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Peipert BJ, Mebane S, Edmonds M, Watch L, Jain T. Economics of Fertility Care. Obstet Gynecol Clin North Am 2023; 50:721-734. [PMID: 37914490 DOI: 10.1016/j.ogc.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
Family building is a human right. The high cost and lack of insurance coverage associated with fertility treatments in the United States have made treatment inaccessible for many patients. The universal uptake of "add-on" services has further contributed to high out-of-pocket costs. Expansion in access to infertility care has occurred in several states through implementation of insurance mandates, and more employers are offering fertility benefits to attract and retain employees. An understanding of the economic issues shaping fertility should inform future policies aimed at promoting evidence-based practices and improving access to care in the United States.
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Affiliation(s)
- Benjamin J Peipert
- Division of Reproductive Endocrinology and Infertility, Hospital of the University of Pennsylvania, 3701 Market Street, 8th Floor, Philadelphia, PA 19104, USA
| | - Sloane Mebane
- Department of Obstetrics & Gynecology, Duke University School of Medicine, 201 Trent Drive, 203 Baker House, Durham, NC 27710, USA
| | - Maxwell Edmonds
- Department of Obstetrics & Gynecology, Duke University School of Medicine, 201 Trent Drive, 203 Baker House, Durham, NC 27710, USA
| | - Lester Watch
- Department of Obstetrics & Gynecology, Duke University School of Medicine, 201 Trent Drive, 203 Baker House, Durham, NC 27710, USA
| | - Tarun Jain
- Division of Reproductive Endocrinology & Infertility, Department of Obstetrics & Gynecology, Northwestern University Feinberg School of Medicine, 676 N. Saint Clair Street, Suite 2310, Chicago, IL 60611, USA.
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He X, Wang X, Shen J, Wan B, Wang Y, Zhang Z, Cai L, Bao Y, Ding H, Li X. Cost-effectiveness of preimplantation genetic testing for aneuploidy for women with subfertility in China: an economic evaluation using evidence from the CESE-PGS trial. BMC Pregnancy Childbirth 2023; 23:254. [PMID: 37060068 PMCID: PMC10103395 DOI: 10.1186/s12884-023-05563-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 03/30/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND There are a large number of infertile couples in China, but its treatment is notoriously expensive and not currently covered by insurance. The utility of preimplantation genetic testing for aneuploidy as an adjunct to in vitro fertilization has been debated. OBJECTIVE To investigate the cost-effectiveness of preimplantation genetic testing for aneuploidy (PGT-A) versus conventional technology in in vitro fertilization (IVF) from the perspective of the healthcare system in China. METHODS Following the exact steps in the IVF protocol, a decision tree model was developed, based on the data from the CESE-PGS trial and using cost scenarios for IVF in China. The scenarios were compared for costs per patient and cost-effectiveness. One-way sensitivity analysis and probabilistic sensitivity analysis were performed to confirm the robustness of the findings. MAIN OUTCOME MEASURES Costs per live birth, Costs per patient, Incremental cost-effectiveness for miscarriage prevention. RESULTS The average costs per live birth of PGT-A were estimated as ¥39230.71, which is about 16.8% higher than that of the conventional treatment. Threshold analysis revealed that PGT-A would need to increase the pregnancy rate of 26.24-98.24% or a cost reduction of ¥4649.29 to ¥1350.71 to achieve the same cost-effectiveness. The incremental costs per prevented miscarriage was approximately ¥45600.23. The incremental cost-effectiveness for miscarriage prevention showed that the willingness to pay would be ¥43422.60 for PGT-A to be cost-effective. CONCLUSION The present cost-effectiveness analysis demonstrates that embryo selection with PGT‑A is not suitable for routine applications from the perspective of healthcare providers in China, given the cumulative live birth rate and the high costs of PGT‑A.
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Affiliation(s)
- Xuan He
- School of Health Policy and Management, Nanjing Medical University, Nanjing, China
| | - Xiao Wang
- School of Health Policy and Management, Nanjing Medical University, Nanjing, China
| | - Jiaojie Shen
- School of Pharmacy, Nanjing Medical University, Nanjing, China
| | - Bin Wan
- Department of Health Insurance Management, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Yingpeng Wang
- Department of Health Insurance Management, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Zhuolin Zhang
- School of Pharmacy, Nanjing Medical University, Nanjing, China
| | - Lele Cai
- School of Pharmacy, Nanjing Medical University, Nanjing, China
| | - Yuwen Bao
- School of Health Policy and Management, Nanjing Medical University, Nanjing, China
| | - Haixia Ding
- Department of Health Insurance Management, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China.
| | - Xin Li
- School of Health Policy and Management, Nanjing Medical University, Nanjing, China.
- School of Pharmacy, Nanjing Medical University, Nanjing, China.
- Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China.
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Keller E, Chambers GM. Valuing infertility treatment: Why QALYs are inadequate, and an alternative approach to cost-effectiveness thresholds. FRONTIERS IN MEDICAL TECHNOLOGY 2022; 4:1053719. [PMID: 36619344 PMCID: PMC9822722 DOI: 10.3389/fmedt.2022.1053719] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022] Open
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In vitro fertilization with preimplantation genetic testing for monogenetic diseases versus unassisted conception with prenatal diagnosis for Huntington disease: a cost-effectiveness analysis. Fertil Steril 2022; 118:56-64. [PMID: 35618525 DOI: 10.1016/j.fertnstert.2022.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 03/02/2022] [Accepted: 03/15/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To investigate if in vitro fertilization (IVF) with preimplantation genetic testing for monogenic disease is cost effective for heterozygous individuals with Huntington disease vs. unassisted conception with prenatal diagnosis. DESIGN Cost-effectiveness analysis in a theoretical cohort of 3,851 couples, where one individual is heterozygous for Huntington disease. SETTING N/A. PATIENTS/ANIMALS None. INTERVENTION In vitro fertilization preimplantation genetic testing for couples attempting conception. MAIN OUTCOME MEASURES Outcomes included cost and quality-adjusted life years (QALYs) for both parents in addition to secondary outcomes of procedure-related loss, spontaneous abortion, termination of pregnancy, and early/normal/late-onset Huntington disease. A willingness-to-pay threshold was set at $100,000/QALY. RESULTS In vitro fertilization preimplantation genetic testing is lower in cost and higher in effectiveness compared to unassisted conception with prenatal diagnosis among couples with one heterozygous Huntington disease individual, making it the dominant strategy. In vitro fertilization preimplantation genetic testing was associated with 77 more QALYs and a cost savings of $46,394,268. All measured outcomes were lower in the IVF preimplantation genetic testing strategy, including 39 fewer procedure-related losses, 39 fewer spontaneous abortions, and 462 fewer terminations of pregnancy. Most notably, in our theoretical cohort of couples, IVF preimplantation genetic testing resulted in 1,079 fewer Huntington disease-affected offspring. Our results were robust over a wide range of assumptions. CONCLUSION In vitro fertilization preimplantation genetic testing is a cost-effective conception strategy compared to unassisted conception with prenatal diagnosis when one individual is heterozygous for Huntington disease. Not only can morbidity and mortality incurred by Huntington disease be mitigated for the offspring with the use of IVF preimplantation genetic testing, but this study demonstrates the cost-effectiveness of using IVF preimplantation genetic testing for those with Huntington disease.
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Facadio Antero M, Singh B, Pradhan A, Gornet M, Kearns WG, Baker V, Christianson MS. Cost-effectiveness of preimplantation genetic testing for aneuploidy for fresh donor oocyte cycles. F S Rep 2020; 2:36-42. [PMID: 34223271 PMCID: PMC8244284 DOI: 10.1016/j.xfre.2020.11.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/19/2020] [Accepted: 11/29/2020] [Indexed: 11/29/2022] Open
Abstract
Objective To determine whether in vitro fertilization (IVF) with preimplantation genetic testing for aneuploidy (PGT-A) is cost effective to achieve a live birth compared with IVF alone in fresh donor oocyte cycles. Design Theoretical cost-effectiveness study. Setting Not applicable. Patient(s) None. Intervention(s) Comparison between the cost of IVF with PGT-A vs. IVF alone to achieve a live birth. The model analyzed a hypothetical single fresh oocyte donor IVF cycle with PGT-A vs. IVF alone and followed the progression of a single embryo through the different decision nodes. Cost estimates assigned to each clinical event were based on data obtained from the literature and institutional costs. Main Outcome Measure(s) Cost per live birth. Result(s) In the base-case analysis, IVF with PGT-A was not cost effective in fresh donor oocyte cycles when compared with IVF alone to achieve a live birth. The cycles using PGT-A cost an additional $6,018.66. The incremental cost-effectiveness ratio was found to be $119,606.59 per additional live birth achieved with IVF with PGT-A. Monte Carlo simulations demonstrated that IVF with PGT-A was not cost effective in nearly all iterations. Conclusion(s) PGT-A in fresh donor oocyte IVF cycles is not cost effective compared with IVF alone over a wide range of probabilities and costs.
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Affiliation(s)
- Maria Facadio Antero
- Division of Reproductive Endocrinology and Infertility, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bhuchitra Singh
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Apoorva Pradhan
- Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Megan Gornet
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Valerie Baker
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mindy S Christianson
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Alteri A, Corti L, Sanchez AM, Rabellotti E, Papaleo E, Viganò P. Assessment of pre-implantation genetic testing for embryo aneuploidies: A SWOT analysis. Clin Genet 2019; 95:479-487. [DOI: 10.1111/cge.13510] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 12/29/2018] [Accepted: 01/04/2019] [Indexed: 12/25/2022]
Affiliation(s)
- Alessandra Alteri
- Obstetrics and Gynaecology Department; IRCCS San Raffaele Scientific Institute; Milan Italy
| | - Laura Corti
- Obstetrics and Gynaecology Department; IRCCS San Raffaele Scientific Institute; Milan Italy
| | - Ana M. Sanchez
- Reproductive Sciences Laboratory; Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute; Milan Italy
| | - Elisa Rabellotti
- Obstetrics and Gynaecology Department; IRCCS San Raffaele Scientific Institute; Milan Italy
| | - Enrico Papaleo
- Obstetrics and Gynaecology Department; IRCCS San Raffaele Scientific Institute; Milan Italy
- Reproductive Sciences Laboratory; Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute; Milan Italy
| | - Paola Viganò
- Reproductive Sciences Laboratory; Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute; Milan Italy
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Neal SA, Morin SJ, Franasiak JM, Goodman LR, Juneau CR, Forman EJ, Werner MD, Scott RT. Preimplantation genetic testing for aneuploidy is cost-effective, shortens treatment time, and reduces the risk of failed embryo transfer and clinical miscarriage. Fertil Steril 2018; 110:896-904. [DOI: 10.1016/j.fertnstert.2018.06.021] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 05/31/2018] [Accepted: 06/13/2018] [Indexed: 10/28/2022]
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Goldman RH, Racowsky C, Farland LV, Fox JH, Munné S, Ribustello L, Ginsburg ES. The cost of a euploid embryo identified from preimplantation genetic testing for aneuploidy (PGT-A): a counseling tool. J Assist Reprod Genet 2018; 35:1641-1650. [PMID: 30066304 DOI: 10.1007/s10815-018-1275-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 07/17/2018] [Indexed: 11/30/2022] Open
Abstract
PURPOSE To determine the expected out-of-pocket costs of IVF with preimplantation genetic testing for aneuploidy (PGT-A) to attain a 50%, 75%, or 90% likelihood of a euploid blastocyst based on individual age and AMH, and develop a personalized counseling tool. METHODS A cost analysis was performed and a counseling tool was developed using retrospective data from IVF cycles intended for PGT or blastocyst freeze-all between January 1, 2014 and August 31, 2017 (n = 330) and aggregate statistics on euploidy rates of > 149,000 embryos from CooperGenomics. Poisson regression was used to determine the number of biopsiable blastocysts obtained per cycle, based on age and AMH. The expected costs of attaining a 50%, 75%, and 90% likelihood of a euploid blastocyst were determined via 10,000 Monte Carlo simulations for each age and AMH combination, incorporating age-based euploidy rates and IVF/PGT-A cost assumptions. RESULTS The cost to attain a 50% likelihood of a euploid blastocyst ranges from approximately $15,000 U.S. dollars (USD) for younger women with higher AMH values (≥ 2 ng/mL) to > $150,000 for the oldest women (44 years) with the lowest AMH values (< 0.1 ng/mL) in this cohort. The cost to attain a 75% versus 90% likelihood of a euploid blastocyst is similar (~ $16,000) for younger women with higher AMH values, but varies for the oldest women with low AMH values (~ $280,000 and > $450,000, respectively). A typical patient (36-37 years, AMH 2.5 ng/mL) should expect to spend ~ $30,000 for a 90% likelihood of attaining a euploid embryo. CONCLUSIONS This tool can serve as a counseling adjunct by providing individualized cost information for patients regarding PGT-A.
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Affiliation(s)
- Randi H Goldman
- Center for Infertility and Reproductive Surgery, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, 02115, USA.
| | - Catherine Racowsky
- Center for Infertility and Reproductive Surgery, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Leslie V Farland
- Center for Infertility and Reproductive Surgery, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Janis H Fox
- Center for Infertility and Reproductive Surgery, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Santiago Munné
- CooperGenomics, Clinical, Livingston, NJ, 07039, USA
- Overture Life, Barcelona, Spain
| | | | - Elizabeth S Ginsburg
- Center for Infertility and Reproductive Surgery, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, 02115, USA
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9
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Collins SC, Xu X, Mak W. Cost-effectiveness of preimplantation genetic screening for women older than 37 undergoing in vitro fertilization. J Assist Reprod Genet 2017; 34:1515-1522. [PMID: 28748493 DOI: 10.1007/s10815-017-1001-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 07/12/2017] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Adding preimplantation genetic screening to in vitro fertilization has been shown to increase live birth rate in women older than 37. However, preimplantation genetic screening is an expensive procedure. Information on the cost-effectiveness of preimplantation genetic screening can help inform clinical decision making. METHODS We constructed a decision analytic model for a hypothetical fresh, autologous in vitro fertilization cycle (with versus without preimplantation genetic screening) for women older than age 37 who had a successful oocyte retrieval and development of at least one blastocyst. The model incorporated probability and cost estimates of relevant clinical events based on data from published literature. Sensitivity analyses were performed to examine the impact of changes in model input parameters. RESULTS In base-case analysis, IVF-PGS offered a 4.2 percentage point increase in live birth rate for an additional cost of $4509, yielding an incremental cost-effectiveness ratio (ICER) of $105,489 per additional live birth. This ICER was below the expected cost of $145,063 for achieving one live birth with IVF (assuming an average LBR of 13.4% and $19,415 per cycle for this patient population). Sensitivity analysis suggested that ICER improved substantially with decreases in PGS cost and increases in PGS effectiveness. Monte Carlo simulation showed PGS to be cost-effective in 93.9% of iterations at an acceptability cutoff of $145,063. CONCLUSIONS Considering the expected cost of achieving one live birth with IVF, PGS is a cost-effective strategy for women older than 37 undergoing IVF. Additional research on patients' willingness-to-pay per live birth would further inform our understanding regarding the cost-effectiveness of PGS.
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Affiliation(s)
- Stephen C Collins
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, 333 Cedar Street, PO Box 208063, New Haven, CT, 06520, USA
| | - Xiao Xu
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, 333 Cedar Street, PO Box 208063, New Haven, CT, 06520, USA
| | - Winifred Mak
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, 333 Cedar Street, PO Box 208063, New Haven, CT, 06520, USA.
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Payne K, Eden M, Davison N, Bakker E. Toward health technology assessment of whole-genome sequencing diagnostic tests: challenges and solutions. Per Med 2017; 14:235-247. [PMID: 29767583 DOI: 10.2217/pme-2016-0089] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Whole-genome sequencing (WGS) is being applied within research settings across Europe to develop genomic WGS-based diagnostic tests. The focus of this perspective paper is to describe if, and how, current approaches of health technology assessment could be applied to WGS-based diagnostic tests. This perspective draws on the collective view from a trans-European multidisciplinary consortium of methodologists, clinicians and scientists. Specific challenges can be described by using the PICO (population, intervention, comparator, outcome) framework to inform health technology assessment. Practical solutions are suggested which require joined-up, multidisciplinary working across healthcare systems using existing expert networks so that emergent issues for the health technology assessment of WGS can be met in a timely fashion.
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Affiliation(s)
- Katherine Payne
- Manchester Centre for Health Economics, The University of Manchester, Manchester M13 9PL, UK
| | - Martin Eden
- Manchester Centre for Health Economics, The University of Manchester, Manchester M13 9PL, UK
| | - Niall Davison
- Manchester Centre for Health Economics, The University of Manchester, Manchester M13 9PL, UK
| | - Egbert Bakker
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
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Abstract
For women of advanced age with abnormally increased FSH levels, standardized hormonal stimulation often represents a cost-intensive procedure with a low success rate. It is well established now that with mild ovarian stimulation, there is a greater percentage of good-quality eggs (although a smaller number) than with higher-dose conventional stimulation. Mild stimulation protocols reduce the mean number of days of stimulation, the total amount of gonadotropins used and the mean number of oocytes retrieved. The proportion of high-quality and euploid embryos seems to be higher compared with conventional stimulation protocols, and the pregnancy rate per embryo transfer is comparable. Moreover, the reduced costs, the better tolerability for patients and the less time needed to complete an IVF cycle make mild approaches clinically and cost-effective over a given period of time. The low number of embryos available for transfer poses a great challenge in the management of older women going in for IVF. A potential management of these older women is to create a sufficient pool of embryos by accumulating vitrified good-grade embryos over several minimal stimulation and natural cycles. At the end of the accumulation process, these embryos can be subjected to a preimplantation genetic screening using next-generation sequencing and then the pool would have only chromosomal normal embryos with maximal chances of implantation. This would potentially make the chances of success for older women similar to normal responders. This management, however, is unthinkable without an outstanding vitrification program. The option of accumulating embryos has become a promising reality with the advent of vitrification technologies.
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Goldhaber-Fiebert JD, Brandeau ML. Evaluating Cost-effectiveness of Interventions That Affect Fertility and Childbearing: How Health Effects Are Measured Matters. Med Decis Making 2015; 35:818-46. [PMID: 25926281 DOI: 10.1177/0272989x15583845] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 04/01/2015] [Indexed: 01/26/2023]
Abstract
BACKGROUND Current guidelines for economic evaluations of health interventions define relevant outcomes as those accruing to individuals receiving interventions. Little consensus exists on counting health impacts on current and future fertility and childbearing. Our objective was to characterize current practices for counting such health outcomes. METHODS We developed a framework characterizing health interventions with direct and/or indirect effects on fertility and childbearing and how such outcomes are reported. We identified interventions spanning the framework and performed a targeted literature review for economic evaluations of these interventions. For each article, we characterized how the potential health outcomes from each intervention were considered, focusing on quality-adjusted life-years (QALYs) associated with fertility and childbearing. RESULTS We reviewed 108 studies, identifying 7 themes: 1) Studies were heterogeneous in reporting outcomes. 2) Studies often selected outcomes for inclusion that tend to bias toward finding the intervention to be cost-effective. 3) Studies often avoided the challenges of assigning QALYs for pregnancy and fertility by instead considering cost per intermediate outcome. 4) Even for the same intervention, studies took heterogeneous approaches to outcome evaluation. 5) Studies used multiple, competing rationales for whether and how to include fertility-related QALYs and whose QALYs to include. 6) Studies examining interventions with indirect effects on fertility typically ignored such QALYs. 7) Even recent studies had these shortcomings. Limitations include that the review was targeted rather than systematic. CONCLUSIONS Economic evaluations inconsistently consider QALYs from current and future fertility and childbearing in ways that frequently appear biased toward the interventions considered. As the Panel on Cost-Effectiveness in Health and Medicine updates its guidelines, making the practice of cost-effectiveness analysis more consistent is a priority. Our study contributes to harmonizing methods in this respect.
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Affiliation(s)
- Jeremy D Goldhaber-Fiebert
- Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA (JDGF)
| | - Margaret L Brandeau
- Department of Management Science and Engineering, Stanford University, Stanford, CA (MLB)
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Abstract
Morphological selection techniques of gametes and embryos are of current interest to clinical practice in ART. Although intracytoplasmic morphologically selected sperm injection (IMSI), time lapse imaging morphometry (TLIM) or quantification of chromosome numbers (PGS) are potentially useful in research, they have not been shown to be of statistically predictive value and, thus, have only limited clinical usefulness. We make the point that morphological markers alone cannot predict the success of the early embryo, which depends on the correct orchestration of a myriad of physiological and biochemical activation events that progress independently of the maternal or zygotic genome. Since previous attempts to identify metabolic markers for embryo quality have failed and there is no evidence that the intrinsic nature of gametes and embryos can be improved in the laboratory, embryologists can only minimize environmental or operator induced damage while these cells are manipulated ex vivo.
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Embryonic aneuploidy: overcoming molecular genetics challenges improves outcomes and changes practice patterns. Trends Mol Med 2014; 20:499-508. [PMID: 25113799 DOI: 10.1016/j.molmed.2014.06.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 06/18/2014] [Accepted: 06/26/2014] [Indexed: 11/20/2022]
Abstract
Since its inception, in vitro fertilization (IVF) has pursued molecular technology to improve patient outcomes, leading to enhanced methods of embryo selection. Comprehensive chromosomal screening (CCS) is a powerful tool that decreases maternal and neonatal morbidity due to multiple gestations by allowing the transfer of fewer embryos while maintaining success rates. To optimize this genetic test, physiological principles limiting the timing and type of cells to be removed had to be realized. Molecular barriers involved in genome amplification and ensuring the accuracy and validity of the CCS platform required a multistep approach to ensure that this technology was not used prematurely. Only after ensuring that the potential for harm was minimized and benefit maximized could clinicians use this technology to improve patient care.
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Geraedts J, Montag M, Magli MC, Repping S, Handyside A, Staessen C, Harper J, Schmutzler A, Collins J, Goossens V, van der Ven H, Vesela K, Gianaroli L. Polar body array CGH for prediction of the status of the corresponding oocyte. Part I: clinical results. Hum Reprod 2011; 26:3173-80. [PMID: 21908463 PMCID: PMC3196878 DOI: 10.1093/humrep/der294] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Revised: 07/29/2011] [Accepted: 08/09/2011] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Several randomized controlled trials have not shown a benefit from preimplantation genetic screening (PGS) biopsy of cleavage-stage embryos and assessment of up to 10 chromosomes for aneuploidy. Therefore, a proof-of-principle study was planned to determine the reliability of alternative form of PGS, i.e. PGS by polar body (PB) biopsy, with whole genome amplification and microarray-based comparative genomic hybridization (array CGH) analysis. METHODS In two centres, all mature metaphase II oocytes from patients who consented to the study were fertilized by ICSI. The first and second PBs (PB1and PB2) were biopsied and analysed separately for chromosome copy number by array CGH. If either or both of the PBs were found to be aneuploid, the corresponding zygote was then also processed by array CGH for concordance analysis. RESULTS Both PBs were biopsied from a total of 226 zygotes from 42 cycles (average 5.5 per cycle; range 1-15) in 41 couples with an average maternal age of 40.0 years. Of these, the ploidy status of the zygote could be predicted in 195 (86%): 55 were euploid (28%) and 140 were aneuploid (72%). With only one exception, there was at least one predicted aneuploid zygote in each cycle and in 19 out of 42 cycles (45%), all zygotes were predicted to be aneuploid. Fresh embryos were transferred in the remaining 23 cycles (55%), and one frozen transfer was done. Eight patients had a clinical pregnancy of which seven were evolutive (ongoing pregnancy rates: 17% per cycle and 30% per transfer). The ploidy status of 156 zygotes was successfully analysed by array CGH: 38 (24%) were euploid and 118 (76%) were aneuploid. In 138 cases complete information was available on both PBs and the corresponding zygotes. In 130 (94%), the ploidy status of the zygote was concordant with the ploidy status of the PBs and in 8 (6%), the results were discordant. CONCLUSIONS This proof-of-principle study indicates that the ploidy of the zygote can be predicted with acceptable accuracy by array CGH analysis of both PBs.
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Affiliation(s)
- Joep Geraedts
- Department of Genetics and Cell Biology, Research Institute GROW, Faculty of Health, Medicine and Life Sciences, Maastricht University, PO Box 5800, Maastricht, AZ 6202, The Netherlands.
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Ly KD, Agarwal A, Nagy ZP. Preimplantation genetic screening: does it help or hinder IVF treatment and what is the role of the embryo? J Assist Reprod Genet 2011; 28:833-49. [PMID: 21743973 DOI: 10.1007/s10815-011-9608-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Accepted: 06/28/2011] [Indexed: 12/31/2022] Open
Abstract
Despite an ongoing debate over its efficacy, preimplantation genetic screening (PGS) is increasingly being used to detect numerical chromosomal abnormalities in embryos to improve implantation rates after IVF. The main indications for the use of PGS in IVF treatments include advanced maternal age, repeated implantation failure, and recurrent pregnancy loss. The success of PGS is highly dependent on technical competence, embryo culture quality, and the presence of mosaicism in preimplantation embryos. Today, cleavage stage biopsy is the most commonly used method for screening preimplantation embryos for aneuploidy. However, blastocyst biopsy is rapidly becoming the more preferred method due to a decreased likelihood of mosaicism and an increase in the amount of DNA available for testing. Instead of using 9 to 12 chromosome FISH, a 24 chromosome detection by aCGH or SNP microarray will be used. Thus, it is advised that before attempting to perform PGS and expecting any benefit, extended embryo culture towards day 5/6 should be established and proven and the clinical staff should demonstrate competence with routine competency assessments. A properly designed randomized control trial is needed to test the potential benefits of these new developments.
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Affiliation(s)
- Kim Dao Ly
- Center for Reproductive Medicine, Cleveland Clinic, Cleveland, Ohio, USA.
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A review of economic evaluations of genetic testing services and interventions (2004–2009). Genet Med 2011; 13:89-94. [DOI: 10.1097/gim.0b013e3182003294] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Geraedts J, Collins J, Gianaroli L, Goossens V, Handyside A, Harper J, Montag M, Repping S, Schmutzler A. What next for preimplantation genetic screening? A polar body approach! Hum Reprod 2010; 25:575-7. [PMID: 20031957 PMCID: PMC2817568 DOI: 10.1093/humrep/dep446] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Screening of human preimplantation embryos for numerical chromosome abnormalities has been conducted mostly at the preimplantation stage using fluorescence in situ hybridization. However, it is clear that preimplantation genetic screening (PGS) as it is currently practiced does not improve live birth rates. Therefore the ESHRE PGS Task Force has decided to start a proof of principle study with the aim of determining whether biopsy of the first and second polar body followed by subsequent analysis of the complete chromosome complement of these polar bodies using an array based technique enables a timely identification of the chromosomal status of an oocyte. If the principle of this approach can be proven, it is obvious that a multicentre randomized controlled trial should then be started to determine the clinical value of this technique. In this way the ESHRE PGS Task Force hopes to redirect preimplantation screening from the blind alley to the main road of assisted reproduction.
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Affiliation(s)
- Joep Geraedts
- Department of Genetics and Cell Biology, Research Institute GROW, Faculty of Health, Medicine and Life Sciences, Maastricht University, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
| | - John Collins
- Department of Obstetrics & Gynecology, McMaster University, Hamilton, Canada
| | - Luca Gianaroli
- Department of Reproductive Medicine, SISMER, Via Mazzini 12, 40138 Bologna, Italy
| | | | - Alan Handyside
- London Bridge Fertility, Gynaecology and Genetics Centre, London and Faculty of Biological Sciences, University of Leeds, Leeds, UK
| | - Joyce Harper
- UCL Centre for PG&D, Institute for Women's Health, University College London, London, UK
| | - Markus Montag
- Department of Gynecologica Endocrinology & Reproductive Medicine, University of Bonn, Bonn, Germany
| | - Sjoerd Repping
- Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Obstetrics and Gynecology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Andreas Schmutzler
- Center for Reproductive Medicine, University Women's Hospital, Christian-Albrechts-University Kiel, Kiel, Germany
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Current World Literature. Curr Opin Obstet Gynecol 2009; 21:353-63. [DOI: 10.1097/gco.0b013e32832f731f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Davis LB, Champion SJ, Fair SO, Baker VL, Garber AM. A cost-benefit analysis of preimplantation genetic diagnosis for carrier couples of cystic fibrosis. Fertil Steril 2009; 93:1793-804. [PMID: 19439290 DOI: 10.1016/j.fertnstert.2008.12.053] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2008] [Revised: 11/21/2008] [Accepted: 12/10/2008] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To perform a cost-benefit analysis of preimplantation genetic diagnosis (PGD) for carrier couples of cystic fibrosis (CF) compared with the alternative of natural conception (NC) followed by prenatal testing and termination of affected pregnancies. DESIGN Cost-benefit analysis using a decision analytic model. SETTING Outpatient reproductive health practices. PATIENT(S) A simulated cohort of 1,000 female patients. INTERVENTION(S) We calculated the net benefit of giving birth to a child as the present value of lifetime earnings minus lifetime medical costs. MAIN OUTCOME MEASURE(S) Net benefits in dollars. RESULT(S) When used for women younger than 35 years of age, the net benefit of PGD over NC was $182,000 ($715,000 vs. $532,000, respectively). For women aged 35-40 years, the net benefit of PGD over NC was $114,000 ($634,000 vs. $520,000, respectively). For women older than 40 years, however, the net benefit of PGD over NC was -$148,000 ($302,000 vs. $450,000, respectively). CONCLUSION(S) Preimplantation genetic diagnosis provides net economic benefits when used by carrier couples of CF. Although there is an upper limit of maternal age at which economic benefit can be demonstrated, carrier couples of CF should be offered PGD for prevention of an affected child.
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Affiliation(s)
- Lynn B Davis
- Department of Obstetrics & Gynecology, Reproductive Endocrinology & Infertility, Stanford University Medical Center, Palo Alto, California, USA.
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