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Zhou Y, Ji H, Zhang M, Zhang J, Li X, Zhang J, Ling X, Chen L, Zhao C. Single versus double blastocyst transfer in first and second frozen-thawed embryo transfer cycle in advance-aged women: a two-center retrospective cohort study. BMC Womens Health 2024; 24:51. [PMID: 38238733 PMCID: PMC10795208 DOI: 10.1186/s12905-023-02753-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 10/31/2023] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND The present evidence is deficient for the trade-offs between the pros and cons of single blastocyst transfer (SBT) versus double blastocyst transfer (DBT) in frozen-thawed embryo transfer cycles for women in advanced reproductive age, especially in the second cycle. The current study aimed to investigate the impact of transferred blastocyst numbers on pregnancy outcomes in the first and second embryo transfer for women ≥ 35 years. METHODS This was a retrospective cohort study including 1284 frozen-thawed blastocyst transfer (FBT) cycles from two reproductive centers. We analyzed the pregnancy outcomes after SBT and DBT in the first and second FBT cycles. Moreover, stratified analysis was conducted by maternal age. RESULTS In the first FBT cycle, the LBR was higher in the DBT group than that in the SBT group [52.3% vs. 33.9%; adjusted odds ratio (aOR), 1.65; 95% confidence interval (CI), 1.26-2.15, P < 0.001]. However, the LBR of the DBT group showed no remarkable difference compared with that of the SBT group in the second cycle of FBT (44.3% vs. 33.3%; aOR, 1.30; 95% CI, 0.81-2.08; P = 0.271). Furthermore, stratified analysis by age showed a higher LBR for the DBT group than the SBT group in patients aged 38-42 years (43.1% vs. 33.9%; aOR, 2.27; 95% CI, 1.05-4.90; P = 0.036). CONCLUSIONS The present study demonstrated that the SBT regimen is a better choice for both, the first and second frozen-thawed embryo transfer cycles, for women aged 35-37 years. Additionally, the DBT regimen is still recommended to achieve a high LBR in women aged 38-42 years in the second FBT cycle. These findings may be beneficial for deciding the embryo transfer regimens in women of advanced reproductive age.
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Affiliation(s)
- Yuxi Zhou
- Department of Reproductive Medicine, Nanjing Women and Children's Healthcare Hospital, Women's Hospital of Nanjing Medical University, Nanjing, 210004, China
| | - Hui Ji
- Department of Reproductive Medicine, Nanjing Women and Children's Healthcare Hospital, Women's Hospital of Nanjing Medical University, Nanjing, 210004, China
| | - Mianqiu Zhang
- Department of Reproductive Medicine, Nanjing Women and Children's Healthcare Hospital, Women's Hospital of Nanjing Medical University, Nanjing, 210004, China
| | - Juanjuan Zhang
- Department of Reproductive Medicine, Nanjing Women and Children's Healthcare Hospital, Women's Hospital of Nanjing Medical University, Nanjing, 210004, China
| | - Xin Li
- Department of Reproductive Medicine, Nanjing Women and Children's Healthcare Hospital, Women's Hospital of Nanjing Medical University, Nanjing, 210004, China
| | - Junqiang Zhang
- Department of Reproductive Medicine, Nanjing Women and Children's Healthcare Hospital, Women's Hospital of Nanjing Medical University, Nanjing, 210004, China
| | - Xiufeng Ling
- Department of Reproductive Medicine, Nanjing Women and Children's Healthcare Hospital, Women's Hospital of Nanjing Medical University, Nanjing, 210004, China
| | - Li Chen
- Department of Reproductive Medicine, Changzhou Maternal and Child Health Care Hospital, Changzhou, 213000, China
| | - Chun Zhao
- Department of Reproductive Medicine, Nanjing Women and Children's Healthcare Hospital, Women's Hospital of Nanjing Medical University, Nanjing, 210004, China.
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Yun I, Cha W, Nam CM, Nam JY, Park EC. The impact of assisted reproductive technology treatment coverage on marriage, pregnancy, and childbirth in women of childbearing age: an interrupted time-series analysis. BMC Public Health 2023; 23:1379. [PMID: 37464391 DOI: 10.1186/s12889-023-16286-3] [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: 04/03/2023] [Accepted: 07/10/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Korea is encountering major challenges related to its declining birth rate and aging population. Various policies have been introduced to prevent further population decrease and boost the birth rate, but their effectiveness has not been verified. Therefore, this study examined the effects of assisted reproductive technology (ART) insurance coverage on marriage, pregnancy, and childbirth in women of childbearing age. METHODS All information on marriage, pregnancy, childbirth of women of childbearing age was obtained from Statistics Korea and Korean National Health Insurance Service database. During a total follow-up period of 54 months (July 2015 to December 2019), an average of 12,524,214 women of childbearing age per month, and 29,701 live births per month were included in the analysis. An interrupted time series with segmented regression was performed to analyze the time trend and changes in outcomes. RESULTS The implementation of ART coverage policies had no significant impact on marriage or pregnancy rates. However, it did affect multiple pregnancy and multiple birth rates, which increased by 1.0% (Exp(β3) = 1.010, P-value = 0.0001) and 1.4% (Exp(β3) = 1.014, P-value = < 0.0001), respectively, compared to the pre-intervention period. Although the effect of covering ART treatment on total birth rates were not confirmed, a slightly slower decline was observed after the intervention (Exp(β1) = 0.993, P-value = < 0.0001, Exp(β1 + β3) = 0.996 P-value = 0.012). CONCLUSION This study identified the effects of ART health insurance coverage policy on the rates of multiple pregnancies and births. After the policy implementation, the downward trend in the total birth rate reduced slightly. Our findings suggest that interventions to support infertile couples should be expanded to solve the problem of low fertility rates. To address the intricate problems related to low birth rates, the Korean government introduced a policy that provides financial support and health insurance coverage for assisted reproductive technology (ART) treatment for infertile couples. As a result of evaluating the effectiveness of the ART coverage policy, it led to higher rates of pregnancies and births. In addition, although the total birth rate has been continuously decreasing over time, the decline may have been slowed down slightly by this policy.
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Affiliation(s)
- Il Yun
- Department of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea
| | - Wontae Cha
- Department of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea
- CHA Hollywood Presbyterian Medical Center, Los Angeles, CA, United States of America
| | - Chung-Mo Nam
- Department of Preventive Medicine, Yonsei University College of Medicine, Yonsei-ro 50-1, Seodaemun-gu, Seoul, Republic of Korea
| | - Jin Young Nam
- Department of Healthcare Management, Eulji University, Sanseongdae-ro 553, Sujeong-gu, Seongnam, Gyeonggi-do, Republic of Korea.
| | - Eun-Cheol Park
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea.
- Department of Preventive Medicine, Yonsei University College of Medicine, Yonsei-ro 50-1, Seodaemun-gu, Seoul, Republic of Korea.
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De Neubourg D, Dancet EAF, Pinborg A. Single-embryo transfer implies quality of care in reproductive medicine. Reprod Biomed Online 2022; 45:899-905. [PMID: 35927209 DOI: 10.1016/j.rbmo.2022.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 03/22/2022] [Accepted: 04/04/2022] [Indexed: 12/24/2022]
Abstract
This review appraises evidence on the difference between single- and double-embryo transfer (SET, DET) in assisted reproductive technology (ART) regarding the four healthcare quality dimensions most important to fertility patients and doctors. Regarding safety, not only does DET create the uncontested perinatal risks of twin pregnancies, but compelling evidence has added that singleton pregnancies after a vanishing twin also have poorer perinatal outcomes. SET is as effective as DET, as shown by meta-analyses of randomized controlled trials, comparing two cycles of SET versus DET and shown by cumulative live birth rates of entire ART trajectories of up to six cycles. Proposing SET, which is safer than DET and as effective, as the gold standard is not irreconcilable with patient-centred care if patients are thoroughly informed on the reasoning behind the proposition and welcomed to challenge whether it fits their personal values. The cost-efficiency of SET is clearly higher, which has even induced certain countries to start reimbursing ART on the condition that SET is used. In conclusion, SET should be the gold standard offered to all patients. The question is not whether to apply SET but how to apply it in terms of patient selection, patient-centred counselling and coverage of treatment.
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Affiliation(s)
- Diane De Neubourg
- Center for Reproductive Medicine, Antwerp University Hospital, Faculty of Medicine and Health Sciences, University of Antwerp, Edegem, Belgium.
| | - Eline A F Dancet
- Leuven University Fertility Clinic - Leuven University Hospitals, Leuven, Belgium
| | - Anja Pinborg
- Fertility Clinic, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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4
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Wei SQ, Bilodeau-Bertrand M, Lo E, Auger N. Effect of publicly funded assisted reproductive technology on maternal and infant outcomes: a pre- and post-comparison study. Hum Reprod 2021; 36:219-228. [PMID: 33246340 DOI: 10.1093/humrep/deaa270] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 09/02/2020] [Indexed: 01/27/2023] Open
Abstract
STUDY QUESTION Does publicly funded assisted reproductive technology result in improved maternal and infant outcomes? SUMMARY ANSWER Publicly funded ART in Quebec was associated with reduced risks of preeclampsia, cesarean delivery, preterm birth, low birth weight and other adverse outcomes. WHAT IS KNOWN ALREADY Publicly funded ART programs that provide free access to single embryo transfer are known to decrease the rate of multiple pregnancy, but the impact on other pregnancy outcomes is unknown. STUDY DESIGN, SIZE, DURATION We conducted a pre- and post-comparison study of 597 416 pregnancies conceived between July 2008 and September 2015 in Quebec, Canada, a region where public funding of ART began in August 2010. PARTICIPANTS/MATERIALS, SETTING, METHODS We included all pregnant women who conceived by ART (n = 14 309) or spontaneously (n = 583 107) and delivered a live or stillborn infant in hospitals of Quebec. The main exposure measure was conception before versus during the publicly funded ART program. Outcomes included measures of maternal and infant morbidity and mortality. We estimated risk ratios (RR) and 95% confidence intervals for the association of publicly funded ART with maternal and infant outcomes using log-binomial regression models adjusted for maternal characteristics. MAIN RESULTS AND THE ROLE OF CHANCE In this study, 2638 pregnancies were conceived by ART before, and 11 671 were conceived by ART, during public funding. Compared with no public funding, ART funding was associated with reduced risks of severe maternal morbidity (RR 0.64, 95% CI 0.50-0.83), preeclampsia (RR 0.55, 95% CI 0.44-0.68), cesarean delivery (RR 0.83, 95% CI 0.77-0.89), preterm birth (RR 0.67, 95% CI 0.60-0.75), low birth weight (RR 0.63, 95% CI 0.55-0.72), severe neonatal morbidity (RR 0.75, 95% CI 0.57-0.99) and neonatal intensive care unit admission (RR 0.65, 95% CI 0.53-0.78). When multiple pregnancies were excluded, ART funding continued to be associated with a lower risk of preeclampsia (RR 0.61, 95% CI 0.48-0.79) and preterm birth (RR 0.85, 95% CI 0.73-0.99). However, ART funding was associated with increased risk of gestational diabetes. LIMITATIONS, REASONS FOR CAUTION We had no information on the type of ART, number of in-vitro fertilization cycles or number of embryos transferred. We lacked data on body mass index, ethnicity and smoking and cannot rule out residual confounding. WIDER IMPLICATION OF THE FINDINGS Our findings suggest that publicly funded ART programs that encourage single embryo transfer may have substantial benefits for a range of maternal and infant outcomes, beyond prevention of multiple births. STUDY FUNDING/COMPETING INTEREST(S) This study was supported by grant 6D02363004 from the Public Health Agency of Canada. N.A. acknowledges a career award from the Fonds de recherche du Québec-Santé (34695). The authors declare no competing interests. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- Shu Qin Wei
- Department of Obstetrics and Gynecology, Sainte-Justine Hospital Research Center, University of Montreal, Montreal, Canada
- Bureau d'information et d'études en santé des populations, Institut national de santé publique du Québec, Montreal, Canada
| | - Marianne Bilodeau-Bertrand
- Bureau d'information et d'études en santé des populations, Institut national de santé publique du Québec, Montreal, Canada
| | - Ernest Lo
- Bureau d'information et d'études en santé des populations, Institut national de santé publique du Québec, Montreal, Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada
| | - Nathalie Auger
- Bureau d'information et d'études en santé des populations, Institut national de santé publique du Québec, Montreal, Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada
- Department of Social and Preventive Medicine, School of Public Health, University of Montreal Hospital Research Centre, University of Montreal, Montreal, Canada
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5
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Chambers GM, Keller E, Choi S, Khalaf Y, Crawford S, Botha W, Ledger W. Funding and public reporting strategies for reducing multiple pregnancy from fertility treatments. Fertil Steril 2021; 114:715-721. [PMID: 33040980 DOI: 10.1016/j.fertnstert.2020.08.1405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/22/2020] [Accepted: 08/24/2020] [Indexed: 10/23/2022]
Abstract
The health of children born through assisted reproductive technologies (ART) is particularly vulnerable to policy decisions and market forces that play out before they are even conceived. ART treatment is costly, and public and third-party funding varies significantly between and within countries, leading to considerable variation in consumer affordability globally. These relative cost differences affect not only who can afford to access ART treatment, but also how ART is practiced in terms of embryo transfer practices, with less affordable treatment creating a financial incentive to transfer more than one embryo to maximize the pregnancy rates in fewer cycles. One mechanism for reducing the burden of excessive multiple pregnancies is to link insurance coverage to the number of embryos that can be transferred; another is to combine supportive funding with patient and clinician education and public reporting that emphasizes a "complete" ART cycle (all embryo transfers associated with an egg retrieval) and penalizes multiple embryo transfers. Improving funding for fertility services in a way that respects clinician and patient autonomy and allows patients to undertake a sufficient number of cycles to minimize moral hazard improves outcomes for mothers and babies while reducing the long-term economic burden associated with fertility treatments.
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Affiliation(s)
- Georgina M Chambers
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health and School of Women's and Children's Health, University of New South Wales, Sydney, Australia.
| | - Elena Keller
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health and School of Women's and Children's Health, University of New South Wales, Sydney, Australia
| | - Stephanie Choi
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health and School of Women's and Children's Health, University of New South Wales, Sydney, Australia
| | - Yakoub Khalaf
- Reproductive Medicine and Surgery, King's College London, London, United Kingdom
| | - Sara Crawford
- Department of Mathematics, University of Mount Union, Alliance, Ohio
| | - Willings Botha
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health and School of Women's and Children's Health, University of New South Wales, Sydney, Australia; RTI Health Solutions, Health Preferences Assessment, Manchester, United Kingdom
| | - William Ledger
- School of Women's and Children's Health, University of New South Wales, Sydney, Australia
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6
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Blakely B, Williams J, Mayes C, Kerridge I, Lipworth W. Conflicts of interest in Australia’s IVF industry: an empirical analysis and call for action. HUM FERTIL 2017; 22:230-237. [DOI: 10.1080/14647273.2017.1390266] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Brette Blakely
- Faculty of Medicine and Health Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Jane Williams
- Centre for Values Ethics and the Law in Medicine, The University of Sydney, Sydney, NSW, Australia
| | - Christopher Mayes
- Centre for Values Ethics and the Law in Medicine, The University of Sydney, Sydney, NSW, Australia
| | - Ian Kerridge
- Centre for Values Ethics and the Law in Medicine, The University of Sydney, Sydney, NSW, Australia
| | - Wendy Lipworth
- Centre for Values Ethics and the Law in Medicine, The University of Sydney, Sydney, NSW, Australia
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7
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Chambers GM, Paul RC, Harris K, Fitzgerald O, Boothroyd CV, Rombauts L, Chapman MG, Jorm L. Assisted reproductive technology in Australia and New Zealand: cumulative live birth rates as measures of success. Med J Aust 2017; 207:114-118. [DOI: 10.5694/mja16.01435] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 03/07/2017] [Indexed: 11/17/2022]
Affiliation(s)
- Georgina M Chambers
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health and School of Women's and Children's Health, University of New South Wales, Sydney, NSW
| | - Repon C Paul
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health and School of Women's and Children's Health, University of New South Wales, Sydney, NSW
| | - Katie Harris
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health and School of Women's and Children's Health, University of New South Wales, Sydney, NSW
| | - Oisin Fitzgerald
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health and School of Women's and Children's Health, University of New South Wales, Sydney, NSW
| | | | | | | | - Louisa Jorm
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW
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8
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Peeraer K, D'Hooghe TM, Vandoren C, Trybou J, Spiessens C, Debrock S, De Neubourg D. A 50% reduction in multiple live birth rate is associated with a 13% cost saving: a real-life retrospective cost analysis. Reprod Biomed Online 2017. [PMID: 28629925 DOI: 10.1016/j.rbmo.2017.05.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Belgian legislation limiting the number of embryos for transfer has been shown to result in a 50% reduction of the multiple live birth rate (MLBR) per cycle without having a negative impact on the cumulative delivery rate per patient within six cycles or 36 months. The objective of the current study was to evaluate the cost saving associated with a 50% reduction in MLBR. A retrospective cost analysis was performed of 213 couples, who became pregnant and had a live birth after one or more assisted reproductive technology treatment cycles, and their 254 children. The mean cost of a singleton (n = 172) and multiple (n = 41) birth was calculated based on individual hospital invoices. The cost analysis showed a significantly higher total cost (assisted reproductive technology treatment, pregnancy follow-up, delivery, child cost until the age of 2 years) for multiple births (both children: mean €43,397) than for singleton births (mean: €17,866) (Wilcoxon-Mann-Whitney P < 0.0001). A 50% reduction in MLBR resulted in a significant cost reduction related to hospital care of 13%.
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Affiliation(s)
- Karen Peeraer
- Leuven University Fertility Center, UZ Leuven Campus Gasthuisberg, Leuven 3000, Belgium.
| | - Thomas M D'Hooghe
- Leuven University Fertility Center, UZ Leuven Campus Gasthuisberg, Leuven 3000, Belgium
| | - Cindy Vandoren
- Department of Management Information and Reporting, UZ Leuven Campus Gasthuisberg, Leuven 3000, Belgium
| | - Jeroen Trybou
- Department of Public Health, Ghent University, De Pintelaan 183, Ghent 9000, Belgium
| | - Carl Spiessens
- Leuven University Fertility Center, UZ Leuven Campus Gasthuisberg, Leuven 3000, Belgium
| | - Sophie Debrock
- Leuven University Fertility Center, UZ Leuven Campus Gasthuisberg, Leuven 3000, Belgium
| | - Diane De Neubourg
- Leuven University Fertility Center, UZ Leuven Campus Gasthuisberg, Leuven 3000, Belgium; Center for Reproductive Medicine, Antwerp University Hospital, Edegem 2650, Belgium
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9
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Abstract
The recently released National Public Health Action Plan for the Detection, Prevention, and Management of Infertility calls for better access to high-quality infertility services and improved safety of fertility treatments. Both assisted reproductive technology (ART) and non-ART fertility treatments have allowed millions of patients worldwide to overcome infertility-a disease of the reproductive system and important public health issue. However, there are substantial disparities in access to effective treatments in the United States, largely attributable to high out-of-pocket costs, especially for ART. Moreover, the outcomes of fertility treatments are often complicated by the large proportion of multiple births with substantial health risks for both neonates and mothers. Prevention of multiple births is difficult during non-ART fertility treatments but can be effective with single-embryo transfer during ART. Several U.S. states have enacted legislative mandates that require private insurers to cover some portion of the costs associated with fertility treatments and thus reduce the financial pressure to transfer multiple embryos during ART. Although studies have shown that insurance coverage reduces per-cycle multiple births to a certain degree, states with insurance mandates have more ART-related multiple births attributable to substantially larger number of ART-conceived neonates. Experience from other countries shows that access to ART can be improved without concomitant increases in multiple births by providing reimbursement for ART in combination with restrictions on the number of embryos transferred per cycle. Such approaches may or may not be successful in the United States with its unique and complex health care system.
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10
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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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Mancuso AC, Boulet SL, Duran E, Munch E, Kissin DM, Van Voorhis BJ. Elective single embryo transfer in women less than age 38 years reduces multiple birth rates, but not live birth rates, in United States fertility clinics. Fertil Steril 2016; 106:1107-1114. [PMID: 27376458 PMCID: PMC11056967 DOI: 10.1016/j.fertnstert.2016.06.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 05/06/2016] [Accepted: 06/07/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To determine the effect of elective single ET (eSET) on live birth and multiple birth rates by a cycle-level and clinic-level analysis. DESIGN Retrospective cohort study. SETTING Not applicable. PATIENT(S) Patient ages <35 and 35-37 years old. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Clinics were divided into groups based on eSET rate for each age group and aggregate rates of live birth per ET and multiple birth per delivery were calculated. A cycle-level analysis comparing eSET and double ET (DET) live birth and multiple birth rates was also performed, stratified based on total number (2, 3, or 4+) of embryos available, embryo stage, and patient age. RESULT(S) There was a linear decrease in multiple birth rate with increasing eSET rate and no significant difference in clinic-level live birth rates for each age group. Cycle-level analysis found slightly higher live birth rates with double ET, but this was mainly observed in women aged 35-37 years or with four or more embryos available for transfer, and confirmed the marked reduction in multiple births with eSET. CONCLUSION(S) Our study showed a marked and linear reduction in multiple birth rates, and important, little to no effect on clinic-level live birth rates with increasing rates of eSET supporting the growing evidence that eSET is effective in decreasing the high multiple birth rates associated with IVF and suggests that eSET should be used more frequently than is currently practiced.
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Affiliation(s)
- Abigail C Mancuso
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa.
| | - Sheree L Boulet
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eyup Duran
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Erika Munch
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Dmitry M Kissin
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Bradley J Van Voorhis
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa
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Chambers GM, Wand H, Macaldowie A, Chapman MG, Farquhar CM, Bowman M, Molloy D, Ledger W. Population trends and live birth rates associated with common ART treatment strategies. Hum Reprod 2016; 31:2632-2641. [PMID: 27664207 DOI: 10.1093/humrep/dew232] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 07/26/2016] [Accepted: 08/22/2016] [Indexed: 11/13/2022] Open
Abstract
STUDY QUESTION Have ART live birth rates improved in Australia over the last 12 years? SUMMARY ANSWER There were striking improvements in per-cycle live birth rates observed for frozen/thaw embryo transfers, blastocyst transfer and single embryo transfer (SET), while live birth rates following ICSI were lower than IVF for non-male factor infertility in most years. WHAT IS ALREADY KNOWN ART and associated techniques have become the predominant treatment of infertility over the past 30 years in most developed countries. However, there are differences in ART laboratory and clinical practices, and success rates worldwide. Australia has one of the highest ART utilization rates and lowest multiple birth rates in the world, thus providing a unique setting to investigate the contribution of common ART strategies in an unrestricted population of patients to ART success rates. STUDY DESIGN, SIZE, DURATION A retrospective cohort study of 585 065 ART treatment cycles performed in Australia between 2002 and 2013 using the Australian and New Zealand Assisted Reproduction Database (ANZARD). PARTICIPANTS MATERIALS, SETTING, METHOD An unrestricted population of all women who underwent autologous ART treatment between 2002 and 2013. Visual descriptive analysis was used to assess the trends in ART procedures by the calendar years. Adjusted odds ratios (aORs) of a live birth for four common ART techniques were calculated after controlling for important confounders including female age, infertility diagnosis, stage of the embryo (blastocyst versus cleavage stage), type of embryo (fresh versus thawed), fertilization method (IVF versus ICSI) and number of embryos transferred (SET versus multiple embryos). MAIN RESULTS AND THE ROLE OF CHANCE The overall live birth rate per embryo transfer increased from 19.2% in 2002 to 23.3% in 2013 (21.9-24.3% for fresh embryo transfers and 14.6-23.3% for frozen/thaw embryo transfers). This occurred concurrently with an increase in SET from 29.7% to 78.9%, and an increase in the average age of women undergoing treatment from 35.0 to 35.9 years. Individuals who had a frozen/thaw embryo transfer cycle in 2002 had 43% (aOR: 0.57, 95% CI: 0.53-0.61) reduced odds of a live birth compared with a fresh embryo transfer cycle. This contrasted with 16% (aOR: 0.84, 95% CI: 0.80-0.98) reduced odds of a live birth from frozen/thaw embryo transfer cycles in 2013. In 2013, the odds of blastocyst transfer resulting in a live birth were more than twice as great as for cleavage stage transfer (aOR 2.01, 95% CI: 1.92-2.11). The adjusted odds of live birth per SET compared with multiple embryo transfer increased significantly over the last 12 years, from a 38% reduced odds of a live birth follow SET in 2002 (aOR: 062, 95% CI: 0.57-0.67) compared to an 8% reduced odds in 2013 (aOR: 0.92, 95% CI: 0.87-0.98). The aOR of a live birth using ICSI compared to IVF in non-male factor patients was lower in most years bringing into question its widespread use. LIMITATION, REASONS FOR CAUTION This is a retrospective cohort analysis and cannot confirm causality. High-level evidence on the effectiveness of particular ART techniques, particularly ICSI and blastocyst culture, requires prospective randomized controlled trials or detailed statistical analysis using large-scale data that counts for fertilization failure, embryo loss, prognostic factors and cycle characteristics. WIDER IMPLICATION OF THE FINDINGS The most striking improvements in ART success rates in Australia have been observed for frozen/thaw embryo transfers, blastocyst transfer and SET. Further studies of the role of ICSI in non-male factor infertility and blastocyst transfer success rates that take into account embryo loss are needed. STUDY FUNDING/COMPETING INTERESTS No funding was received to undertake this study. The authors declare that they do not have competing interests with this study. TRIAL REGISTRATION NUMBER NA.
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Affiliation(s)
- Georgina M Chambers
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health and School of Women's and Children's Health, University of New South Wales, Level 1, AGSM Building, Sydney 2052, Australia
| | - Handan Wand
- The Kirby Institute, University of New South Wales, Sydney 2052, Australia
| | - Alan Macaldowie
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health and School of Women's and Children's Health, University of New South Wales, Level 1, AGSM Building, Sydney 2052, Australia
| | | | - Cynthia M Farquhar
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland 1142, New Zealand
| | - Mark Bowman
- Genea Fertility, Sydney 2000, Australia.,Department of Obstetrics and Gynaecology, University of Sydney, Sydney 2006, Australia
| | - David Molloy
- Queensland Fertility Group, Spring Hill, 4000, Australia
| | - William Ledger
- School of Women's and Children's Health, University of New South Wales, Sydney 2052, Australia
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13
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Harris K, Burley H, McLachlan R, Bowman M, Macaldowie A, Taylor K, Chapman M, Chambers GM. Socio-economic disparities in access to assisted reproductive technologies in Australia. Reprod Biomed Online 2016; 33:575-584. [PMID: 27595434 DOI: 10.1016/j.rbmo.2016.07.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 05/16/2016] [Accepted: 07/28/2016] [Indexed: 11/30/2022]
Abstract
Women from disadvantaged socio-economic groups access assisted reproductive technology treatment less than women from more advantaged groups. However, women from disadvantaged groups tend to start families younger, making them less likely to suffer from age-related subfertility and potentially have less need for fertility treatment. Whether socio-economic disparities in access to assisted reproductive technology treatment persist after controlling for the need for treatment, has not been previously explored. This population based study demonstrates that socio-economic disparities in access to assisted reproductive technology treatment persist after adjusting for several confounding factors, including age at first birth (used as a measure of delayed childbearing, hence a proxy for need for fertility treatment), geographic remoteness and Australian jurisdiction. Assisted reproductive technology access progressively decreased as socio-economic quintiles became more disadvantaged, with a 15.8% decrease in access in the most disadvantaged quintile compared with the most advantaged quintile after controlling for confounding factors. The adjusted rate of access to assisted reproductive technology treatment also decreased by 12.3% for women living in regional and remote areas compared with those in major cities. These findings indicate that financial and sociocultural barriers to assisted reproductive technology treatment remain in disadvantaged groups after adjusting for need.
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Affiliation(s)
- Katie Harris
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health and School of Women's and Children's Health UNSW, University of New South Wales, Sydney, Australia.
| | - Hugh Burley
- School of Biological, Earth and Environmental Sciences, University of New South Wales, Sydney, Australia; Commonwealth Scientific and Industrial Research Organisation (CSIRO), CSIRO Land and Water, Canberra, ACT, Australia
| | - Robert McLachlan
- Hudson Institute of Medical Research, Australia; Department of Endocrinology, Monash Medical Centre, Clayton, Australia; Andrology Australia, Alfred Hospital, Monash University School of Public Health, Prahran, Australia
| | - Mark Bowman
- Genea, Sydney, NSW, Australia; Department of Obstetrics and Gynaecology, University of Sydney, Australia
| | - Alan Macaldowie
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health and School of Women's and Children's Health UNSW, University of New South Wales, Sydney, Australia
| | - Kate Taylor
- Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia; Australian Fertility Medicine Foundation, Sydney, New South Wales, Australia
| | - Michael Chapman
- School of Women's and Children's Health UNSW, University of New South Wales, Sydney, Australia; St George Private Hospital, IVF Australia, Pty Ltd, Sydney, Australia
| | - Georgina Mary Chambers
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health and School of Women's and Children's Health UNSW, University of New South Wales, Sydney, Australia
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Tobias T, Sharara FI, Franasiak JM, Heiser PW, Pinckney-Clark E. Promoting the use of elective single embryo transfer in clinical practice. FERTILITY RESEARCH AND PRACTICE 2016; 2:1. [PMID: 28620526 PMCID: PMC5424309 DOI: 10.1186/s40738-016-0024-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 08/02/2016] [Indexed: 11/12/2022]
Abstract
Background The transfer of multiple embryos after in vitro fertilization (IVF) increases the risk of twins and higher-order births. Multiple births are associated with significant health risks and maternal and neonatal complications, as well as physical, emotional, and financial stresses that can strain families and increase the incidence of depression and anxiety disorders in parents. Elective single embryo transfer (eSET) is among the most effective methods to reduce the risk of multiple births with IVF. Main body Current societal guidelines recommend eSET for patients <35 years of age with a good prognosis, yet even this approach is not widely applied. Many patients and clinicians have been reluctant to adopt eSET due to studies reporting higher live birth rates with the transfer of two or more embryos rather than eSET. Additional barriers to eSET include risk of treatment dropout after embryo transfer failure, patient preference for twins, a lack of knowledge about the risks and complications associated with multiple births, and the high costs of multiple IVF cycles. This review provides a comprehensive summary of strategies to increase the rate of eSET, including personalized counseling, access to educational information regarding the risks of multiple pregnancies and births, financial incentives, and tools to help predict the chances of IVF success. The use of comprehensive chromosomal screening to improve embryo selection has been shown to improve eSET outcomes and may increase acceptance of eSET. Conclusions eSET is an effective method for reducing multiple pregnancies resulting from IVF. Although several factors may impede the adoption of eSET, there are a number of strategies and tools that may encourage the more widespread adoption of eSET in clinical practice.
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Affiliation(s)
- Tamara Tobias
- Seattle Reproductive Medicine, 1505 Westlake Ave North, Suite 400, Seattle, WA 98109 USA
| | - Fady I Sharara
- Virginia Center for Reproductive Medicine, 11150 Sunset Hills Rd, Suite #100, Reston, VA 20190 USA.,Department of Obstetrics and Gynecology, George Washington University, 2150 Pennsylvania Ave NW, Suite 6A 4169, Washington, DC 20037 USA
| | - Jason M Franasiak
- Division of Reproductive Endocrinology, Department of Obstetrics, Gynecology and Reproductive Sciences, Robert Wood Johnson Medical School, Rutgers University, 125 Paterson St, New Brunswick, NJ 08901 USA.,Reproductive Medicine Associates of New Jersey, 140 Allen Road, Basking Ridge, NJ 07920 USA
| | - Patrick W Heiser
- Ferring Pharmaceuticals, Inc., 100 Interpace Parkway, Parsippany, NJ 07054 USA
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15
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Mayes C, Blakely B, Kerridge I, Komesaroff P, Olver I, Lipworth W. On the fragility of medical virtue in a neoliberal context: the case of commercial conflicts of interest in reproductive medicine. THEORETICAL MEDICINE AND BIOETHICS 2016; 37:97-111. [PMID: 26935437 DOI: 10.1007/s11017-016-9353-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Social, political, and economic environments play an active role in nurturing professional virtue. Yet, these environments can also lead to the erosion of virtue. As such, professional virtue is fragile and vulnerable to environmental shifts. While physicians are often considered to be among the most virtuous of professional groups, concern has also always existed about the impact of commercial arrangements on physicians' willingness and capacity to enact their professional virtues. This article examines the ways in which commercial arrangements have been negotiated to secure medical virtue from real or perceived threats of erosion. In particular, we focus on the concern surrounding conflicts of interest arising from commercial arrangements that have developed as a result of neoliberal economic and social policies. The deregulation of medical markets and privatization of services have produced new commercial relationships that are often misunderstood by patients, publics, and physicians themselves. 'Conflicts of interest' policies have been introduced in an attempt to safeguard ethical conduct and medical practice. However, a number of virtue ethicists have critiqued these policies as inadequate for securing virtue. We examine the ways in which commercial arrangements have been seen to impact upon medical virtue, both historically and in the context of modern medicine (using the example of fertility services in Australia). We then describe and critique current efforts to restore clinical virtue through both conflict of interest policies and through virtue ethics. Finally, we suggest some possible ways of addressing the corrosive effects of neoliberalism on medical virtue.
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Affiliation(s)
- Christopher Mayes
- Centre for Values, Ethics and the Law in Medicine, Sydney School of Public Health, University of Sydney, Level 1, Medical Foundation Building, K25, Sydney, NSW, 2006, Australia.
| | - Brette Blakely
- Centre for Healthcare Resilience and Implementation Science (CHRIS), Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talevera Rd, Sydney, NSW, 2109, Australia
| | - Ian Kerridge
- Centre for Values, Ethics and the Law in Medicine, Sydney School of Public Health, University of Sydney, Level 1, Medical Foundation Building, K25, Sydney, NSW, 2006, Australia
| | - Paul Komesaroff
- Centre for Ethics in Medicine and Society, The Alfred Hospital, Monash University, Commercial Road, Prahran, VIC, 3181, Australia
| | - Ian Olver
- Division of Health Sciences, Sansom Institute for Health Research, University of South Australia, P5-06e Playford Building I City East Campus I, GPO Box 2471, Adelaide, SA, 5001, Australia
| | - Wendy Lipworth
- Centre for Values, Ethics and the Law in Medicine, Sydney School of Public Health, University of Sydney, Level 1, Medical Foundation Building, K25, Sydney, NSW, 2006, Australia
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16
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Hann SK, Kang HS. Infertile Women's Perception on the National Support Program for Infertile Couples. KOREAN JOURNAL OF WOMEN HEALTH NURSING 2015; 21:171-183. [PMID: 37684822 DOI: 10.4069/kjwhn.2015.21.3.171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 06/15/2015] [Accepted: 07/22/2015] [Indexed: 09/10/2023] Open
Abstract
PURPOSE The purpose of this study was to explore the perception of infertile women on the use of the national support program that provides medical expense aid to infertile couples. METHODS Thirty Korean infertile women participated in five focus groups. Data were collected from January to August 2014. After obtaining permission from the participants, each session of the focus group was audio-taped and transcribed. The responses were analyzed using qualitative content analysis. RESULTS The main themes identified from the sessions with the participants were "feeling thankful for the reliable support program," "feeling happy or unhappy," "enduring inconveniences," and "hoping for a more comprehensive support service." Although most of the participants perceived the benefits of the national support service positively, they stated that the service was not comprehensive because it did not cover all the medical expenses for tests and other medical treatments. CONCLUSION The benefits given to infertile couples by the program should be increased by covering all the medical expenses, expanding its criteria to include more eligible candidates, and by including special leave benefits for working women. Furthermore, it is essential to take measures for infertility prevention at the individual and national policy levels.
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Affiliation(s)
- Soo Kyoung Hann
- Red Cross College of Nursing, Chung-Ang University, Seoul, Korea
| | - Hee Sun Kang
- Red Cross College of Nursing, Chung-Ang University, Seoul, Korea
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17
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van Heesch MMJ, 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. Hospital costs during the first 5 years of life for multiples compared with singletons born after IVF or ICSI. Hum Reprod 2015; 30:1481-90. [PMID: 25840426 DOI: 10.1093/humrep/dev059] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 02/13/2015] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION Do in vitro fertilization (IVF) multiples generate higher hospital costs than IVF singletons, from birth up to age 5? SUMMARY ANSWER Hospital costs from birth up to age 5 were significantly higher among IVF/ICSI multiple children compared with IVF/ICSI singletons; however, when excluding the costs incurred during the birth admission period, hospital costs of multiples and singletons were comparable. WHAT IS KNOWN ALREADY Concern has risen over the long-term outcome of children born after IVF. The increased incidence of multiple births in IVF as a result of double-embryo transfer predisposes children to a poorer neonatal outcome such as preterm birth and low birthweight. As a consequence, IVF multiples require more medical care. Costs and consequences of poorer neonatal outcomes in multiples may also exist later in life. STUDY DESIGN, SIZE, DURATION All 5497 children born from IVF in 2003-2005, whose parents received IVF or ICSI treatment in one of five participating Dutch IVF centers, served as a basis for a retrospective cohort study. Based on gestational age, birthweight, Apgar and congenital malformation, children were assigned to one of three risk strata (low-, moderate- or high-risk). PARTICIPANTS/MATERIALS, SETTING, METHODS To enhance the efficiency of the data collection, 816 multiples and 584 singletons were selected for 5-year follow-up based on stratified (risk) sampling. Parental informed consent was received of 322 multiples and 293 singletons. Individual-level hospital resource use data (hospitalization, outpatient visits and medical procedures) were retrieved from hospital information systems and patient charts for 302 multiples and 278 singletons. MAIN RESULTS AND THE ROLE OF CHANCE The risk of hospitalization (OR 4.9, 95% CI 3.3-7.0), outpatient visits (OR 2.6, 95% CI 1.8-3.6) and medical procedures (OR 1.7, 95% CI 1.2-2.2) was higher for multiples compared with singletons. The average hospital costs amounted to €10 018 and €2093 during the birth admission period (P < 0.001), €1131 and €696 after the birth admission period to the first birthday (not significant (n.s.)) and €1084 and €938 from the second to the fifth life year (n.s.) for multiples and singletons, respectively. Hospital costs from birth up to age 5 were 3.3-fold higher for multiples compared with singletons (P < 0.001). Among multiples and singletons, respectively, 90.8 and 76.2% of the total hospital costs were caused by hospital admission days and 8.9 and 25.2% of the total hospital costs during the first 5 years of life occurred after the first year of life. LIMITATIONS, REASONS FOR CAUTION Resource use and costs outside the hospital were not included in the analysis. WIDER IMPLICATIONS OF THE FINDINGS This study confirms the increased use of healthcare resources by IVF/ICSI multiples compared with IVF/ICSI singletons. Single-embryo transfer may result in substantial savings, particularly in the birth admission period. These savings need to be compared with the extra costs of additional embryo transfers needed to achieve a successful pregnancy. Besides costs, health outcomes of children born after single-embryo transfer should be compared with those born after double-embryo transfer. 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, Maastricht 6202 AZ, The Netherlands
| | - J L H Evers
- Department of Obstetrics and Gynecology, Maastricht University Medical Center, PO Box 5800, Maastricht 6202 AZ, The Netherlands GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, PO Box 5800, Maastricht 6202 AZ, The Netherlands
| | - M A H B M van der Hoeven
- Department of Neonatology, Maastricht University Medical Center, PO Box 5800, Maastricht 6202 AZ, The Netherlands
| | - J C M Dumoulin
- Department of Obstetrics and Gynecology, Maastricht University Medical Center, PO Box 5800, Maastricht 6202 AZ, The Netherlands GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, PO Box 5800, Maastricht 6202 AZ, The Netherlands
| | - C E M van Beijsterveldt
- Department of Biological Psychology, VU University, Van der Boechorststraat 1, Amsterdam 1081 BT, The Netherlands
| | - G J Bonsel
- Department of Obstetrics and Prenatal Medicine, Erasmus Medical Center, PO Box 2040, Rotterdam 3000 CA, The Netherlands Midwifery Academy Rotterdam, Rochussenstraat 198, Rotterdam 3015 EK, The Netherlands Department of Public Health, Erasmus Medical Center, PO Box 2040, Rotterdam 3000 CA, The Netherlands
| | - R H M Dykgraaf
- Department of Obstetrics and Gynecology, Erasmus Medical Center, PO Box 2040, Rotterdam 3000 CA, The Netherlands
| | - J B van Goudoever
- Department of Pediatrics, Emma Children's Hospital, Academic Medical Center, PO Box 22660, Amsterdam 1100 DD, The Netherlands Department of Pediatrics, VU University Medical Center, PO Box 7057, Amsterdam 1007 MB, The Netherlands
| | - C Koopman-Esseboom
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, PO Box 85090, Utrecht 3508 AB, The Netherlands
| | - W L D M Nelen
- Department of Obstetrics and Gynecology, Radboud University Medical Center, PO Box 9101, Nijmegen 6500 HB, The Netherlands
| | - K Steiner
- Department of Neonatology, Radboud University Medical Center, PO Box 9101, Nijmegen 6500 HB, The Netherlands
| | - P Tamminga
- Department of Neonatology, Emma Children's Hospital, Academic Medical Center, PO Box 22660, Amsterdam 1100 DD, The Netherlands
| | - N Tonch
- Academic Medical Center, Center of Reproductive Medicine, PO Box 22660, Amsterdam 1100 DD, The Netherlands
| | - H L Torrance
- Department of Reproductive Medicine, University Medical Center Utrecht, PO Box 85090, Utrecht 3508 AB, The Netherlands
| | - C D Dirksen
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, PO Box 5800, Maastricht 6202 AZ, The Netherlands
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18
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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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Kissin DM, Kulkarni AD, Mneimneh A, Warner L, Boulet SL, Crawford S, Jamieson DJ. Embryo transfer practices and multiple births resulting from assisted reproductive technology: an opportunity for prevention. Fertil Steril 2015; 103:954-61. [PMID: 25637480 PMCID: PMC4607049 DOI: 10.1016/j.fertnstert.2014.12.127] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 12/16/2014] [Accepted: 12/30/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To evaluate assisted reproductive technology (ART) ET practices in the United States and assess the impact of these practices on multiple births, which pose health risks for both mothers and infants. DESIGN Retrospective cohort analysis using the National ART Surveillance System data. SETTING US fertility centers reporting to the National ART Surveillance System. PATIENT(S) Noncanceled ART cycles conducted in the United States in 2012. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Multiple birth (birth of two or more infants, at least one of whom was live-born). RESULT(S) Of 134,381 ART transfer cycles performed in 2012, 51,262 resulted in live births, of which 13,563 (26.5%) were multiple births: 13,123 twin and 440 triplet and higher order births. Almost half (46.1%) of these multiple births resulted from the following four cycle types: two fresh blastocyst transfers among favorable or average prognosis patients less than 35 years (1,931 and 1,341 multiple births, respectively), two fresh blastocyst transfers among donor-oocyte recipients (1,532 multiple births), and two frozen/thawed ETs among patients less than 35 years (1,452 multiple births). More than half of triplet or higher order births resulted from the transfer of two embryos (52.5% of births among fresh autologous transfers, 67.2% of births among donor-oocyte recipient transfers, and 42.9% among frozen/thawed autologous transfers). CONCLUSION(S) A substantial reduction of ART-related multiple (both twin and triplet or higher order) births in the United States could be achieved by single blastocyst transfers among favorable and average prognosis patients less than 35 years of age and donor-oocyte recipients.
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Affiliation(s)
- Dmitry M Kissin
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Aniket D Kulkarni
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Allison Mneimneh
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lee Warner
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sheree L Boulet
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sara Crawford
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Denise J Jamieson
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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Xu XK, Wang YA, Li Z, Lui K, Sullivan EA. Risk factors associated with preterm birth among singletons following assisted reproductive technology in Australia 2007-2009--a population-based retrospective study. BMC Pregnancy Childbirth 2014; 14:406. [PMID: 25481117 PMCID: PMC4266897 DOI: 10.1186/s12884-014-0406-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 11/27/2014] [Indexed: 11/25/2022] Open
Abstract
Background Preterm birth, a leading cause of neonatal death, is more common in multiple births and thus there has being an increasing call for reducing multiple births in ART. However, few studies have compared risk factors for preterm births amongst ART and non-ART singleton birth mothers. Methods A population-based study of 393,450 mothers, including 12,105 (3.1%) ART mothers, with singleton gestations born between 2007 and 2009 in 5 of the 8 jurisdictions in Australia. Univariable and multivariable logistic regression models were conducted to evaluate socio-demographic, medical and pregnancy factors associated with preterm births in contrasting ART and non-ART mothers. Results Ten percent of singleton births to ART mothers were preterm compared to 6.8% for non-ART mothers (P < 0.01). Compared with non-ART mothers, ART mothers were older (mean 34.0 vs 29.7 yr respectively), less socio-economically disadvantaged (12.4% in the lowest quintile vs 20.7%), less likely to be smokers (3.8% vs 19.4%), more likely to be first time mothers (primiparous 62.4% vs 40.5%), had more preexisting hypertension and complications during pregnancy. Irrespective of the mode of conception, preexisting medical and pregnancy complications of hypertension, diabetes and antepartum hemorrhages were consistently associated with preterm birth. In contrast, socio-demographic variables, namely young and old maternal age (<25 and >34), socioeconomic disadvantage (most disadvantaged quintile Odds Ratio (OR) 0.95, 95% Confidence Interval (CI): 0.77–1.17), smoking (OR 1.12, 95%CI: 0.79–1.61) and priminarity (OR 1.19, 95% CI: 1.05–1.35, AOR not significant) shown to be associated with elevated risk of preterm birth for non-ART mothers were not demonstrated for ART mothers, even after adjusting for potential confounders. Nonetheless, in multivariable analysis, the association between ART and the elevated risk for singleton preterm birth persisted after controlling for all included confounding medical, pregnancy and socio-economic factors (AOR 1.51, 95% CI: 1.42–1.61). Conclusions Preterm birth rate is approximately one-and-a-half-fold higher in ART mothers than non-ART mothers albeit for singleton births after controlling for confounding factors. However, ART mothers were less subject to the adverse influence from socio-demographic factors than non-ART mothers. This has implications for counselling prospective parents.
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Affiliation(s)
- Xu K Xu
- School of Medical Sciences, University of New South Wales, Kensington Campus, Sydney, NSW, 2052, Australia.
| | - Yueping A Wang
- School of Women's and Children's Health, University of New South Wales, Randwick Hospitals Campus, Sydney, NSW, 2031, Australia. .,Faculty of Health, University of Technology Sydney, City Campus, Sydney, NSW, 2007, Australia.
| | - Zhuoyang Li
- School of Women's and Children's Health, University of New South Wales, Randwick Hospitals Campus, Sydney, NSW, 2031, Australia. .,Faculty of Health, University of Technology Sydney, City Campus, Sydney, NSW, 2007, Australia.
| | - Kei Lui
- School of Women's and Children's Health, University of New South Wales, Randwick Hospitals Campus, Sydney, NSW, 2031, Australia. .,Department of Newborn Care, Royal Hospital for Women, Sydney, NSW, 2031, Australia.
| | - Elizabeth A Sullivan
- School of Women's and Children's Health, University of New South Wales, Randwick Hospitals Campus, Sydney, NSW, 2031, Australia. .,Faculty of Health, University of Technology Sydney, City Campus, Sydney, NSW, 2007, Australia.
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Stafford-Bell MA, Everingham SG, Hammarberg K. Outcomes of surrogacy undertaken by Australians overseas. Med J Aust 2014; 201:330-3. [PMID: 25222456 DOI: 10.5694/mja14.01086] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 08/20/2014] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To describe the outcomes of surrogacy among Australian intended parents who engage in compensated surrogacy overseas. DESIGN, SETTING AND PARTICIPANTS Members of two Australian parenting support forums who were considering surrogacy or were currently or previously in a surrogacy arrangement were invited to complete an anonymous online survey during July 2013. MAIN OUTCOME MEASURES Destination countries; source of eggs; number of surrogates and embryo transfers; proportions who experienced pregnancy loss after 12 weeks' gestation, multiple pregnancy, prematurity, and live birth by destination country; and intentions regarding disclosure to children about the way they were conceived. RESULTS Of 1135 potential participants 259 (23%) completed the survey. Of these, 112 (43%) had undertaken at least one surrogacy attempt overseas. India and the United States were the two most common destination countries. Most respondents (95/112; 85%) had used donor eggs; half (57/112; 51%) had used more than one surrogate; and the mean number of embryo transfer procedures was 2.9. As a result of surrogacy, 85% (95/112) had at least one child; 55% (62/112) reported that their surrogate had a multiple pregnancy; 10% (11/112) reported that a pregnancy had ended in a late miscarriage or perinatal death; and 45% of births (35/78) were premature. Most respondents (80/112; 71%) were most comfortable with using an identity-release donor, and 87% (97/112) believed that this would also be in their child's best interests. Almost universally, parents were planning to disclose the use of a surrogate and/or a donor to their child. CONCLUSIONS Almost half of the intended parents via surrogacy who completed this survey had undertaken compensated surrogacy overseas; most of these used donor eggs, but few considered Australian donors. A high proportion of surrogates had multiple pregnancies and there was a high rate of premature birth. These adverse outcomes could be avoided if the surrogacy was undertaken in Australia. Removing some of the existing barriers to surrogacy in Australia may reduce the number of surrogacy arrangements carried out overseas.
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Affiliation(s)
| | | | - Karin Hammarberg
- Jean Hailes Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Abstract
Despite the development of in vitro fertilization (IVF) more than 30 years ago, the cost of treatment remains high. Furthermore, over the years, more sophisticated technologies and expensive medications have been introduced, making IVF increasingly inaccessible despite the increasing need. Globally, the option to undergo IVF is only available to a privileged few. In recent years, there has been growing interest in exploring strategies to reduce the cost of IVF treatment, which would allow the service to be provided in low-resource settings. In this review, we explore the various ways in which the cost of this treatment can be reduced.
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Affiliation(s)
- Pek Joo Teoh
- Aberdeen Fertility Centre, Aberdeen Maternity Hospital, University of Aberdeen, Aberdeen, UK
| | - Abha Maheshwari
- Aberdeen Fertility Centre, Aberdeen Maternity Hospital, University of Aberdeen, Aberdeen, UK
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Abstract
The clinical risks to mothers and babies associated with assisted reproductive technology (ART) multiple birth pregnancies are well described and widely recognized. In contrast, the long-term economic consequences that follow are less appreciated. The few economic analyses that do exist consistently demonstrate the greater patient, healthcare and societal costs associated with twins and higher-order multiples when compared with singleton infants, and convincingly add to the argument that single embryo transfer should be standard practice in most patient groups. Several recent studies have shown that the relative price paid by patients for ART treatment not only has implications for who can afford to access treatment, but also plays an important role in incentivizing embryo transfer practices and thus ART multiple birth rates. This review summarizes the current literature on the costs and consequences of ART multiple births, the contribution of ART multiple births to the economic burden associated with preterm birth, the evidence for the cost-effectiveness of single embryo transfer, and the association between the cost of treatment and the downstream costs associated with multiple births.
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López-Regalado ML, Clavero A, Gonzalvo MC, Serrano M, Martínez L, Mozas J, Rodríguez-Serrano F, Fontes J, Castilla JA. Randomised clinical trial comparing elective single-embryo transfer followed by single-embryo cryotransfer versus double embryo transfer. Eur J Obstet Gynecol Reprod Biol 2014; 178:192-8. [DOI: 10.1016/j.ejogrb.2014.04.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 03/22/2014] [Accepted: 04/08/2014] [Indexed: 11/25/2022]
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Evans J, Hannan NJ, Edgell TA, Vollenhoven BJ, Lutjen PJ, Osianlis T, Salamonsen LA, Rombauts LJF. Fresh versus frozen embryo transfer: backing clinical decisions with scientific and clinical evidence. Hum Reprod Update 2014; 20:808-21. [PMID: 24916455 DOI: 10.1093/humupd/dmu027] [Citation(s) in RCA: 213] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Improvements in vitrification now make frozen embryo transfers (FETs) a viable alternative to fresh embryo transfer, with reports from observational studies and randomized controlled trials suggesting that: (i) the endometrium in stimulated cycles is not optimally prepared for implantation; (ii) pregnancy rates are increased following FET and (iii) perinatal outcomes are less affected after FET. METHODS This review integrates and discusses the available clinical and scientific evidence supporting embryo transfer in a natural cycle. RESULTS Laboratory-based studies demonstrate morphological and molecular changes to the endometrium and reduced responsiveness of the endometrium to hCG, resulting from controlled ovarian stimulation. The literature demonstrates reduced endometrial receptivity in controlled ovarian stimulation cycles and supports the clinical observations that FET reduces the risk of ovarian hyperstimulation syndrome and improves outcomes for both the mother and baby. CONCLUSIONS This review provides the basis for an evidence-based approach towards changes in routine IVF, which may ultimately result in higher delivery rates of healthier term babies.
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Affiliation(s)
- Jemma Evans
- Uterine Biology, Prince Henry's Institute of Medical Research, Clayton, VIC 3168, Australia Department of Physiology, Monash University, Clayton, VIC 3168, Australia
| | - Natalie J Hannan
- Uterine Biology, Prince Henry's Institute of Medical Research, Clayton, VIC 3168, Australia Department of Obstetrics and Gynaecology, University of Melbourne, Heidelberg, VIC 3084, Australia
| | - Tracey A Edgell
- Uterine Biology, Prince Henry's Institute of Medical Research, Clayton, VIC 3168, Australia
| | - Beverley J Vollenhoven
- Monash Health, Clayton, VIC 3168, Australia Monash IVF, Clayton, VIC 3168, Australia Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia
| | | | - Tiki Osianlis
- Monash Health, Clayton, VIC 3168, Australia Monash IVF, Clayton, VIC 3168, Australia Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia
| | - Lois A Salamonsen
- Uterine Biology, Prince Henry's Institute of Medical Research, Clayton, VIC 3168, Australia Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia
| | - Luk J F Rombauts
- Monash Health, Clayton, VIC 3168, Australia Monash IVF, Clayton, VIC 3168, Australia Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia
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An international survey of assisted reproductive technologies (ARTs) policies and the effects of these policies on costs, utilization, and health outcomes. Health Policy 2014; 116:238-63. [PMID: 24698476 DOI: 10.1016/j.healthpol.2014.03.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Revised: 02/07/2014] [Accepted: 03/07/2014] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The purpose of this study was to compare existing policies regarding access to 7 assisted reproductive technologies (ARTs) and to examine the effects of these policies on costs, utilization, and health outcomes in 14 countries and 2 Canadian provinces based on publicly available information. METHODS A systematic review of publicly available information from peer-reviewed literature (using biomedical and social science databases) and grey literature (e.g., health ministry websites, health technology assessment agency websites, etc.) was performed. RESULTS ARTs services permitted or funded vary across jurisdictions. The goals and eligibility restrictions (e.g., on maternal age, number of embryos transferred, and number of cycles) defined in ARTs policies also vary across jurisdictions. Studies on the impact of such policies have primarily been retrospective and focused on short-term service utilization. Nevertheless, they suggest that the policies have achieved specific outcomes, such as reductions in multiple births and in costs to payers. CONCLUSIONS Based on the evidence reviewed, policies aimed at reducing public coverage of ARTs or restricting the number of embryos transferred have achieved these goals. However, their effects on maternal and infant health outcomes have not been well explored.
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Aitken RJ. Age, the environment and our reproductive future: bonking baby boomers and the future of sex. Reproduction 2013; 147:S1-S11. [PMID: 24194569 DOI: 10.1530/rep-13-0399] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
There has never been a greater need for scientists trained in reproductive science. Most developed countries are witnessing unprecedented rates of recourse to assisted conception sitting cheek-by-jowl with high rates of induced abortion. This article addresses these two incongruous faces of reproductive healthcare. Every year at least 44 million abortions are performed worldwide, many under unsafe and insanitary conditions that carry a significant risk to the lives of women deprived of safe, effective methods for controlling their fertility. Although birth control is a complex issue involving myriad social and political factors, the technical vacuum in this area is significant. Through no fault of the family planning authorities, there have been no radically new methods of fertility control since the oral contraceptive pill was introduced in 1960 and even this contribution to planned parenthood has its roots in the biochemistry of the 1920s and 1930s. Moreover, the pharmaceutical industry has, by and large, turned its back on fundamental research activities in this area. At present, our major investment in reproductive healthcare involves treating ever-increasing numbers of couples with assisted reproductive technologies (ART). However, these treatments are often delivered without critically considering the underlying causes of this condition or seriously contemplating the long-term consequences of the current enthusiasm for such therapy. Significantly, the clinical factors underpinning the commitment of couples to ART include advanced maternal age and a variety of lifestyle factors, such as smoking and obesity, which are known to compromise the developmental potential of the oocyte and DNA integrity in spermatozoa.
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Affiliation(s)
- R John Aitken
- Discipline of Biological Sciences, Faculty of Science and IT, Hunter Medical Research Institute, Priority Research Centre in Reproductive Science, University of Newcastle, Newcastle, New South Wales 2308, Australia
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Chambers GM, Adamson GD, Eijkemans MJC. Acceptable cost for the patient and society. Fertil Steril 2013; 100:319-27. [PMID: 23905708 DOI: 10.1016/j.fertnstert.2013.06.017] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Revised: 06/08/2013] [Accepted: 06/10/2013] [Indexed: 11/18/2022]
Abstract
Alongside the debate around clinical, scientific, and ethical aspects of assisted reproductive technology (ART), there exists a parallel debate around the economics of ART treatment and what is the most appropriate funding framework for providing safe, equitable, and cost-effective treatment. The cost of ART treatment from a patient perspective exhibits striking differences worldwide due to the costliness of underlying health care systems and the level of public and third-party subsidization. These relative cost differences affect not only who can afford to access ART treatment but how ART is practiced in terms of embryo transfer practices; in turn significantly impacting the health outcomes and costs of caring for ART conceived children. Although empirical evidence indicates that ART treatment is "good value money" from a societal and patient perspective, the challenge remains to communicate this to policy makers, primarily because fertility treatments are not easily accommodated by traditional health economic methods. Furthermore, with global demand for ART treatment likely to increase, it is important that future funding decisions are informed by what has been learned about how costs and economic incentives influence equity of access and clinical practice. In this review we provide an international perspective on the costs and consequences of ART and summarize key economic considerations from the perspective of ART patients, providers, and society as a whole in the coming decade.
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Affiliation(s)
- Georgina M Chambers
- National Perinatal Epidemiology and Statistics Unit, School of Women's and Children's Health, University of New South Wales, Randwick Hospitals Campus, Sydney, New South Wales, Australia.
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Chambers GM, Hoang VP, Sullivan EA, Chapman MG, Ishihara O, Zegers-Hochschild F, Nygren KG, Adamson GD. The impact of consumer affordability on access to assisted reproductive technologies and embryo transfer practices: an international analysis. Fertil Steril 2013; 101:191-198.e4. [PMID: 24156958 DOI: 10.1016/j.fertnstert.2013.09.005] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Revised: 09/04/2013] [Accepted: 09/04/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To systematically quantify the impact of consumer cost on assisted reproduction technology (ART) utilization and numbers of embryos transferred. DESIGN Ordinary least squared (OLS) regression models were constructed to measure the independent impact of ART affordability-measured as consumer cost relative to average disposable income-on ART utilization and embryo transfer practices. SETTING Not applicable. PATIENT(S) Women undergoing ART treatment. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) OLS regression coefficient for ART affordability, which estimates the independent effect of consumer cost relative to income on utilization and number of embryos transferred. RESULT(S) ART affordability was independently and positively associated with ART utilization with a mean OLS coefficient of 0.032. This indicates that, on average, a decrease in the cost of a cycle of 1 percentage point of disposable income predicts a 3.2% increase in utilization. ART affordability was independently and negatively associated with the number of embryos transferred, indicating that a decrease in the cost of a cycle of 10 percentage points of disposable income predicts a 5.1% increase in single-embryo transfer cycles. CONCLUSION(S) The relative cost that consumers pay for ART treatment predicts the level of access and number of embryos transferred. Policies that affect ART funding should be informed by these findings to ensure equitable access to treatment and clinically responsible embryo transfer practices.
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Affiliation(s)
- Georgina M Chambers
- National Perinatal Epidemiology and Statistics Unit, School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia.
| | - Van Phuong Hoang
- National Perinatal Epidemiology and Statistics Unit, School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Elizabeth A Sullivan
- National Perinatal Epidemiology and Statistics Unit, School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Michael G Chapman
- School of Women's and Children's Health, Royal Hospital for Women, Sydney, New South Wales, Australia; IVF Australia, Sydney, New South Wales, Australia
| | - Osamu Ishihara
- Department of Obstetrics and Gynecology, Faculty of Medicine, Saitama Medical University, Moroyama, Saitama, Japan
| | - Fernando Zegers-Hochschild
- Clinica las Condes and Program of Ethics and Public Policies, University Diego Portales, Santiago, Chile
| | - Karl G Nygren
- Institute of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - G David Adamson
- Palo Alto Medical Foundation Fertility Physicians of Northern California, Palo Alto, California; Department of Gynecology and Obstetrics, Stanford University School of Medicine, Stanford, California; Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California
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Stillman RJ, Richter KS, Jones HW. Refuting a misguided campaign against the goal of single-embryo transfer and singleton birth in assisted reproduction. Hum Reprod 2013; 28:2599-607. [PMID: 23904468 DOI: 10.1093/humrep/det317] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Much recent progress has been made by assisted reproductive technology (ART) professionals toward minimizing the incidence of multiple pregnancy following ART treatment. While a healthy singleton birth is widely considered to be the ideal outcome of such treatment, a vocal minority continues a campaign to advocate the benefits of multiple embryo transfer as treatment and twin pregnancy as outcome for most ART patients. Proponents of twinning argue four points: that patients prefer twins, that multiple embryo transfer maximizes success rates, that the costs per infant are lower with twins and that one twin pregnancy and birth is associated with no higher risk than two consecutive singleton pregnancies and births. We find fault with the reasoning and data behind each of these tenets. First, we respect the principle of patient autonomy to choose the number of embryos for transfer but counter that it has been shown that better patient education reduces their desire for twins. In addition, reasonable and evidentially supported limits may be placed on autonomy in exchange for public or private insurance coverage for ART treatment, and counterbalancing ethical principles to autonomy exist, especially beneficence (doing good) and non-maleficence (doing no harm). Second, comparisons between success rates following single-embryo transfer (SET) and double-embryo transfers favor double-embryo transfers only when embryo utilization is not comparable; cumulative pregnancy and birth rates that take into account utilization of cryopreserved embryos (and the additional cryopreserved embryo available with single fresh embryo transfer) consistently demonstrate no advantage to double-embryo transfer. Third, while comparisons of costs are system dependent and not easy to assess, several independent studies all suggest that short-term costs per child (through the neonatal period alone) are lower with transfers of one rather than two embryos. And, finally, abundant evidence conclusively demonstrates that the risks to both mother and especially to children are substantially greater with one twin birth compared with two singleton births. Thus, the arguments used by some to promote multiple embryo transfer and twinning are not supported by the facts. They should not detract from efforts to further promote SET and thus reduce ART-associated multiple pregnancy and its inherent risks.
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Affiliation(s)
- Robert J Stillman
- Shady Grove Fertility Reproductive Science Center, 15001 Shady Grove Road, Rockville, MD 20850, USA
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31
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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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32
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Chambers GM, Wang YA, Chapman MG, Hoang VP, Sullivan EA, Abdalla HI, Ledger W. What can we learn from a decade of promoting safe embryo transfer practices? A comparative analysis of policies and outcomes in the UK and Australia, 2001-2010. Hum Reprod 2013; 28:1679-86. [DOI: 10.1093/humrep/det080] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Umstad MP, Hale L, Wang YA, Sullivan EA. Multiple deliveries: The reduced impact ofin vitrofertilisation in Australia. Aust N Z J Obstet Gynaecol 2013; 53:158-64. [DOI: 10.1111/ajo.12048] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 11/29/2012] [Indexed: 11/27/2022]
Affiliation(s)
- Mark P. Umstad
- Department of Obstetrics and Gynaecology; University of Melbourne; Multiple Pregnancy Clinic; Royal Women's Hospital; Melbourne; Victoria; Australia
| | - Lyndon Hale
- Melbourne IVF ; Gynaecologist Reproductive Services; Royal Women's Hospital; Melbourne; Victoria; Australia
| | - Yueping A. Wang
- Perinatal and Reproductive Epidemiology Research Unit; The University of New South Wales; Sydney; NSW; Australia
| | - Elizabeth A. Sullivan
- Perinatal and Reproductive Epidemiology Research Unit; The University of New South Wales; Sydney; NSW; Australia
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Abstract
OBJECTIVE To estimate the prevalence of major birth defects diagnosed by 6 years of age in all births and terminations of pregnancy for fetal anomaly conceived by assisted reproductive technology (when this included intracytoplasmic sperm injection and in vitro fertilization [IVF]) and the remainder of nonassisted reproductive technology-conceived children born in Western Australia from 1994 to 2002. METHODS This retrospective cohort study used data linkage between three population-based registers (Reproductive Technology Register, Western Australian Register of Developmental Anomalies, and Midwives' Notification of Birth System) to identify all assisted reproductive technology (n=2,911) and nonassisted reproductive technology (n=210,997) births with and without birth defects diagnosed by age 6 and all terminations of pregnancy for fetal anomaly. RESULTS A major birth defect was diagnosed in 8.7% of assisted reproductive technology and 5.4% of nonassisted reproductive technology singletons (odds ratio [OR] 1.53, 95% confidence interval [CI] 1.30-1.79), as well as 7.1% of assisted reproductive technology twins and 5.9% of nonassisted reproductive technology twins of unlike sex (OR 1.08, 95% CI 0.77-1.51). The prevalence of birth defects in assisted reproductive technology singletons and twins decreased markedly over the study period. This change was evident across all three clinics contributing data over the whole study and was particularly marked for children conceived as a result of IVF. CONCLUSION There has been a decrease in the prevalence of birth defects over time in children born as a result of assisted reproductive technology in Western Australia; however, the prevalence of major birth defects in assisted reproductive technology singletons remains increased compared with nonassisted reproductive technology singletons. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Nadia Badawi
- Macquarie Group Foundation, Cerebral Palsy Institute, University of Notre Dame, Sydney, New South Wales, Australia.
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A reduction in public funding for fertility treatment--an econometric analysis of access to treatment and savings to government. BMC Health Serv Res 2012; 12:142. [PMID: 22682009 PMCID: PMC3464128 DOI: 10.1186/1472-6963-12-142] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Accepted: 06/08/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Almost all assisted reproductive technology (ART) and intrauterine insemination (IUI) treatments performed in Australia are subsidized through the Australian Government's universal insurance scheme, Medicare. In 2010 restrictions on the amount Medicare paid in benefits for these treatments were introduced, increasing patient out-of-pocket payments for fresh and frozen embryo ART cycles and IUI. The aim of this study was to evaluate the impact of the policy on access to treatment, savings in Medicare benefits and the number of ART conceived children not born. METHODS Pooled quarterly cross-sectional Medicare data from 2007 and 2011 where used to construct a series of Ordinary Least Squares (OLS) regression models to evaluate the impact of the policy on access to treatment by women of different ages. Government savings in the 12 months after the policy was calculated as the difference between the predicted and observed Medicare benefits paid. RESULTS After controlling for underlying time trends and unobserved factors the policy change reduced the number of fresh embryo cycles by almost 8600 cycles over 12 months (a 16% reduction in cycles, p < 0.001). The policy effect was greatest on women aged 40 years and older (38% reduction in cycles, p < 0.001). Younger women engaged in relatively more anticipatory behaviour by bringing forward their fresh cycles to 2009. Frozen embryo cycles, which are approximately one quarter of the cost of a fresh cycle, were only marginally impacted by the policy. Utilisation of IUI cycles were not impacted by the policy. After adjusting for anticipatory behaviour, $76 million in Medicare benefits was saved in the 12 months after the policy change (0.47% of annual Medicare benefits). Between 1200 and 1500 ART conceived children were not born in 2010 as a consequence of the policy. CONCLUSIONS The introduction of the policy resulted in a significant reduction in fresh ART cycles in the first 15 months after its introduction. Further evaluation on the long-term impact of the policy with regard access to treatment and on clinical practice, particularly the number of embryos transferred, is crucial to ensuring equitable access to fertility treatment and the health and welfare of ART children.
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