 2009 in Japan. The multiple pregnancy rate decreased almost linearly where the SET pregnancy rate was between about 40% and 80% of regression approximation. The linear approximation overestimated multiple pregnancy rates in an early period and underestimated multiple pregnancy rates in the final period. The multiple pregnancy rate seemed to be influenced by the improvement of the total pregnancy rate of ART in the early period and by the MZ twinning after SET in the final period. The estimated MZ twinning rate after SET was around 2%.
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