"The Back-up Vasectomy Reversal." Simultaneous Sperm Retrieval and Vasectomy Reversal in the Couple With Advanced Maternal Age: A Cost-Effectiveness Analysis

Effect of time since vasectomy on live birth rate of TESE‒ICSI egg donation cycles and male-related prognostic factors

BACKGROUND

Vasectomy is a widely used method of contraception. However, some men may have the desire to become biological fathers again after a period.

OBJECTIVE

To explore the effect of time since vasectomy and different male comorbidities on live birth rates from intracytoplasmic sperm injection cycles using donated oocytes by using testicular spermatozoa obtained by testicular sperm extraction.

MATERIALS AND METHODS

This was a retrospective study of 123 couples who underwent a testicular sperm extraction‒intracytoplasmic sperm injection cycle after vasectomy using donated oocytes. Subjects were divided into groups according to time since vasectomy and the male risk factor evaluated. The main outcomes measured were live birth rate per embryo transfer, per oocyte donation cycle, and per couple. We assessed the cumulative live birth rate according to the time since vasectomy and considered male comorbidities: body mass index, hypertension, diabetes mellitus, dyslipidemia, and smoking.

RESULTS

The overall live birth rate per couple was 59.3% (50.6-68.0). Considering the number of embryo transfer and oocyte donation cycle, the live birth rates were 34.1% (27.8-40.4) and 44.5% (36.9-52.1), respectively. The live birth rate according to time since vasectomy was not statistically different between groups. Consequently, the cumulative live birth rate was similar between the different interval times when considering one to eight embryo transfers (p = 0.74). No statistical differences in live birth rate and cumulative live birth rate were found between groups clustered according to male body mass index, smoking, hypertension, and dyslipidemia. However, diabetic male patients had a significantly lower rate of live birth rate per couple (22.2% [4.94-49.4]) than non-diabetic patients did (62.7% [53.7-71.8]) (p = 0.03), but not in their cumulative live birth rate.

CONCLUSIONS

The time since vasectomy seems to have no detrimental effects on the live birth rate and cumulative live birth rate in testicular sperm extraction‒intracytoplasmic sperm injection cycles with donated oocytes. Male diabetes negatively affects the overall live birth rate per couple, but not the cumulative live birth rate. These results could be useful for multidisciplinary patient-tailored counseling, regarding the chance of having a pregnancy and facilitating the decision-making process of the fertility specialists.

[Desire to have children after vasectomy : Vasectomy reversal or assisted reproductive technology?]

The vasectomy is a safe and effective method of contraception for men. Up to 6% of men who underwent vasectomy have a renewed child wish. Microsurgical vasectomy reversal (VR) in men, microsurgical epididymal sperm aspiration (MESA), or testicular sperm extraction (TESE) in men plus assisted reproductive technology (ART) in the female partner as well as the combination of VR and MESA/TESE plus ART represent established therapeutic strategies. Various factors may impact the success of VR, as defined by patency and pregnancy rate following VR, including the female partner's age, the obstructive interval, and the surgical VR technique. There is no difference in the pregnancy and live birth rate following VR or MESA/TESE plus ART. However, following MESA/TESE plus ART, time to pregnancy is shorter compared with VR. Overall, VR is more cost-effective than MESA/TESE plus ART and allows for a lower therapeutic burden, especially in the female partner. In addition, VR combined with TESE plus-if necessary-ART is more cost-effective than MESA/TESE plus ART alone, even in female partners with advanced age. For successful counseling regarding the different therapy options for a renewed child wish after vasectomy, it is important to evaluate the underlying individual situation of the couple.

Economic evaluation of GnRH-agonist long protocol and GnRH-antagonist protocol in IVT/ICSI among the Chinese population: using pharmacoeconomic models

OBJECTIVE

This paper uses health economics methods to discuss the cost-effectiveness value of long protocol and antagonist protocol for in vitro fertilisation and embryo transfer (ET) in the Chinese population.

DESIGN

Health economic evaluation study.

SETTING

The data needed to construct the model for this study were derived from published studies and other secondary sources in China.

PARTICIPANTS

No patients participated in the study.

MEASURES

The main outcomes were live birth rate (LBR) and cost. From the societal perspective, we considered the direct and indirect costs over the course of the treatment cycles. A cost-effectiveness was measured using the incremental cost-effectiveness ratio and the probability that a protocol has higher net monetary benefit. Sensitivity analysis was carried out to verify the reliability of the simulation results.

RESULTS

For the Chinese population, the long protocol resulted in a higher LBR than the antagonist protocol (29.33% vs 20.39%), but at the same time, it was more expensive (￥29 146.26 (US$4333.17) vs ￥23 343.70 (US$3470.51)), in the case of considering only one fresh ET cycle. It was the same when considering subsequent frozen ET (FET) cycles (51.78% vs 42.81%; ￥30 703.02 (US$4564.62) vs ￥24 740.95 (US$3678.24)). The results of most subgroups were consistent with the results of the basic analysis. However, for certain populations, the long protocol was the inferior protocol (less effective and more expensive).

CONCLUSION

For the Chinese population, when the monetary value per live birth was greater than ￥65 420 (US$9726) and ￥66 400 (US$9872), respectively, considering only one fresh cycle and considering subsequent frozen cycles, the long protocol is the preferred protocol. This threshold also varies for women of different ages and ovarian response capacities. For women in POSEIDON (Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number) group 2, group 3 and group 4, antagonist protocol is recommended as the preferred protocol. The results of this study need to be verified by further large-scale randomised controlled trials.

Systematic review of the economic evaluation model of assisted reproductive technology

BACKGROUND

With the increasing demand for fertility services, it is urgent to select the most cost-effective assisted reproductive technology (ART) treatment plan and include it in medical insurance. Economic evaluation reports are an important reference for medical insurance negotiation. The aim of this study is to systematically evaluate the economic evaluation research of ART, analyze the existing shortcomings, and provide a reference for the economic evaluation of ART.

METHODS

PubMed, EMbase, Web of Science, Cochrane Library and ScienceDirect databases were searched for relevant articles on the economic evaluation of ART. These articles were screened, and their quality was evaluated based on the Comprehensive Health Economics Evaluation Report Standard (CHEERS 2022), and the data on the basic characteristics, model characteristics and other aspects of the included studies were summarized.

RESULTS

One hundred and two related articles were obtained in the preliminary search, but based on the inclusion criteria, 12 studies were used for the analysis, of which nine used the decision tree model. The model parameters were mainly derived from published literature and included retrospective clinical data of patients. Only two studies included direct non-medical and indirect costs in the cost measurement. Live birth rate was used as an outcome indicator in half of the studies.

CONCLUSION

Suggesting the setting of the threshold range in the field of fertility should be actively discussed, and the monetary value of each live birth is assumed to be in a certain range when the WTP threshold for fertility is uncertain. The range of the parameter sources should be expanded. Direct non-medical and indirect costs should be included in the calculation of costs, and the analysis should be carried out from the perspective of the whole society. In the evaluation of clinical effect, the effectiveness and safety indexes should be selected for a comprehensive evaluation, thereby making the evaluation more comprehensive and reliable. At least subgroup analysis based on age stratification should be considered in the relevant economic evaluation.

Economic Evaluation of Medically Assisted Reproduction: A Methodological Systematic Review

BACKGROUND

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

PURPOSE

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

DATA SOURCES

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

STUDY SELECTION

All economic evaluations of MAR published from 2010 to 2022.

DATA EXTRACTION

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

DATA SYNTHESIS

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

LIMITATIONS

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

CONCLUSIONS

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

HIGHLIGHTS

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