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Chung EH, Lim SL, Myers E, Moss HA, Acharya KS. Oocyte cryopreservation versus ovarian tissue cryopreservation for adult female oncofertility patients: a cost-effectiveness study. J Assist Reprod Genet 2021; 38:2435-2443. [PMID: 33977465 PMCID: PMC8490495 DOI: 10.1007/s10815-021-02222-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 05/06/2021] [Indexed: 10/21/2022] Open
Abstract
PURPOSE In December 2019, the American Society for Reproductive Medicine designated ovarian tissue cryopreservation (OTC) as no longer experimental and an alternative to oocyte cryopreservation (OC) for women receiving gonadotoxic therapy. Anticipating increased use of OTC, we compare the cost-effectiveness of OC versus OTC for fertility preservation in oncofertility patients. METHODS A cost-effectiveness model to compare OC versus OTC was built from a payer perspective. Costs and probabilities were derived from the literature. The primary outcome for effectiveness was the percentage of patients who achieved live birth. Strategies were compared using incremental cost-effectiveness ratios (ICER). All inputs were varied widely in sensitivity analyses. RESULTS In the base case, the estimated cost for OC was $16,588 and for OTC $10,032, with 1.56% achieving live birth after OC, and 1.0% after OTC. OC was more costly but more effective than OTC, with an ICER of $1,163,954 per live birth. In sensitivity analyses, OC was less expensive than OTC if utilization was greater than 63%, cost of OC prior to chemotherapy was less than $8100, cost of laparoscopy was greater than $13,700, or standardized discounted costs were used. CONCLUSIONS With current published prices and utilization, OC is more costly but more effective than OTC. OC becomes cost-saving with increased utilization, when cost of OC prior to chemotherapy is markedly low, cost of laparoscopy is high, or standardized discounted oncofertility pricing is assumed. We identify the critical thresholds of OC and OTC that should be met to deliver more cost-effective care for oncofertility patients.
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Affiliation(s)
- Esther H Chung
- Division of Reproductive Endocrinology & Infertility, Department of Obstetrics and Gynecology, Duke Fertility Center, Duke University, 200 Trent Drive (Baker House 236), Durham, NC, 27713, USA.
| | - Stephanie L Lim
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University, Durham, NC, 27710, USA
| | - Evan Myers
- Division of Women's Community and Population Health, Department of Obstetrics and Gynecology, Duke University, Durham, NC, 27710, USA
| | - Haley A Moss
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University, Durham, NC, 27710, USA
| | - Kelly S Acharya
- Division of Reproductive Endocrinology & Infertility, Department of Obstetrics and Gynecology, Duke Fertility Center, Duke University, 200 Trent Drive (Baker House 236), Durham, NC, 27713, USA
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Affiliation(s)
- Erica C Kaye
- From St. Jude Children's Research Hospital, Memphis, TN
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Liu Y, Su R, Wu Y. Cumulative Live Birth Rate and Cost-Effectiveness Analysis of Gonadotropin Releasing Hormone-Antagonist Protocol and Multiple Minimal Ovarian Stimulation in Poor Responders. Front Endocrinol (Lausanne) 2020; 11:605939. [PMID: 33519714 PMCID: PMC7841408 DOI: 10.3389/fendo.2020.605939] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 11/30/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The overall cumulative live birth rate (CLBR) of poor ovarian responders (POR) is extremely low. Minimal ovarian stimulation (MOS) provides a relatively realistic solution for ovarian stimulation in POR. Our study aimed to investigate whether multiple MOS strategies resulted in higher CLBR compared to conventional gonadotropin releasing hormone (GnRH) antagonists in POR. METHODS This retrospective study included 699 patients (1,058 cycles) from one center, who fulfilled the Bologna criteria between 2010 and 2018. Overall, 325 women (325 cycles) were treated with one-time conventional GnRH antagonist ovarian stimulation (GnRH-antagonist). Another 374 patients (733 cycles) were treated with multiple MOS including natural cycles. CLBR and time-and-cost-benefit analyses were compared between these two groups of women. RESULTS GnRH antagonists provided more retrieved oocytes, meiosis II oocytes, fertilized oocytes, and more viable embryos compared to both the first MOS (p < 0.001) and the cumulative corresponding numbers in multiple MOSs (p < 0.001). For the first in vitro fertilization (IVF) cycle, GnRH antagonists resulted in higher CLBR than MOS [12.92 versus 4.54%, adjusted OR (odds ratio) 2.606; 95% CI (confidence interval) 1.386, 4.899, p = 0.003]. The one-time GnRH-antagonist induced comparable CLBR (12.92 versus 7.92%, adjusted OR 1.702; 95% CI 0.971, 2.982, p = 0.063), but a shorter time to live birth [9 (8, 10.75) months versus 11 (9, 14) months, p = 0.014] and similar financial expenditure compared to repeated MOS [20,838 (17,953, 23,422) ¥ versus 21,261.5 (15,892.5, 35,140.25) ¥, p = 0.13]. CONCLUSION Both minimal ovarian stimulation (MOS) and GnRH-antagonists provide low chances of live birth in poor responders. The GnRH antagonist protocol is considered a suitable choice for PORs with comparable CLBR, shorter times to live birth, and similar financial expenditure compared to repeated MOS.
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Affiliation(s)
- Yuan Liu
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Rongjia Su
- Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yu Wu
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- *Correspondence: Yu Wu,
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Ludwin A, Ludwin I, Coelho Neto MA, Nastri CO, Bhagavath B, Lindheim SR, Martins WP. Septate uterus according to ESHRE/ESGE, ASRM and CUME definitions: association with infertility and miscarriage, cost and warnings for women and healthcare systems. Ultrasound Obstet Gynecol 2019; 54:800-814. [PMID: 30977223 DOI: 10.1002/uog.20291] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 03/05/2019] [Accepted: 04/03/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To estimate the differences in frequency of diagnosis of septate uterus using three different definitions and determine whether these differences are significant in clinical practice, and to examine the association between diagnosis of septate uterus, using each of the three definitions, and infertility and/or previous miscarriage as well as the cost of allocation to surgery. METHODS This was a secondary analysis of data from a prospective study of 261 consecutive women of reproductive age attending a private clinic focused on the diagnosis and treatment of congenital uterine malformations. Reanalysis of the datasets was performed according to three different means of defining septate uterus: following the recommendations of the American Society for Reproductive Medicine (ASRM), a 2016 update of those of the American Fertility Society from 1988 (ASRM-2016: internal fundal indentation depth ≥ 1.5 cm, angle of internal indentation < 90° and external indentation depth < 1 cm); following the recommendations of the European Society of Human Reproduction and Embryology/European Society for Gynaecological Endoscopy (ESHRE/ESGE), published in 2013 and reaffirmed in 2016 (ESHRE/ESGE-2016: internal fundal/uterine indentation depth > 50% of uterine-wall thickness and external indentation depth < 50% of uterine-wall thickness, with uterine-wall thickness measured above interostial/intercornual line); and using a definition published last year which was based on the decision made most often by a group of experts (Congenital Uterine Malformation by Experts; CUME) (CUME-2018: internal fundal indentation depth ≥ 1 cm and external fundal indentation depth < 1 cm). We compared the rate of diagnosis of septate uterus using each of these three definitions and, for each, we estimated the association between the diagnosis and infertility and/or previous miscarriage, and anticipated the costs associated with their implementation using a guesstimation method. RESULTS Although 32.6% (85/261) of the subjects met the criteria for one of the three definitions of septate uterus, only 2.7% (7/261) of them were defined as having septate uterus according to all three definitions. We diagnosed significantly more cases of septate uterus using ESHRE/ESGE-2016 than using ASRM-2016 (31% vs 5%, relative risk (RR) = 6.7, P < 0.0001) or CUME-2018 (31% vs 12%, RR = 2.6, P < 0.0001) criteria. We also observed frequent cases that could not be classified definitively by ASRM-2016 (gray zone: neither normal/arcuate nor septate; 6.5%). There were no significant differences (P > 0.05) in the prevalence of septate uterus in women with vs those without infertility according to ASRM-2016 (5% vs 4%), ESHRE/ESGE-2016 (35% vs 28%) or CUME-2018 (11% vs 12%). Septate uterus was diagnosed significantly more frequently in women with vs those without previous miscarriage according to ASRM-2016 (11% vs 3%; P = 0.04) and CUME-2018 (22 vs 10%; P = 0.04), but not according to ESHRE/ESGE-2016 (42% vs 28%; P = 0.8) criteria. Our calculations showed that global costs to the healthcare system would be highly dependent on the criteria used in the clinical setting to define septate uterus, with the costs associated with the ESHRE/ESGE-2016 definition potentially being an extra US$ 100-200 billion over 5 years in comparison to ASRM-2016 and CUME-2018 definitions. CONCLUSIONS The prevalence of septate uterus according to ESHRE/ESGE-2016, ASRM-2016 and CUME-2018 definitions differs considerably. An important limitation of the ASRM classification, which needs to be addressed, is the high proportion of unclassifiable cases originally named, by us, the 'gray zone'. The high rate of overdiagnosis of septate uterus according to ESHRE/ESGE-2016 may lead to unnecessary surgery and therefore unnecessary risk in these women and may impose a considerable financial burden on healthcare systems. Efforts to define clinically meaningful and universally applicable criteria for the diagnosis of septate uterus should be encouraged. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland
- Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland
| | - I Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland
- Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland
| | - M A Coelho Neto
- Department of Obstetrics and Gynecology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - C O Nastri
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
| | - B Bhagavath
- Department of Obstetrics and Gynecology, School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, NY, USA
| | - S R Lindheim
- Department of Obstetrics and Gynecology, Wright State University, Boonshoft School of Medicine, Dayton, OH, USA
- Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - W P Martins
- Department of Obstetrics and Gynecology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
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Pan W, Tu H, Jin L, Hu C, Li Y, Wang R, Huang W, Liao S. Decision analysis about the cost-effectiveness of different in vitro fertilization-embryo transfer protocol under considering governments, hospitals, and patient. Medicine (Baltimore) 2019; 98:e15492. [PMID: 31083186 PMCID: PMC6531099 DOI: 10.1097/md.0000000000015492] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE The aim of this study was to explore the benefits of in vitro fertilization (IVF) for patients and hospitals under different protocols and if IVF treatment should be incorporated into health care. PERSPECTIVE The government should consider including IVF treatment in health insurance. Hospitals and patients could obtain the best benefit by following the hospital's recommended protocol. SETTING This retrospective study was conducted from January 2014 to August 2017 at an academic hospital. METHODS A total of 7440 patients used gonadotropin-releasing hormone agonists (GnRHa) protocol, 2619 patients used, gonadotropin-releasing hormone antagonists (GnRHant) protocol, and 1514 patients used GnRHa ultra-long protocol. Primary outcomes were live birth rate (LBR), cost-effectiveness, hospital revenue, and government investment. RESULTS The cycle times for the GnRHa protocol and the GnRHa ultra-long protocol were significantly higher than the GnRHant protocol. Patients who were ≤29 years chose the GnRHant protocol. The cost of a successful cycle was 67,579.39 ± 9,917.55 ¥ and LBR was 29.25%. Patients who were >30 years had the GnRHa protocol as the dominant strategy, as it was more effective at lower costs and higher LBR. When patients were >30 to ≤34 years, the cost of a successful cycle was 66,556.7 ± 8,448.08 ¥ and the LBR was 31.05%. When patients were >35 years, the cost of a successful cycle was 83,297.92 ± 10,918.05 ¥ and the LBR was 25.07%. The government reimbursement for a cycle ranged between 11,372.12 ± 2,147.71 ¥ and 12,753.67 ± 1,905.02 ¥. CONCLUSIONS The government should consider including IVF treatment in health insurance. Hospitals recommend the GnRHant protocol for patients <29 years old and the GnRHa protocol for patients >30 years old, to obtain the best benefits. Patients could obtain the best benefit by using the protocol recommended by the hospital.
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Affiliation(s)
- Wei Pan
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei
- School of Economic and Management, Wuhan University, Wuhan
- Management Science and Data Analytics Research Center, Wuhan University, Wuhan, China
| | - Haiting Tu
- School of Economic and Management, Wuhan University, Wuhan
- Management Science and Data Analytics Research Center, Wuhan University, Wuhan, China
| | - Lei Jin
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei
| | - Cheng Hu
- School of Economic and Management, Wuhan University, Wuhan
- Management Science and Data Analytics Research Center, Wuhan University, Wuhan, China
| | - Yuehan Li
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei
| | - Renjie Wang
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei
| | - Weiming Huang
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei
| | - ShuJie Liao
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei
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Abstract
Claims about whether or not infertility is a disease are sometimes invoked to defend or criticize the provision of state-funded treatment for infertility. In this paper, I suggest that this strategy is problematic. By exploring infertility through key approaches to disease in the philosophy of medicine, I show that there are deep theoretical disagreements regarding what subtypes of infertility qualify as diseases. Given that infertility's disease status remains unclear, one cannot uncontroversially justify or undermine its claim to medical treatment by claiming that it is or is not a disease. Instead of focusing on disease status, a preferable strategy to approach the debate about state-funded treatment is to explicitly address the specific ethical considerations raised by infertility. I show how this alternative strategy can be supported by a recent theoretical framework in the philosophy of medicine which avoids the problems associated with the concepts of health and disease.
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Affiliation(s)
- Hane Htut Maung
- Department of PhilosophySchool of Social SciencesUniversity of ManchesterManchesterUnited Kingdom
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Hamilton BH, Jungheim E, McManus B, Pantano J. Health Care Access, Costs, and Treatment Dynamics: Evidence from In Vitro Fertilization. Am Econ Rev 2018; 108:3725-3777. [PMID: 30497124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
We study public policies designed to improve access and reduce costs for in vitro fertilization (IVF). High out-of-pocket prices can deter potential patients from IVF, while active patients have an incentive to risk costly high-order pregnancies to improve their odds of treatment success. We analyze IVF's rich choice structure by estimating a dynamic model of patients' choices within and across treatments. Policy simulations show that insurance mandates for treatment or hard limits on treatment aggressiveness can improve access or costs, but not both. Insurance plus price-based incentives against risky treatment, however, can together improve patient welfare and reduce medical costs.
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Affiliation(s)
| | - Emily Jungheim
- School of Medicine, Washington University, St. Louis, MO
| | | | - Juan Pantano
- Department of Economics, Stony Brook University, Stony Brook, NY
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Sundheimer LW, Kathiresan A, Dumesic D, Parvataneni R, Shamonki M. Cost-Benefit Analysis of Hysteroscopic Polypectomy Before Controlled Ovarian Hyperstimulation and Intrauterine Insemination in Infertile Women. J Reprod Med 2017; 62:127-132. [PMID: 30230303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To examine the cost benefit of performing hysteroscopic polypectomy (HP) in infertile women with endometrial polyp(s) before controlled ovarian hyperstimulation with intrauterine insemination (COH/IUI). STUDY DESIGN Decision analytic model comparing costs and clinical outcomes. RESULTS HP and COH/IUI costs ranged from $537–$12,530 and $800–$7,600, respectively. Performing an HP before COH/IUI lowered fertility cost by $7,652 per clinical pregnancy. When COH/IUI costs remained constant, HP was most cost beneficial when the cost of HP was below a threshold value of $9,452. When HP costs remained constant, the threshold value at which HP was no longer cost beneficial was at COH/IUI costs below $704. The cost benefit was greatest when an office-based HP is performed. CONCLUSION HP before COH/IUI is more cost beneficial than fertility treatment alone, particularly when office-based hysteroscopy is performed.
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Abstract
Since 2000, 11 human uterine transplantation procedures (UTx) have been performed across Europe and Asia. Five of these have, to date, resulted in pregnancy and four live births have now been recorded. The most significant obstacles to the availability of UTx are presently scientific and technical, relating to the safety and efficacy of the procedure itself. However, if and when such obstacles are overcome, the most likely barriers to its availability will be social and financial in nature, relating in particular to the ability and willingness of patients, insurers or the state to pay. Thus, publicly funded healthcare systems such as the UK's National Health Service (NHS) will eventually have to decide whether UTx should be funded. With this in mind, we seek to provide an answer to the question of whether there exist any compelling reasons for the state not to fund UTx. The paper proceeds as follows. It assumes, at least for the sake of argument, that UTx will become sufficiently safe and cost-effective to be a candidate for funding and then asks, given that, what objections to funding there might be. Three main arguments are considered and ultimately rejected as providing insufficient reason to withhold funding for UTx. The first two are broad in their scope and offer an opportunity to reflect on wider issues about funding for infertility treatment in general. The third is narrower in scope and could, in certain forms, apply to UTx but not other assisted reproductive technologies (ARTs). The first argument suggests that UTx should not be publicly funded because doing so would be inconsistent with governments' obligations to prevent climate change and environmental pollution. The second claims that UTx does not treat a disorder and is not medically necessary. Finally, the third asserts that funding for UTx should be denied because of the availability of alternatives such as adoption and surrogacy.
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Affiliation(s)
- Stephen Wilkinson
- Department of Politics, Philosophy and Religion, Lancaster University, Lancaster, UK
| | - Nicola Jane Williams
- Department of Politics, Philosophy and Religion, Lancaster University, Lancaster, UK
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Abstract
The purpose of this article is to evaluate the extent to which single women have access to publicly funded fertility treatment. It claims that, despite the fact that great progress has been made in removing gender inequalities in the area of assisted reproduction in England and Wales in recent years, there are points in the regulatory framework that still allow for discrimination against single women. The article builds on recent studies concerning the reforms brought about by the Human Fertilisation and Embryology Act 2008 (HFEA 2008). However, it focusses on publicly funded treatment, thus directing scholarly attention away from the controversies over the amended s 13(5) HFEA 1990. It argues that the primary reason for remaining inequalities can be traced back to (a) the limitations of the current legislative framework; (b) the ambiguities inherent in the regulatory framework, which in the context of publicly funded fertility treatment is determined by the National Institute for Health and Care Excellence clinical guidelines and Clinical Commissioning Groups and Health Boards' resource allocation policies; and (c) the remaining confusion about the relationship between 'welfare of the child' assessments and eligibility criteria in National Health Service rationing decisions. The article argues that the current regulation does not go far enough in acknowledging the inability of single women to conceive naturally, but at the same time that it struggles to address the fluidity of contemporary familial relationships. The analysis presents an opportunity to contribute to debates about the role of law in shaping the scope of reproductive autonomy, gender equality and social justice.
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Affiliation(s)
- Atina Krajewska
- Cardiff School of Law and Politics, Cardiff University, Law Building, Museum Avenue, CF10 3AX Cardiff, UK
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Abstract
OBJECTIVE To estimate the optimal age to pursue elective oocyte cryopreservation. DESIGN A decision-tree model was constructed to determine the success and cost-effectiveness of oocyte preservation versus no action when considered at ages 25-40 years, assuming an attempt at procreation 3, 5, or 7 years after initial decision. SETTING Not applicable. PATIENT(S) Hypothetical patients 25-40 years old presenting to discuss elective oocyte cryopreservation. INTERVENTION(S) Decision to cryopreserve oocytes from age 25 years to age 40 years versus taking no action. MAIN OUTCOME AND MEASURE(S) Probability of live birth after initial decision whether or not to cryopreserve oocytes. RESULT(S) Oocyte cryopreservation provided the greatest improvement in probability of live birth compared with no action (51.6% vs. 21.9%) when performed at age 37 years. The highest probability of live birth was seen when oocyte cryopreservation was performed at ages <34 years (>74%), although little benefit over no action was seen at ages 25-30 years (2.6%-7.1% increase). Oocyte cryopreservation was most cost-effective at age 37 years, at $28,759 per each additional live birth in the oocyte cryopreservation group. When the probability of marriage was included, oocyte cryopreservation resulted in little improvement in live birth rates. CONCLUSION(S) Oocyte cryopreservation can be of great benefit to specific women and has the highest chance of success when performed at an earlier age. At age 37 years, oocyte cryopreservation has the largest benefit over no action and is most cost-effective.
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Affiliation(s)
- Tolga B. Mesen
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, The University of North Carolina at Chapel Hill, Campus Box 7570, Chapel Hill, NC 27599, Telephone: 919-966-1390
| | - Jennifer E. Mersereau
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, The University of North Carolina at Chapel Hill, Campus Box 7570, Chapel Hill, NC 27599, Telephone: 919-966-1390
| | - Jennifer B. Kane
- Carolina Population Center, The University of North Carolina at Chapel Hill, Room 206, W. Franklin Street
| | - Anne Z. Steiner
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, The University of North Carolina at Chapel Hill, Campus Box 7570, Chapel Hill, NC 27599, Telephone: 919-966-1390
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Abstract
BACKGROUND The overall prevalence of infertility was estimated to be 3.5-16.7% in developing countries and 6.9-9.3% in developed countries. Furthermore, according to reports from some regions of sub-Saharan Africa, the prevalence rate is 30-40%. The consequences of infertility and how it affects the lives of women in poor-resource settings, particularly in developing countries, has become an important issue to be discussed in reproductive health. In some societies, the inability to fulfill the desire to have children makes life difficult for the infertile couple. In many regions, infertility is considered a tragedy that affects not only the infertile couple or woman, but the entire family. METHODS This is a position paper which encompasses a review of the needs of low-income infertile couples, mainly those living in developing countries, regarding access to infertility care, including ART and initiatives to provide ART at low or affordable cost. Information was gathered from the databases MEDLINE, CENTRAL, POPLINE, EMBASE, LILACS, and ICTRP with the key words: infertility, low income, assisted reproductive technologies, affordable cost, low cost. RESULTS There are few initiatives geared toward implementing ART procedures at low cost or at least at affordable cost in low-income populations. Nevertheless, from recent studies, possibilities have emerged for new low-cost initiatives that can help millions of couples to achieve the desire of having a biological child. CONCLUSIONS It is necessary for healthcare professionals and policymakers to take into account these new initiatives in order to implement ART in resource-constrained settings.
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Affiliation(s)
- Luis Bahamondes
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP Brazil
| | - Maria Y Makuch
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP Brazil
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Hershberger PE, Stevenson EL. In support of equitable infertility health insurance. J Obstet Gynecol Neonatal Nurs 2014; 43:401-2. [PMID: 24980203 DOI: 10.1111/1552-6909.12473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Farland LV, Missmer SA, Rich-Edwards J, Chavarro JE, Barbieri RL, Grodstein F. Use of fertility treatment modalities in a large United States cohort of professional women. Fertil Steril 2014; 101:1705-10. [PMID: 24746739 DOI: 10.1016/j.fertnstert.2014.03.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 02/21/2014] [Accepted: 03/11/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the use of fertility treatments among a large cohort of women in the United States. DESIGN Cohort study. SETTING Nurses' Health Study II. PATIENT(S) Ten thousand thirty-six women who reported having used fertility treatment on biennial questionnaires from 1993-2009. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Data on patterns of treatment modality were collected via self-report from validated mailed questionnaires. Information on clomiphene, gonadotropin injections alone, and gonadotropin injections as part of intrauterine insemination (IUI) and in vitro fertilization (IVF) was queried. RESULT(S) Most women who reported fertility treatment used clomiphene (94%), with a large majority reporting clomiphene as their only form of treatment (73%). Of women who reported treatment more advanced than clomiphene, 13% had used gonadotropin injections alone, 11% IUI treatment, and 11% IVF. Several subgroups were more likely to use multiple treatment modalities and to initiate treatment with gonadotropins rather than clomiphene, including women living in states with insurance coverage of fertility procedures, with higher household income, younger in age, who remained nulliparous at the study close, and treated after 2000. CONCLUSION(S) Results should be interpreted cautiously, but to our knowledge, this represents the first study of fertility treatment patterns in the United States and could inform public health planning.
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MESH Headings
- Adult
- Age Factors
- Clomiphene/therapeutic use
- Combined Modality Therapy
- Drug Utilization Review
- Female
- Fertility
- Fertility Agents, Female/economics
- Fertility Agents, Female/therapeutic use
- Fertilization in Vitro/statistics & numerical data
- Financing, Personal
- Gonadotropins/therapeutic use
- Health Care Surveys
- Humans
- Income
- Infertility, Female/diagnosis
- Infertility, Female/economics
- Infertility, Female/physiopathology
- Infertility, Female/therapy
- Insemination, Artificial/statistics & numerical data
- Insurance Coverage
- Nurses/economics
- Nurses/statistics & numerical data
- Parity
- Pregnancy
- Reproductive Techniques, Assisted/economics
- Reproductive Techniques, Assisted/statistics & numerical data
- Surveys and Questionnaires
- United States
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Affiliation(s)
- Leslie V Farland
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts.
| | - Stacey A Missmer
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts; Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Janet Rich-Edwards
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts; Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jorge E Chavarro
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts; Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts
| | - Robert L Barbieri
- Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Francine Grodstein
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts; Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Child T. Optimising the management of patients with infertility. Practitioner 2013; 257:19-3. [PMID: 23634635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The main causes of infertility are female factor (anovulation, tubal damage, endometriosis and ovarian failure), male factor (low or absent numbers of motile sperm in the ejaculate, and erectile dysfunction), or unexplained infertility. More than 80% of couples will conceive within one year if the woman is aged under 40 and they have regular sexual intercourse. Of those who fail to conceive in the first year, around half will do so in the second year, giving a cumulative pregnancy rate > 90%. A woman of reproductive age who has not conceived after a year of regular sexual intercourse, and has no known cause of infertility, should be offered referral for further clinical assessment and investigation with her partner. Women who have a BMI > or = 30 are likely to take longer to conceive. Those with a BMI < 19 who have irregular or absent menstruation should be advised that putting on weight is likely to improve their chance of conception. The best test of ovulation is an appropriately timed mid-luteal serum progesterone level. Women with irregular or absent menstrual cycles should be offered a blood test to measure serum gonadotrophin levels (FSH and LH). Women with no known comorbidities should be screened for tubal occlusion. Those who are thought to have comorbidities should be offered laparoscopy and dye testing.
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Affiliation(s)
- Tim Child
- Oxford Fertility Unit, University of Oxford, Oxford, UK
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Butts SF, Ratcliffe S, Dokras A, Seifer DB. Diagnosis and treatment of diminished ovarian reserve in assisted reproductive technology cycles of women up to age 40 years: the role of insurance mandates. Fertil Steril 2012; 99:382-8. [PMID: 23102859 DOI: 10.1016/j.fertnstert.2012.09.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Revised: 09/03/2012] [Accepted: 09/13/2012] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To explore correlates of diminished ovarian reserve (DOR) and predictors of assisted reproductive technologies (ART) treatment outcome in DOR cycles using the Society for Assisted Reproductive Technologies-Clinical Outcomes Reporting System (SART-CORS) database; we hypothesized that mandated state insurance coverage for ART is associated with the prevalence of DOR diagnosis in ART cycles and with treatment outcomes in DOR cycles. DESIGN Cross-sectional study using ART cycles between 2004 and 2007. SETTING Not applicable. PATIENT(S) A total of 182,779 fresh, nondonor, initial ART cycles in women up to age 40 years. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Prevalence of DOR and elevated FSH, odds ratio of DOR and elevated FSH in ART mandated vs. nonmandated states, live birth rates. RESULT(S) Compared with cycles performed in states with mandated ART coverage, cycles in states with no ART mandate were more likely to have DOR (adjusted odds ratio 1.43, 95% confidence interval 1.37-1.5) or elevated FSH (adjusted odds ratio 1.69, 95% confidence interval 1.56-1.85) as the sole reason for treatment. Lack of mandated ART coverage was associated with increased live birth rates in cycles diagnosed as DOR, but not in cycles characterized only by an elevated FSH. CONCLUSION(S) A significant association was observed between lack of mandated insurance for ART and the proportion of cycles treating DOR or elevated FSH. The presence or absence of state-mandated ART coverage could impact access to care and the mix of patients that pursue and initiate ART cycles in ways that influence these proportions. Additional studies are needed that consider the coalescence of insurance mandates, patient and provider factors, and state-level variables on the odds of specific infertility diagnoses and treatment prognosis.
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Affiliation(s)
- Samantha F Butts
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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Hakimi R. [Need for counseling in artificial insemination has increased by several 100%]. MMW Fortschr Med 2012; 154:34. [PMID: 22997939 DOI: 10.1007/s15006-012-1065-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Sills ES, Collins GS, Salem SA, Jones CA, Peck AC, Salem RD. Balancing selected medication costs with total number of daily injections: a preference analysis of GnRH-agonist and antagonist protocols by IVF patients. Reprod Biol Endocrinol 2012; 10:67. [PMID: 22935199 PMCID: PMC3447708 DOI: 10.1186/1477-7827-10-67] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Accepted: 08/27/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND During in vitro fertilization (IVF), fertility patients are expected to self-administer many injections as part of this treatment. While newer medications have been developed to substantially reduce the number of these injections, such agents are typically much more expensive. Considering these differences in both cost and number of injections, this study compared patient preferences between GnRH-agonist and GnRH-antagonist based protocols in IVF. METHODS Data were collected by voluntary, anonymous questionnaire at first consultation appointment. Patient opinion concerning total number of s.c. injections as a function of non-reimbursed patient cost associated with GnRH-agonist [A] and GnRH-antagonist [B] protocols in IVF was studied. RESULTS Completed questionnaires (n = 71) revealed a mean +/- SD patient age of 34 +/- 4.1 yrs. Most (83.1%) had no prior IVF experience; 2.8% reported another medical condition requiring self-administration of subcutaneous medication(s). When out-of-pocket cost for [A] and [B] were identical, preference for [B] was registered by 50.7% patients. The tendency to favor protocol [B] was weaker among patients with a health occupation. Estimated patient costs for [A] and [B] were $259.82 +/- 11.75 and $654.55 +/- 106.34, respectively (p < 0.005). Measured patient preference for [B] diminished as the cost difference increased. CONCLUSIONS This investigation found consistently higher non-reimbursed direct medication costs for GnRH-antagonist IVF vs. GnRH-agonist IVF protocols. A conditional preference to minimize downregulation (using GnRH-antagonist) was noted among some, but not all, IVF patient sub-groups. Compared to IVF patients with a health occupation, the preference for GnRH-antagonist was weaker than for other patients. While reducing total number of injections by using GnRH-antagonist is a desirable goal, it appears this advantage is not perceived equally by all IVF patients and its utility is likely discounted heavily by patients when nonreimbursed medication costs reach a critical level.
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Affiliation(s)
- E Scott Sills
- Reproductive Research Division, Pacific Reproductive Center, PRC—Orange County, 10 Post, Irvine, CA, 92618, USA
| | - Gary S Collins
- Centre for Statistics in Medicine, Wolfson College Annexe, University of Oxford, Oxford, UK
| | - Shala A Salem
- Reproductive Research Division, Pacific Reproductive Center, PRC—Orange County, 10 Post, Irvine, CA, 92618, USA
| | - Christopher A Jones
- Global Health Economics Unit and Department of Surgery, UVM College of Medicine, Burlington, VT, USA
| | - Alison C Peck
- Reproductive Research Division, Pacific Reproductive Center, PRC—Orange County, 10 Post, Irvine, CA, 92618, USA
| | - Rifaat D Salem
- Reproductive Research Division, Pacific Reproductive Center, PRC—Orange County, 10 Post, Irvine, CA, 92618, USA
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Check JH, Wilson C, Jamison T, Choe JK, Cohen R. The sharing of eggs by infertile women who are trying to conceive themselves with an egg recipient for financial advantages does not jeopardize the donor's chance of conceiving. CLIN EXP OBSTET GYN 2012; 39:432-433. [PMID: 23444735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
PURPOSE To determine if the sharing of oocytes by an infertile woman with an egg recipient for financial advantages has any negative impact on the success rate for the donor. METHODS A matched controlled study was performed comparing pregnancy outcome of women undergoing in vitro fertilization-embryo transfer (IVF-ET) but sharing half of their eggs with a recipient vs women undergoing IVF-ET but not sharing oocytes. RESULTS Even though more women sharing oocytes deferred fresh transfer and cryopreserved the embryos because of a greater likelihood of ovarian hyperstimulation syndrome, there was no difference in pregnancy rates between the two groups after their first embryo transfer whether it was with fresh or frozen-thawed embryos. CONCLUSIONS Sharing of oocytes by a woman undergoing IVF-ET does not jeopardize her chance of a successful outcome following embryo transfer.
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Affiliation(s)
- J H Check
- The University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School at Camden Cooper Hospital/University Medical Center, Department of Obstetrics and Gynecology Division of Reproductive Endocrinology & Infertility, Camden, NJ, USA.
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Melo M, Bellver J, Garrido N, Meseguer M, Pellicer A, Remohí J. A prospective, randomized, controlled trial comparing three different gonadotropin regimens in oocyte donors: ovarian response, in vitro fertilization outcome, and analysis of cost minimization. Fertil Steril 2010; 94:958-64. [PMID: 19931075 DOI: 10.1016/j.fertnstert.2009.05.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2009] [Revised: 04/25/2009] [Accepted: 05/04/2009] [Indexed: 11/29/2022]
Affiliation(s)
- Marco Melo
- Instituto Valenciano de Infertilidad, Universidad de Valencia, Department of Obsterics and Gynaecology, University Hospital Dr. Peset, Valencia, Spain.
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Omurtag KR, Styer AK, Session D, Toth TL. Economic implications of insurance coverage for in vitro fertilization in the United States. A review. J Reprod Med 2009; 54:661-668. [PMID: 20120898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To analyze cost-effectiveness studies in regard to the costs of in vitro fertilization (IVF) and discuss specific economic trends that may affect the future utilization of IVF in the United States. STUDY DESIGN Health economics. A Pub Med literature review and the Centers for Disease Control's (CDC) Fertility Clinic Success Rate registry served to access cost analyses and trends, respectively. RESULTS The average cost of an IVF cycle in the U.S. is $9,226. Among policies that provide IVF services, the increase in premium per month ranges from $0.67 to $14. CONCLUSION When IVF is provided as a health benefit, the cost increases can be variable. As utilization increases, contemporary cost analyses and outcomes research will aid providers, third-party payers and policymakers in better understanding the economic impact of lVF.
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Affiliation(s)
- Kenan R Omurtag
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia 30303, USA.
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Rosenfeld Y, Strulov A. [Clinical reports on IVF cycle rank--reliability and validity]. Harefuah 2009; 148:22-4, 26, 89 passim. [PMID: 19320384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND Accurate clinical reports of in vitro fertilization cycle rank (IVF-CR] are important because of their predictive value of treatment success--clinical pregnancy. This parameter, therefore, facilitates decision-making on both individual and population levels. The District of Haifa and Western GaLilee currently enrolls about 700,000 insured people, and provides hundreds of IVF cycles (pick-ups and frozen-thawed) at a cost of millions of shekels each year. Hence, accurate reports of IVF cycle rank is extremely important in order to ensure that public funds are actually directed to couples who may benefit from them. OBJECTIVE The study objective was to evaluate the accuracy of IVF units' reports of IVF-CR. METHODS Reports of IVF-CR from local IVF units were correlated with administrative data. Couples undergoing IVF treatments during one month were included in the study. RESULTS A total number of 108 IVF cycle treatments were reported. Accurate IVF-CR was reported for 29 patients (27%), "too high" for 30 patients (28%), and "too low" for 10 (9%). For 39 patients (36%) data was missing. CONCLUSIONS CLinicaL reports of IVF-CR are currently accurate in less than a third of the cases. It is recommended that national regulatory bodies should issue compulsory guidelines in relation to recording and reporting of IVF-CR.
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Bhattacharya S, Harrild K, Mollison J, Wordsworth S, Tay C, Harrold A, McQueen D, Lyall H, Johnston L, Burrage J, Grossett S, Walton H, Lynch J, Johnstone A, Kini S, Raja A, Templeton A. Clomifene citrate or unstimulated intrauterine insemination compared with expectant management for unexplained infertility: pragmatic randomised controlled trial. BMJ 2008; 337:a716. [PMID: 18687718 PMCID: PMC2505091 DOI: 10.1136/bmj.a716] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To compare the effectiveness of clomifene citrate and unstimulated intrauterine insemination with expectant management for the treatment of unexplained infertility. DESIGN Three arm parallel group, pragmatic randomised controlled trial. SETTING Four teaching hospitals and a district general hospital in Scotland. PARTICIPANTS Couples with infertility for over two years, confirmed ovulation, patent fallopian tubes, and motile sperm. INTERVENTION Expectant management, oral clomifene citrate, and unstimulated intrauterine insemination. MAIN OUTCOME MEASURES The primary outcome was live birth. Secondary outcome measures included clinical pregnancy, multiple pregnancy, miscarriage, and acceptability. RESULTS 580 women were randomised to expectant management (n=193), oral clomifene citrate (n=194), or unstimulated intrauterine insemination (n=193) for six months. The three randomised groups were comparable in terms of age, body mass index, duration of infertility, sperm concentration, and motility. Live birth rates were 32/193 (17%), 26/192 (14%), and 43/191 (23%), respectively. Compared with expectant management, the odds ratio for a live birth was 0.79 (95% confidence interval 0.45 to 1.38) after clomifene citrate and 1.46 (0.88 to 2.43) after unstimulated intrauterine insemination. More women randomised to clomifene citrate (159/170, 94%) and unstimulated intrauterine insemination (155/162, 96%) found the process of treatment acceptable than those randomised to expectant management (123/153, 80%) (P=0.001 and P<0.001, respectively). CONCLUSION In couples with unexplained infertility existing treatments such as empirical clomifene and unstimulated intrauterine insemination are unlikely to offer superior live birth rates compared with expectant management. TRIAL REGISTRATION ISRCT No: 71762042.
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Affiliation(s)
- S Bhattacharya
- Department of Obstetrics and Gynaecology, University of Aberdeen, Aberdeen AB25 2ZD.
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Henne MB, Stegmann BJ, Neithardt AB, Catherino WH, Armstrong AY, Kao TC, Segars JH. The combined effect of age and basal follicle-stimulating hormone on the cost of a live birth at assisted reproductive technology. Fertil Steril 2007; 89:104-10. [PMID: 17669406 PMCID: PMC2278028 DOI: 10.1016/j.fertnstert.2007.02.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2006] [Revised: 02/07/2007] [Accepted: 02/07/2007] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To predict the cost of a delivery following assisted reproductive technologies (ART). DESIGN Cost analysis based on retrospective chart analysis. SETTING University-based ART program. PATIENT(S) Women aged >or=26 and <or=42 years with FSH levels <or=12 IU/L on day 3 undergoing a first cycle of fresh, nondonor ART. INTERVENTION(S) Logit regression using a fractional polynomial model of age and basal FSH was used to estimate the probability of a live birth. Cost analysis was applied to the resulting prediction. MAIN OUTCOME MEASURE(S) The predicted probability of a live birth following ART based on a woman's age and FSH and the associated cost of a live birth. RESULT(S) Analysis of 1,238 first ART cycles produced a prediction model for live birth rates following ART incorporating both age and FSH. A cost analysis based upon combination of age and FSH revealed the cost of a live birth exceeded $100,000 when the probability of a live birth fell below 15% and the cost rose exponentially at lower probabilities of live birth. CONCLUSIONS(S) Based upon a woman's age and FSH and expected cost for a live birth using ART may be calculated. At live birth rates <5%, the cost of ART is high and greatly exceeds the cost of donor cycles. This information is vital for patient counseling.
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Affiliation(s)
- Melinda B. Henne
- Walter Reed ART Program, Walter Reed Army Medical Center, 6900 Georgia Ave., NW, Washington, DC 20307
| | - Barbara J. Stegmann
- Reproductive Biology and Medicine Branch, NICHD, NIH, 10 Center Dr., Bld 10, Rm 1-3140, Bethesda, MD 20892-1109
- Uniformed Services University of Health Sciences, Dept. of Obstetrics and Gynecology Building A, Room 3077, 4301 Jones Bridge Road, Bethesda, MD 20814-4799
| | - Adrienne B. Neithardt
- Reproductive Biology and Medicine Branch, NICHD, NIH, 10 Center Dr., Bld 10, Rm 1-3140, Bethesda, MD 20892-1109
- Uniformed Services University of Health Sciences, Dept. of Obstetrics and Gynecology Building A, Room 3077, 4301 Jones Bridge Road, Bethesda, MD 20814-4799
| | - William H. Catherino
- Reproductive Biology and Medicine Branch, NICHD, NIH, 10 Center Dr., Bld 10, Rm 1-3140, Bethesda, MD 20892-1109
- Uniformed Services University of Health Sciences, Dept. of Obstetrics and Gynecology Building A, Room 3077, 4301 Jones Bridge Road, Bethesda, MD 20814-4799
| | - Alicia Y. Armstrong
- Reproductive Biology and Medicine Branch, NICHD, NIH, 10 Center Dr., Bld 10, Rm 1-3140, Bethesda, MD 20892-1109
- Uniformed Services University of Health Sciences, Dept. of Obstetrics and Gynecology Building A, Room 3077, 4301 Jones Bridge Road, Bethesda, MD 20814-4799
| | - Tzu-Cheg Kao
- Uniformed Services University of Health Sciences, Dept. of Preventive Medicine and Biometrics, Building A, Rm 1039, 4301 Jones Bridge Road, Bethesda, MD 20814-4799
| | - James H. Segars
- Reproductive Biology and Medicine Branch, NICHD, NIH, 10 Center Dr., Bld 10, Rm 1-3140, Bethesda, MD 20892-1109
- Uniformed Services University of Health Sciences, Dept. of Obstetrics and Gynecology Building A, Room 3077, 4301 Jones Bridge Road, Bethesda, MD 20814-4799
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Abstract
OBJECTIVE To estimate the effects of financial access and other individual characteristics on the likelihood that a woman pursues infertility treatment and the choice of treatment type. DATA SOURCE/STUDY SETTING The 1995 National Survey of Family Growth. STUDY DESIGN We use a binomial logit model to estimate the effects of financial access and individual characteristics on the likelihood that a woman pursues infertility treatment. We then use a multinomial logit model to estimate the differential effects of these variables across treatment types. DATA COLLECTION/EXTRACTION METHOD This study analyzes the subset of 1,210 women who meet the definition of infertile or subfecund from the 1995 National Survey of Family Growth. PRINCIPAL FINDINGS We find that income, insurance coverage, age, and parity (number of previous births) all significantly affect the probability of seeking infertility treatment; however, the effect of these variables on choice of treatment type varies significantly. Neither income nor insurance influences the probability of seeking advice, a relatively low cost, low yield treatment. At the other end of the spectrum, the choice to pursue assisted reproductive technologies (ARTs)-a much more expensive but potentially more productive option-is highly influenced by income, but merely having private insurance has no significant effect. In the middle of the spectrum are treatment options such as testing, surgery, and medications, for which "financial access" increases their probability of selection. CONCLUSIONS Our results illustrate that for the sample of infertile of subfecund women of childbearing age studied, and considering their options, financial access to infertility treatment does matter.
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Blandford JM, Gift TL. Productivity Losses Attributable to Untreated Chlamydial Infection and Associated Pelvic Inflammatory Disease in Reproductive-Aged Women. Sex Transm Dis 2006; 33:S117-21. [PMID: 17003678 DOI: 10.1097/01.olq.0000235148.64274.2f] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES The productivity losses attributable to disease-related morbidity and mortality impose a burden on society in general and on employers in particular. A reliable assessment of the productivity losses associated with untreated infection with Chlamydia trachomatis (Ct) would complement earlier work on direct medical costs and contribute to an estimate of the full cost of chlamydial disease. GOAL The goal of this study was to estimate the discounted lifetime productivity losses attributable to untreated chlamydial infection in reproductive-aged women. STUDY DESIGN We developed a cost model using Monte Carlo methods to estimate the lifetime discounted productivity losses attributable to untreated lower genital tract Ct infection among reproductive-aged women. The model considered the impact of disability resulting from acute pelvic inflammatory disease (PID) associated with untreated Ct infection and from the sequelae of acute PID, including chronic pelvic pain, ectopic pregnancy, and infertility. To accommodate disparate Ct infection rates and labor market characteristics across age groups, we matched age-based risk factors for Ct infection with labor market patterns. Data sources included the 2001 National Chlamydia Surveillance Data, the 2001 Current Population Survey, and published literature. RESULTS Estimates indicate that the mean weighted productivity losses per untreated Ct infection were approximately US dollars 130 (in year 2001 dollars). Mean weighted productivity losses per case of acute PID were estimated at US dollars 649. Estimated productivity losses were highly correlated with age, reflecting age-dependent differences in labor market characteristics. CONCLUSIONS The productivity losses attributable to untreated infection with Ct and to sequelae of this infection form a substantial portion of the total economic burden of disease. Effective programs to prevent chlamydial infection and effective screening, diagnosis, and treatment of Ct-infected women may reduce productivity losses and substantially lessen the economic burden of disease to employers.
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Affiliation(s)
- John M Blandford
- National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.
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Revelli A, Poso F, Gennarelli G, Moffa F, Grassi G, Massobrio M. Recombinant versus highly-purified, urinary follicle-stimulating hormone (r-FSH vs. HP-uFSH) in ovulation induction: a prospective, randomized study with cost-minimization analysis. Reprod Biol Endocrinol 2006; 4:38. [PMID: 16848893 PMCID: PMC1550405 DOI: 10.1186/1477-7827-4-38] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2006] [Accepted: 07/18/2006] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Both recombinant FSH (r-FSH) and highly-purified, urinary FSH (HP-uFSH) are frequently used in ovulation induction associated with timed sexual intercourse. Their effectiveness is reported to be similar, and therefore the costs of treatment represent a major issue to be considered. Although several studies about costs in IVF have been published, data obtained in low-technology infertility treatments are still scarce. METHODS Two hundred and sixty infertile women (184 with unexplained infertility, 76 with CC-resistant polycystic ovary syndrome) at their first treatment cycle were randomized and included in the study. Ovulation induction was accomplished by daily administration of rFSH or HP-uFSH according to a low-dose, step-up regimen aimed to obtain a monofollicular ovulation. A bi- or tri-follicular ovulation was anyway accepted, whereas hCG was withdrawn and the cycle cancelled when more than three follicles greater than or equal to 18 mm diameter were seen at ultrasound. The primary outcome measure was the cost of therapy per delivered baby, estimated according to a cost-minimization analysis. Secondary outcomes were the following: monofollicular ovulation rate, total FSH dose, cycle cancellation rate, length of the follicular phase, number of developing follicles (>12 mm diameter), endometrial thickness at hCG, incidence of twinning and ovarian hyperstimulation syndrome, delivery rate. RESULTS The overall FSH dose needed to achieve ovulation was significantly lower with r-FSH, whereas all the other studied variables did not significantly differ with either treatments. However, a trend toward a higher delivery rate with r-FSH was observed in the whole group and also when results were considered subgrouping patients according to the indication to treatment. CONCLUSION Considering the significantly lower number of vials/patient and the slight (although non-significant) increase in the delivery rate with r-FSH, the cost-minimization analysis showed a 9.4% reduction in the overall therapy cost per born baby in favor of r-FSH.
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Affiliation(s)
- Alberto Revelli
- Reproductive Medicine and IVF Unit, Department of Obstetrical and Gynecological Sciences, University of Torino, S. Anna Hospital, Torino, Italy
| | - Francesca Poso
- Reproductive Medicine and IVF Unit, Department of Obstetrical and Gynecological Sciences, University of Torino, S. Anna Hospital, Torino, Italy
| | - Gianluca Gennarelli
- Reproductive Medicine and IVF Unit, Department of Obstetrical and Gynecological Sciences, University of Torino, S. Anna Hospital, Torino, Italy
| | - Federica Moffa
- Reproductive Medicine and IVF Unit, Department of Obstetrical and Gynecological Sciences, University of Torino, S. Anna Hospital, Torino, Italy
| | - Giuseppina Grassi
- Reproductive Medicine and IVF Unit, Department of Obstetrical and Gynecological Sciences, University of Torino, S. Anna Hospital, Torino, Italy
| | - Marco Massobrio
- Reproductive Medicine and IVF Unit, Department of Obstetrical and Gynecological Sciences, University of Torino, S. Anna Hospital, Torino, Italy
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Chetkowski RJ. The ever-rising spiral of technology and cost. Fertil Steril 2006; 86:e7; author reply e8. [PMID: 16750204 DOI: 10.1016/j.fertnstert.2006.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2006] [Indexed: 11/26/2022]
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Bitler M, Schmidt L. Health disparities and infertility: impacts of state-level insurance mandates. Fertil Steril 2006; 85:858-65. [PMID: 16580365 DOI: 10.1016/j.fertnstert.2005.11.038] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2005] [Revised: 11/29/2005] [Accepted: 11/29/2005] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine whether important racial, ethnic, or socioeconomic status (SES) health disparities exist in infertility, impaired fecundity, or infertility treatment. DESIGN Four waves of the National Survey of Family Growth (NSFG) were pooled. Measures were compared across various race/ethnicity, education, and age groups. PARTICIPANT(S) Data for 31,047 women 15-44 years old from the NSFG were pooled. INTERVENTION(S) Outcomes were compared by whether the women's states of residence had a mandate in place (at least 1 year before the interview) to compel insurers to cover or offer to cover infertility treatment. MAIN OUTCOME MEASURE(S) Infertility status, impaired fecundity, ever having sought infertility treatment. RESULT(S) Infertility is more common for non-Hispanic black women, non-Hispanic other race women, and Hispanic women than for non-Hispanic white women, and both infertility and impaired fecundity are more common for high school dropouts and high school graduates with no college than for 4-year college graduates, and for older women compared with women 29 and younger. Older women, non-Hispanic white women, and women who are more educated (with at least some college) are more likely to have ever received treatment. No evidence has been found that the racial, ethnic, or education disparities are ameliorated by the health insurance mandates. CONCLUSION(S) Racial, ethnic, and educational disparities exist in infertility status and treatment, and educational disparities in impaired fecundity. More study of the impact of infertility treatment mandates on these disparities is needed.
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Affiliation(s)
- Marianne Bitler
- Public Policy Institute of California, San Francisco, California 95111, USA.
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Abstract
OBJECTIVE To examine sociodemographic differences based on patient race/ethnicity among infertility patients seeking care in a state with mandated coverage of infertility treatment. DESIGN Cross-sectional survey. SETTING University-hospital-based fertility center. PATIENT(S) A total of 1,500 consecutive women who presented for infertility care. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Self-report questionnaire assessing patient race/ethnicity, diagnosis, income, education level, and duration of infertility before seeking care. RESULT(S) African American women experienced a significantly longer duration of infertility before seeking care compared with Caucasian women (4.3 vs. 3.3 years, respectively; P=.03). With regard to infertility diagnosis, a significantly greater proportion of African American and Hispanic women had tubal factor infertility compared with Caucasian women (24.0% and 27.3% vs. 5.3%, respectively; P=.001). Looking at the highest level of education attained by patients, a significantly greater proportion of African American and Hispanic women had less than a 4-year college degree compared with Caucasian women (48% and 40.9% vs. 13.2%, respectively; P<.001). Examining the gross annual household income of patients, a significantly greater proportion of African American and Hispanic women had household incomes below $100,000 compared with Caucasian women (72% and 68.2% vs. 37.3%, respectively; P<.01). CONCLUSION(S) African American women are more likely to seek infertility treatment after a longer duration of failed conception compared with Caucasian women. Furthermore, African American, and Hispanic women are more likely to have tubal factor infertility, a lower education level, and a lower household income compared with Caucasian women.
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Affiliation(s)
- Tarun Jain
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Illinois Medical Center, Chicago, Illinois 60612, USA.
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Feinberg EC, Larsen FW, Catherino WH, Zhang J, Armstrong AY. Comparison of assisted reproductive technology utilization and outcomes between Caucasian and African American patients in an equal-access-to-care setting. Fertil Steril 2006; 85:888-94. [PMID: 16580370 DOI: 10.1016/j.fertnstert.2005.10.028] [Citation(s) in RCA: 140] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2005] [Revised: 10/16/2005] [Accepted: 10/16/2005] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Racial disparity in assisted reproductive technology (ART) outcomes has been reported but remains controversial. Reasons for the disparity are unclear, and access to care has been suggested as a causative factor. In this study, we sought to examine minority utilization of ART in the Department of Defense (DoD) compared with minority utilization in the U.S. ART population. Outcomes from ART were compared between Caucasian (Cau) and African American (AA) patients, and etiologies of disparity were examined. DESIGN Retrospective cohort study. SETTING University-based ART program. PATIENT(S) A total of 1,457 patients undergoing first-cycle fresh, nondonor ART. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Clinical pregnancy rate, live birth rate, implantation rate, spontaneous abortion rate. RESULT(S) Within the DoD population, AA women had a fourfold increase in utilization of ART services relative to the U.S. ART population. In this equal-access-to-care setting, AA women experienced a clinically significant decrease in live birth rate that did not reach statistical significance (29.6% vs. 35.8%, risk ratio [RR] 0.83, 95% confidence interval [CI] 0.67-1.02) and a statistically significant increase in spontaneous abortions compared with Cau women (25% vs. 15.9%, RR 1.57, 95% CI 1.05-2.36). This might be explained, in part, by a higher prevalence of uterine leiomyomas in AA women (30.8% AA vs. 10.7% Cau, RR 2.85, 95% CI 2.06-3.95). For both AA and Cau women, the presence of fibroids at baseline ultrasound was associated with reductions in clinical pregnancy rates (35% with leiomyomas vs. 43.2% without leiomyomas, RR 0.74, 95% CI 0.51-0.98), live birth rates (26.2% vs. 36.0%, RR 0.63, 95% CI 0.44-0.90), and implantation rates (25.6% vs. 31.1% RR 0.82, 95% CI 0.69-0.98). CONCLUSION(S) Utilization of ART services among AA women increased when access to care was improved. A clinically significant reduction in live birth rate and statistically significant increase in spontaneous abortion rate was observed in AA women compared with Cau women. Leiomyomas were three times more prevalent in AA women and reduced ART success, regardless of race. The persistence of racial differences in an equal-access-to-care environment might be explained, in part, by the increased prevalence of leiomyomas in AA women.
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Affiliation(s)
- Eve C Feinberg
- Reproductive Biology and Medicine Branch, National Institute of Child Health and Human Development, NIH, Bethesda, Maryland 20892, USA
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Sophonsritsuk A, Choktanasiri W, Weerakiet S, Rojanasakul A. Comparison of outcomes and direct cost between minimal stimulation and conventional protocols on ovarian stimulation in in vitro fertilization. J Obstet Gynaecol Res 2005; 31:459-63. [PMID: 16176518 DOI: 10.1111/j.1447-0756.2005.00320.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To determine whether minimal stimulation with clomiphene and gonadotropin provides outcomes and direct costs comparable with those of a conventional GnRHa-gonadotropin stimulation protocol for infertile patients undergoing in vitro fertilization. METHODS A non-randomized clinical trial was conducted from 1 July 1996 to 31 March 2003 at the Infertility and Assisted Reproductive Unit, Ramathibodi Hospital, Faculty of Medicine, Mahidol University, Thailand. A total of 192 patients were recruited of whom 96 cases underwent ovarian stimulated cycles with minimal stimulation protocol, and 96 controls underwent ovarian stimulated cycles with GnRHa-gonadotropin protocol, with cases and controls matched for age and infertility cause. RESULTS The median patient age was 35 years. Endometriosis was the most frequent infertility cause (28.1%). The conventional GnRHa-gonadotropin protocol could give more oocyte numbers than the minimal stimulation protocol (7.3 +/- 4.9 vs 4.5 +/- 3.3 oocytes). The fertilization rate and cleavage rate were similar (73.4 +/- 31.9 and 84.9 +/- 32.6 in minimal stimulation protocol, 69.3 +/- 29.6 and 88.4 +/- 28.0 in GnRHa-gonadotropin protocol, respectively). The pregnancy rate per oocyte retrieval cycle in the GnRHa-gonadotropin protocol was similar to the minimal stimulation protocol. (13.1%vs 13.0%, P = 1.000). However, the cost per pregnancy of minimal stimulation protocol was less than that of GnRHa-gonadotropin protocol. (6021.95 US dollars for minimal stimulation protocol per pregnancy, 10,785.65 US dollars for GnRHa-gonadotropin protocol per pregnancy, P < 0.000). CONCLUSION Minimal stimulation was less effective than conventional GnRHa-gonadotropin on the ovarian stimulation. However, the total costs of minimal stimulation were cheaper than the conventional GnRHa-gonadotropin protocol. The decreased costs of minimal stimulation justifies further evaluation of its role in the treatment of infertility in selected cases.
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Affiliation(s)
- Areepan Sophonsritsuk
- Infertility and Assisted Reproductive Unit, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
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Kansal-Kalra S, Milad MP, Grobman WA. In vitro fertilization (IVF) versus gonadotropins followed by IVF as treatment for primary infertility: a cost-based decision analysis. Fertil Steril 2005; 84:600-4. [PMID: 16169391 DOI: 10.1016/j.fertnstert.2005.03.049] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2004] [Revised: 03/17/2005] [Accepted: 03/17/2005] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare the economic consequences of proceeding directly to IVF to those of proceeding with gonadotropins followed by IVF in patients <35 years of age with unexplained infertility. DESIGN A decision-tree model. The model incorporated the cost and success of each infertility regimen as well as the pregnancy-associated costs of singleton or multiple gestations and the risk and cost of cerebral palsy. MAIN OUTCOME MEASURE(S) Cost per live birth. RESULT(S) Both treatment arms resulted in a >80% chance of birth. The gonadotropin arm was over four times more likely to result in a high-order multiple pregnancy (HOMP). Despite this, when the base case estimates were utilized, immediate IVF emerged as more costly per live birth. In sensitivity analysis, immediate IVF became less costly per live birth when IVF was more likely to achieve birth (55.1%) or cheaper (11,432 dollars) than our base case assumptions. CONCLUSION(S) After considering the risk and cost of HOMP, immediate IVF is more costly per live birth than a trial of gonadotropins prior to IVF.
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Affiliation(s)
- Suleena Kansal-Kalra
- Department of Reproductive Endocrinology and Infertility, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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Abstract
This study aimed to observe diagnostic work-up and cost evaluation of infertile couples to identify opportunities for improvement. One hundred and seventy-four new referrals to the gynaecology clinic in a District General Hospital during 1996 and 1997 provided the cohort for analysis. Data from case notes were transferred on to data collection sheets. Data were inputted into SPSS for analysis. Primary infertility accounted for 62% of couples. One hundred and forty-two couples (81.6%) had a definitive diagnosis, and the analyses relate to these couples only. There was no single investigation performed on the whole cohort studied. Semen analysis was undertaken in 80.3% of the couples; couples with suspected male infertility were over four times more likely to have had more than two semen tests (P = 0.0005); 77.5% of couples had FSH and LH tests; and midluteal progesterone was tested in 76.1%. An increased intensity of FSH-LH hormone testing was associated with couples with anovulation (chi(2) = 6.79, P = 0.03). Serial repeat progesterone tended to be given to women with irregular or prolonged cycles (35 days or more), although this tendency was not statistically significant. The most common test for tubal patency was hysterosalpingography. Higher costs are generally associated with diagnosing endometriosis and tubal factor because of the relatively high cost of laparoscopy. The average cost of diagnosis for each patient was pound 365 and ranged from pound 64 to pound 851. In conclusion, a standard protocol of basic investigative procedures should be offered in secondary centres to all couples. Avoiding duplication and unnecessary investigations (for example, serial progesterone) may reduce costs, although offering all couples a standard protocol of tests would probably offset this observation.
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Affiliation(s)
- Kamal Ojha
- Department of Obstetrics and Gynaecology, St George's Hospital Medical School, London SW17 0RE, UK
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Jain T, Hornstein MD. Disparities in access to infertility services in a state with mandated insurance coverage. Fertil Steril 2005; 84:221-3. [PMID: 16009188 DOI: 10.1016/j.fertnstert.2005.01.118] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2004] [Revised: 01/07/2005] [Accepted: 01/07/2005] [Indexed: 10/25/2022]
Abstract
The objective of our study was to examine the demographic and socioeconomic characteristics of patients accessing infertility services in a state (Massachusetts) with mandated and comprehensive insurance coverage for such services. Even in a state with such insurance coverage, disparities in access to infertility services exist, with the majority of individuals accessing those services being Caucasian, highly educated, and wealthy.
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Affiliation(s)
- Tarun Jain
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Illinois Medical Center, Chicago, Illinois 60612, USA.
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van der Steeg JW, Steures P, Hompes PGA, Eijkemans MJC, van der Veen F, Mol BWJ. Investigation of the infertile couple: a basic fertility work-up performed within 12 months of trying to conceive generates costs and complications for no particular benefit. Hum Reprod 2005; 20:2672-4. [PMID: 15979991 DOI: 10.1093/humrep/dei157] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The current approach of the basic fertility work-up has been questioned recently in this journal. Based on new data on human fecundity, the authors advocated starting the fertility work-up after just 6 months of trying to conceive instead of the usual 12 months. In women younger than 39 years and with a regular cycle, there are several arguments why the basic fertility work-up should not be done earlier than after 12 months of child wish. Firstly, 50% of couples who have tried to conceive for 6 months without success will conceive in the next 6 months without any treatment. Secondly, the prevalence of fertility diseases is lower in couples who have been trying to conceive for 6 months as compared with those who have been trying for 12 months. Performance of a fertility work-up at this stage will lead to an increase in false-positive diagnoses compared with performing them at 12 months of subfertility. Thirdly, fertility treatment will have fewer additional effects in couples with good spontaneous conception prospects (6-12 months child wish), compared with subfertile couples who have poor prospects. At present, none of the available fertility treatments have success rates comparable with no intervention in these women, and postponement of treatment in such couples will prevent complications such as ovarian hyperstimulation syndrome and multiple pregnancies. We argue that the fertility work-up should not be offered to couples with a duration of child wish of <12 months, except for women with ovulation disorders and women of 39 years and older.
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Affiliation(s)
- Jan W van der Steeg
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, The Netherlands.
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Abstract
BACKGROUND For the evaluation of tubal function, Chlamydia antibody testing (CAT) has been introduced as a screening test. We compared six CAT screening strategies (five CAT tests and one combination of tests), with respect to their cost-effectiveness, by using IVF pregnancy rate as outcome measure. METHODS A decision analytic model was developed based on a source population of 1715 subfertile women. The model incorporates hysterosalpingography (HSG), laparoscopy and IVF. To calculate IVF pregnancy rates, costs, effects, cost-effectiveness and incremental costs per effect of the six different CAT screening strategies were determined. RESULTS pELISA Medac turned out to be the most cost-effective CAT screening strategy (15 075 per IVF pregnancy), followed by MIF Anilabsystems (15 108). A combination of tests (pELISA Medac and MIF Anilabsystems; 15 127) did not improve the cost-effectiveness of the single strategies. Sensitivity analyses showed that the results are robust for changes in the baseline values of the model parameters. CONCLUSIONS Only small differences were found between the screening strategies regarding the cost-effectiveness, although pELISA Medac was the most cost-effective strategy. Before introducing a particular CAT test into clinical practice, one should consider the effects and consequences of the entire screening strategy, instead of only the diagnostic accuracy of the test used.
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Affiliation(s)
- A A A Fiddelers
- Department of Clinical Epidemiology and Medical Technology Assessment, Academisch Ziekenhuis Maastricht, PO Box 5800, 6202 AZ Maastricht, The Netherlands.
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Heng BC. Egg-sharing in return for subsidized fertility treatment – an ethically justifiable and practical solution to overcome the shortage of donor oocytes for therapeutic cloning. Med Hypotheses 2005; 65:999-1000. [PMID: 16002230 DOI: 10.1016/j.mehy.2005.05.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2005] [Accepted: 05/24/2005] [Indexed: 11/29/2022]
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Hreinsson J, Fridström M. [In vitro oocyte maturation for safer treatment of infertility. The risk of ovarian overstimulation syndrome is minimized]. Lakartidningen 2004; 101:3665-8, 3671. [PMID: 15586490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Ovarian hyperstimulation syndrome is a well known side effect of hormone stimulation in assisted reproduction. New treatments using minimal amounts of gonadotropins or no hormone supplementation may reduce this risk. In-vitro maturation (IVM) is a treatment where final oocyte maturation is achieved in the laboratory. Results have been acceptable and this method may provide a low-risk and cost-effective alternative to traditional IVF. IVM would thus avoid the high amounts of exogenous gonadotropins required for controlled ovarian hyperstimulation. Currently, only a few teams internationally are pursuing research in this field of human reproduction. IVM is a promising treatment alternative and can be recommended especially for patients at risk of developing ovarian hyperstimulation syndrome.
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Affiliation(s)
- Julius Hreinsson
- Enheten för obstetrik och gynekologi, Karolinska Universitetssjukhuset Huddinge, Stockholm, Sweden.
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Pratt KT. Inconceivable? Deducting the costs of fertility treatment. Cornell Law Rev 2004; 89:1121-1200. [PMID: 15287147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
This Article considers whether infertile taxpayers can deduct their fertility treatment costs as medical expenses under Internal Revenue Code section 213 and whether they should be able to deduct them. Internal Revenue Code section 213 defines medical expenses as "amounts paid-for the diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body." This definition is interpreted by reference to a baseline of normal biological functioning, which includes reproductive functioning. Most people conceive and bear children without having to incur expenses for fertility treatment. Expenses incurred to approximate the baseline of normal reproductive health are deductible, even if the taxpayer winds up better off, with a child, after the fertility treatment. The medical profession recognizes that infertility is a disease or condition. Infertility is a loss, just as a broken leg is a loss. Fertility treatment costs are thus medical expenses under section 213. In addition, given the existence of the medical expense deduction, taxpayers should be able to deduct the cost of fertility treatments, including IVF, egg donor, and surrogate procedures, under either an "ability-to-pay" or consequentialist normative approach. Reproduction is extremely important to most people. In addition, allowing taxpayers to deduct the costs of fertility treatment will encourage infertile taxpayers to elect the most effective treatment option and reduce the rate of risky multifetal pregnancies. This Article concludes that fertility treatment costs are deductible as medical expenses under current law and should be deductible as medical expenses.
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Gerli S, Casini ML, Unfer V, Costabile L, Mignosa M, Di Renzo GC. Ovulation induction with urinary FSH or recombinant FSH in polycystic ovary syndrome patients: a prospective randomized analysis of cost-effectiveness. Reprod Biomed Online 2004; 9:494-9. [PMID: 15588465 DOI: 10.1016/s1472-6483(10)61632-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The aim of this prospective, randomized trial was to compare the clinical results and the cost-effectiveness of urinary FSH (uFSH) and recombinant FSH (rFSH) in ovarian stimulation for intrauterine insemination (IUI) cycles in polycystic ovary syndrome (PCOS) patients. One-hundred and seventy PCOS infertile patients undergoing IUI were enrolled, and protocols of ovarian stimulation with uFSH or rFSH were randomly assigned. The total number of cycles performed was 379 (182 and 197, respectively). The main outcome measures were the number of mature follicles, the days of stimulation, the number of ampoules and IU used per cycle, the biochemical/clinical pregnancy rates, the number of multiple pregnancies and the cost-effectiveness. No statistically significant differences were found in the follicular development, length of stimulation, pregnancy rates, delivery rates and multiple pregnancies between the two groups. In the uFSH group, the cost per cycle remained significantly lower (218.51 +/- 88.69 versus 312.22 +/- 118.12; P < 0.0001), even though a significantly higher number of IU of gonadotrophins were used (809.3 +/- 271.9 versus 589.1 +/- 244.7; P < 0.0001). The cost-effectiveness (i. e. within a group, the total cost of all cycles divided by no. of clinical pregnancies) was 1729.08 in the uFSH group and 3075.37 in the rFSH group. In conclusion, uFSH and rFSH demonstrated the same effectiveness in ovarian stimulation in IUI cycles in PCOS patients. The urinary preparation is more cost-effective due to the difference of its cost per IU.
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Affiliation(s)
- Sandro Gerli
- Centre of Reproductive and Perinatal Medicine, Department of Gynecological, Obstetrical and Pediatric Sciences, University of Perugia, Italy.
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Abstract
PURPOSE The number of published studies comparing cost-effectiveness of tubal surgery and IVF treatment is limited, in part because of the difficulties of conducting randomized trials, given that IVF is now a clinically accepted treatment and the decision to offer surgery or IVF is often dictated by the severity of the tubal disease and by the availability of the methods. The aim of this study was to compare the costs of our policy of offering tubal surgery to patients with mild or moderate tubal disease with the cost of offering IVF to these and severe tubal disease. METHODS In this retrospective cohort study patients with tubal pathology as the sole reason for their infertility were included: 61 patients in the tubal surgery group and 464 patients in the IVF group. The delivery rates and costs per delivery were compared. RESULTS Delivery rates were 28% in the tubal surgery group within 2 years of follow-up and 52% in the IVF group that involved up to three cycles of treatment. This economic evaluation demonstrated only small differences in the average cost when considering the cost per delivery. CONCLUSIONS With a policy involving strict selection of patients, tubal surgery will continue to have a role in the treatment of infertility.
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Affiliation(s)
- M Granberg
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Abstract
BACKGROUND The major complications of pelvic inflammatory disease (infertility, ectopic pregnancy, and chronic pelvic pain) are the leading cause of non-HIV sexually transmitted disease morbidity in the United States. GOAL The goal of the study was to estimate a plausible range for the average lifetime cost of pelvic inflammatory disease (PID) and its major complications in a cohort of U.S. women of reproductive age. STUDY DESIGN We developed a state-transition computer-based model to simulate the natural history of PID, incorporating the severity of infection, number of recurrent episodes, treatment setting, and the risk over time of major complications. Clinical and cost data were from the published literature. Model outcomes included life expectancy, quality-adjusted life expectancy, and lifetime costs. RESULTS In a cohort of 100,000 females acquiring PID between 20 and 24 years of age, 8550 ectopic pregnancies, 16,800 cases of infertility, and 18,600 cases of chronic pelvic pain were projected to occur. Assuming a 3% annual discount rate, we found the average per-person lifetime cost to be $2150. Average lifetime costs for women who developed major complications were $6350 for chronic pelvic pain, $6840 for ectopic pregnancy, and $1270 for infertility. The majority of costs (79%) were accrued within 5 years of upper genital tract infection. Results were most sensitive to assumptions about the timing of major complications and the discount rate. CONCLUSION The average per-person lifetime cost of PID ranges between $1060 and $3180. Future cost-effectiveness analyses of STD screening programs can include this range as a reasonable upper and lower bound. These findings suggest successful PID prevention efforts may avert substantial costs for care providers such as managed care organizations while providing well documented clinical benefits for women in the United States.
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Affiliation(s)
- Jennifer M Yeh
- Department of Health Policy and Management, Center for Risk Analysis, Harvard School of Public Health, 718 Huntington Avenue, 2nd Floor, Boston, MA 02115-5924, USA.
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Abstract
OBJECTIVE To consider the arguments for and against funding for in vitro fertilization (IVF) and to explore potential avenues for policy change. DESIGN Narrative literature review, policy analysis. SETTING University Department of Obstetrics and Gynecology. PATIENT(S) Sub-fertile women and men. INTERVENTION(S) Fertility treatments, in particular IVF. RESULT(S) The two main arguments used against funding for IVF are that [1] subfertility is a social, not a medical problem, and therefore its treatment is not medically indicated or necessary, and [2] the clinical effectiveness of IVF is unproven. These and other major arguments are critiqued. CONCLUSION(S) Dismissing IVF as medically unnecessary seems premature because medical necessity has not been operationally defined. Demonstrating IVF effectiveness through a randomized trial has not been done but is feasible: a multicenter trial is currently underway in Canada. Dealing with the concern that subfertility treatment challenges the role of women in society, as well as with questions of cost-effectiveness, are more difficult challenges that deserve further debate. The potential for unethical uses and broader social implications of IVF add to its dubious status and provide a convenient rationale for refusing to pay. However, none of these concerns is unique to IVF: many currently covered health services are susceptible to the same criticisms. For all services, judgments of eligibility for coverage should be consistent and transparent and should explicitly separate the issues of cost from other factors.
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Affiliation(s)
- E G Hughes
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada.
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van Valkengoed IG, Postma MJ, Morré SA, van den Brule AJ, Meijer CJ, Bouter LM, Boeke AJ. Cost effectiveness analysis of a population based screening programme for asymptomatic Chlamydia trachomatis infections in women by means of home obtained urine specimens. Sex Transm Infect 2001; 77:276-82. [PMID: 11463928 PMCID: PMC1744325 DOI: 10.1136/sti.77.4.276] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To evaluate the cost effectiveness of a systematic screening programme for asymptomatic Chlamydia trachomatis infections in a female inner city population. To determine the sensitivity of the cost effectiveness analysis to variation in the probability of developing sequelae. METHODS A decision tree was constructed to evaluate health effects of the programme, such as averted sequelae of chlamydial infection. Cost effectiveness from a societal perspective was estimated for screening by means of a ligase chain reaction on mailed, home obtained urine specimens, in a population with a C trachomatis test prevalence of 2.9%. An extensive sensitivity analysis was performed for the probability of sequelae, the percentage of preventable pelvic inflammatory disease (PID), and the discount rate. RESULTS The estimated net cost of curing one woman, aged 15-40 years, of a C trachomatis infection is US$1210. To prevent one major outcome (PID, tubal factor infertility, ectopic pregnancy, chronic pelvic pain, or neonatal pneumonia), 479 women would have to be screened. The net cost of preventing one major outcome is $15 800. Changing the probability of PID after chlamydial infection from 5% to 25% decreases the net cost per major outcome averted from $28 300 to $6380, a reduction of 78%. Results were less sensitive to variations in estimates for other sequelae. The breakeven prevalence of the programme ranges from 6.4% for the scenario with all probabilities for complications set at the maximum value to a prevalence of 100% for probabilities set at the minimum value. CONCLUSIONS Systematic screening of all women aged 15-40 years for asymptomatic C trachomatis infections is not cost effective. Although the results of the analyses are sensitive to variation in the assumptions, the costs exceed the benefits, even in the most optimistic scenario.
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Affiliation(s)
- I G van Valkengoed
- Institute for Research in Extramural Medicine, Vrije Universiteit, Amsterdam, Netherlands
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Morán C, Huerta R, Azziz R. [Infertility treatment before assisted reproductive techniques]. Ginecol Obstet Mex 2001; 69:167-71. [PMID: 11452416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
The prevalence of infertility has increased in recent years, but the medical services to treat these problems are not available for most of the affected couples. The prognosis for fertility is important in order to determine the therapeutic capacity of each service, and to select the couples that could be treated at a primary level, or to send them to more advanced levels of reproductive technology. In practice, the infertility is treated in primary medical levels and the assisted reproductive technology is available only to a limited sector of the poblation. In general, the managed-care plans do not compensate directly for infertility treatments, but they are indirectly paying some therapeutic procedures for fertility.
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Affiliation(s)
- C Morán
- Division of Reproductive Biology and Endocrinology, Departament of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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