[Fertility treatments: possibilities for fewer multiple births and lower costs--the 'Umbrella' study]

Since the 1980s, increasingly more fertility treatments have been performed in the Netherlands. The use of ovarian hyperstimulation during in vitro fertilisation (IVF) and intrauterine insemination (IUI) has contributed to an explosive increase in the number of multiple births. To control the costs of treatment and outcomes, the Minister of Health, Welfare and Sport commissioned research on possible improvements in the performance of fertility treatments in 1999. The results of this research ('Umbrella study'), reported in 2005, suggested that costs and the incidence of multiple births could be reduced if (a) IUI is only performed if the chance of spontaneous pregnancy is less than 30%; (b) the guideline 'Intrauterine insemination' is followed more closely regarding hormonal stimulation; (c) stimulation is used less frequently during IVF; and (d) no more than 1 embryo is placed in the uterus at a time. To achieve these results, all parties involved must revise their policies. In particular, current reimbursement regulations inhibit the implementation of the research results in practice.

NHS funded fertility treatment--a national service in name only?

The variable nature of NHS provision of fertility services has again been highlighted by the response of commissioners to the recent guidance from the National Institute of Clinical Excellence. This paper describes an evidence-based model for policy aimed at minimising inequity across one Strategic Health Authority. The paper highlights the difficulties resulting from the current Department of Health guidance on targeting those in greatest need. A different way of describing this group is proposed, namely, defining childlessness in terms of parental status alone. This is clear to both patient and clinician at the outset, not subject to variable interpretation and because it is quantifiable for any given population, facilitates the commissioning of a level of service provision that reflects expressed need. A clinical audit suggests that the annual incidence of fertility problems prompting attendance at secondary care clinics is similar to levels observed nearly 20 years ago, at around 98 per 10,000 of the fertile population (proxy denominator, women aged 25 - 39). Our model further indicates that, for the more complex treatments, if both partners were required to be childless and treatments were to be delivered within 12 - 18 months of listing, commissioners would need to fund treatment for around 15 - 20 patients per 10,000 of the fertile population. If only one partner was required to be childless this figure would rise by 15 - 20%. We argue that despite the clinical guidelines, fertility treatments will remain a 'postcode lottery' unless central government addresses the priority to be given to fertility treatment on a national basis.

[Pharmacoeconomic advantages of recombinant FSH vs urinary derived FSH]

Nowadays, the use of urinary FSH is essentially justified by a lower acquisition price compared to modern products generated by Biotechnology (recombinant FSH). However, the public price of a product is only one element of the total cost of a therapeutic regimen that must be taken into account in medical decision-making. This is the role of pharmacoeconomic studies including cost-effectiveness models, which allow proceeding to complex situational comparisons such as several attempts of Assisted Reproduction Techniques. Different models have been carried out and published in several countries and present consistently that recombinant FSH is more cost-effective that urinary derived FSH.

Inconceivable? Deducting the costs of fertility treatment

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.

Using attitudinal indicators to explain the public's intention to have recourse to gamete donation and surrogacy

BACKGROUND

Although the donation and receipt of gametes has become an integral part of infertility management, previous research in the field of social attitudes and intention to use medical technologies is limited. This study aimed to investigate attitudinal indicators and their potential relationship with the public's intention to have recourse to gamete donation and surrogacy.

METHODS

A total of 365 individuals of reproductive age (49.3% men and 50.7% women) completed a questionnaire referring to their intention to receive or donate sperm/oocytes and their acceptance of becoming a commissioning couple or surrogate mother, and also to explore their attitudes towards gamete donation and surrogacy. Two attitudinal indicators emerged from the principal component analysis identifying (i). recipients' and donors' choice for anonymity, donors' renunciation of parental obligations and refusal of children's rights to know their biological parents and (ii). favourable attitudes towards legislative and financial measures to be adopted by the Government for the promotion of reproductive technologies.

RESULTS

It was found that the indicator of 'Donors Anonymity and Refusal of Children's Rights' (DARCR) and the 'Legislative and Financial Support' (LFS) scale are positively associated with intention to have recourse to Gamete Donation and Surrogacy (GDS) (regression coefficients 0.31 and 1.08 respectively). Moreover, among the other variables used in the analysis only the 'church attendance' variable is negatively related with reported rates of intention to have recourse to GDS (P = 0.029), suggesting that the more religious respondents are less willing to use GDS.

CONCLUSION

Social, legislative and financial implications provide a convenient rationale for adopting a favourable intention towards reproductive technologies. The findings of the present research should be given close consideration by policy makers and health education campaigns.

[Infertility treatment before assisted reproductive techniques]

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.

The lived experience of premature ovarian failure

OBJECTIVE

To describe the lived experience of women who have been diagnosed with idiopathic premature ovarian failure (POF).

DESIGN

Phenomenology was used to achieve the purpose. Women were asked to share their experiences in living with premature ovarian failure during an approximately 1-hour interview. The interviews were tape-recorded, transcribed, and analyzed for emergent themes.

SETTING

Interviews were conducted in the participants' homes and in a conference room in a hospital.

PARTICIPANTS

The six participants were drawn from a multicultural sample of women with idiopathic POF.

RESULTS

The women in this study expressed anger at their health care providers for their perceived lack of quality care they had experienced and at the insurance industry for its lack of reimbursement for fertility interventions; they expressed depression and sadness at the prospective outcome of the diagnosis, mixed emotions regarding their significant others, and sadness and resignation about their menopausal symptoms.

CONCLUSIONS

Health care providers who create an environment in which women and their significant others will feel supported in asking questions, be assured that their concerns are taken seriously, and be provided with the physical and emotional resources they need can help these women to continue to build and live their lives.

[Microsurgical vasovasostomy in the age of modern reproduction medicine. A cost-benefit analysis]

WS represents the standard procedure of choice for the treatment of obstructive azoospermia following vasectomy. However, recently, ICSI has been suggested by some to represent the solution for all cases of male factor infertility regardless of its etiology based on its success rates. Therefore, we compared VVS to MESA/TESE and ICSI in terms of pregnancy, complications, and costs. Between 1/93 and 6/98 157 VVS was performed microsurgically using the 2-layer technique in 157 patients following prior vasectomy. Between 9/94 and 9/97 69 couples underwent MESA/ICSI for epididymal obstruction not amenable to micro-surgical reconstruction such as post-inflammatory obstruction and congenital absence of the vas deferens; in the same time period 42 couples underwent TESE/ICSI for azoospermia of testicular origin due to cryptorchidism, testicular atrophy, obstruction of the rete testis. In most cases MESA or TESE and ICSI were performed metachronously. Mean intervall of vasal obstruction was 7.6 (0.5-18) years; patency after VVS was 77%, pregnancy rate was 52%. Local complication rate was 4.7%, no major complications were observed. Costs per life birth after VVS were as high as 5,447,-DM or 2,800 Euro. Pregnancy rates after MESA/TESE and ICSI were 22.5% and 19.5%, respectively with 16 singletons, 3 twins and 3 abortions; local complications occurred in 3.9% of the men. Multiple birth were noticed in 15.8% following ICSI, but only in 0.7% following VVS. 5.7% and 1.4% of the female partners experienced serious complications as a mild or severe ovarian hyperstimulation-syndrome, respectively. Costs per life birth after MESA/TESE cycle were as high as 28,804,-DM or 14,100 Euro. Even in the era of ICSI microsurgical vasovasostomy represents the standard approach for obstructive azoospermia following vasectomy. Based on a cost-benefit analysis VVS is more successful in terms of pregnancy rates (52% vs. 22.5%). We conclude that MESA/ICSI should be reserved for patients not amenable for microsurgical reconstruction.

Cost-effective infertility care

Cost-effective healthcare has become a principal paradigm in all areas of medicine. In order to establish cost-effective care, clinical outcomes under various cost conditions have to be examined. Such a process cannot be static since it has to consider ever evolving treatments and outcome results. In infertility, the evaluation of cost-effective care should be simpler than in most other areas of medicine since treatment end-points are easily defined. Nevertheless, the field is lagging in the establishment of cost-effective treatment algorithms. In this review, an effort is made to define the current state of the art of cost effective infertility care, to suggest steps that can be taken to drive the process forward and to encourage the introduction of even limited processes to further the concept of outcome-dependent cost assessment within a practice setting. The limited availability of resources mandates their judicious use throughout medicine. In a field like infertility, by many (rightly or wrongly) perceived as 'elective', the judicious use of resources seems even more necessary since it would permit the treatment of larger patient populations than have currently access to care without further expense to third-party payments.

Economical and ecological importance of indigenous livestock and the application of assisted reroduction to their preservation

Among the many mammalian species that are threatened as the result of habitat destruction are numerous species of rare or little-known native livestock that possess features that render them ideally adapted to their environment. Because of the vital and valuable role many of these species play both to the ecology and economy of their native countries, attention is being directed towards initiating breeding programs that might insure their continued survival. This review introduces and highlights the importance of some of these indigenous species and outlines efforts currently underway to apply assisted reproductive technologies to their conservation.

Evaluation of the relative cost-effectiveness of treatments for infertility in the UK

This paper aims to complement existing clinical guidelines by providing evidence of the relative cost-effectiveness of treatments for infertility in the UK. A series of decision-analytical models have been developed to reflect current diagnostic and treatment pathways for the five main causes of infertility. Data to populate the models are derived from a systematic review and routine National Health Service activity data, and are augmented with expert opinion. Costs are derived from an analysis of extra-contractual referral tariffs and private sector data. Sensitivity analysis has been carried out to take account of the uncertainty of model parameters and to allow results to be interpreted in the light of local circumstances. Results of the modelling exercise suggest in-vitro fertilization is the most cost-effective treatment option for severe tubal factors and endometriosis, with surgery the most cost-effective in the case of mild or moderate disease. Ovulatory factors should be treated medically with the addition of laparoscopic ovarian diathermy in the presence of polycystic ovarian syndrome. For other causes, stimulated intrauterine insemination (unexplained and moderate male factor) and stimulated donor intrauterine insemination (severe male) are cost-effective.

Issues affecting commercialization of sexed sperm

A decision tree for genetics or sperm-sexing entities considering sales of sexed sperm is discussed in terms of: (a) how best to avoid harm; (b) how best to do good; (c) needed synergy with other assisted reproductive technologies; (d) constraints on biotechnology; and (e) costs with current and likely technologies versus potential benefits to producers. The sexed-sperm industry might wish to take a pro-active stance on societal issues potentially affecting use of sexed sperm. For most sales in animal agriculture, cost of added value must be < 50% of benefit. Cost is less important for emotionally-driven uses with horses and human beings. Current procedures for flow-sorting allow most sperm to retain their fertilizing potential. Added cost to produce and package 2 x 10(6) sperm is estimated at US $30 to US $46 with flow sorted sperm. Estimating cost of any alternative technology is premature. For IVF/embryo transfer (ET), cost and numbers of flow-sorted sexed sperm are appropriate for commercial use. For use in low-dose AI, however, added cost to supply one insemination dose must be near US $12. Flow-sorting instruments with higher throughput and lower purchase and operating costs are obligatory for economic application in most AI situations. Developers of antibody-based separations also will face issues of retention of fertilizing potential while minimizing cell loss, separation of living from dead sperm concurrent with sperm sexing, output, and cost. To benefit producers and consumers in a changing world, genetics and sperm-sexing companies will have to collaborate and interface to provide funding for needed research and development and to recover these costs, using mechanisms not yet obvious.

Resource allocation and the beginning of life

Like many other countries, Australia is increasingly being forced to face the spiralling costs of health care. Population increases, an aging population, and the high cost of many items of modern medical equipment and of medical care generally, have all contributed to the pressure on health care resources. Within this climate of resource scarcity, more and more questions are being asked about the prioritization of items of health expenditure. The aim of this article is to consider the claim of reproductive technology, prenatal care, and prenatal diagnosis on health care resources and to evaluate the balance between treatments and preventative measures.

Infertility: from a personal to a public health problem

The inability to conceive a child is most often viewed as a private matter, but public health perspectives and skills can contribute greatly to our knowledge about infertility, and the development of effective and rational public policy for prevention, access to health care, and regulation of new technologies. We offer a primer of public health aspects of infertility in an effort to encourage the broad spectrum of public health professionals to become more knowledgeable about these topics and join in the national debate about preventive strategies, cost-benefit assessment, resource allocation, and ethics.

Trends and international comparisons in infertility in circumpolar areas

Infertility is an increasing problem for both individuals and societies. The number of couples seeking treatment for infertility is increasing each year, and public interest seems to be rising along with the new treatment methods and the improving results. Male infertility is also of great interest now that several studies suggest a deterioration in the quality of semen in many countries, Finland being an exception. The assisted reproductive technologies have improved tremendously since the first child conceived by in vitro fertilization was born in 1978. The new techniques include e.g. intrauterine insemination (IUI), gamete intrafallopian transfer (GIFT), in vitro fertilization (IVF), intracellular sperm injection (ICSI) and various combination treatments. These treatments are costly and both physically and emotionally stressful, and the success rate varies according to the aetiology of infertility, the age of the woman treated and the method used. More information is needed about the aetiology and incidence of fertility disorders as well as about the availability of treatment in the circumpolar areas and the couples' opinions of treatment. Our own study population, which was drawn form the northern Finland birth cohort for 1966, provides an outstanding opportunity to study these issues, since data are available for the whole life course of the individuals, dating back to prenatal life.

Relative concerns associated with genetics and surrogacy

Assisted reproductive technologies, incorporating artificial insemination and in-vitro fertilization techniques, are widely practised across Europe. Concern about surrogacy prompted the UK Government to commission a review and consultation on surrogacy arrangements. The ensuing document was concerned primarily with the questions of payment to the surrogate, and the regulation of agencies involved in surrogacy arrangements. This author feels that more fundamental issues should first be debated by both health professionals and society. Genetic aspects of surrogacy merit special attention, particularly regarding the genetic contribution to parenthood and the ownership and use of genetic information. Health professionals need to be fully aware of the ethical implications of advances in genetics and technology when they are applied to assisted reproduction.

Enabling conception and pregnancy. Midwifery care of women experiencing infertility

This article provides a comprehensive and thoughtful overview of primary midwifery care of the woman experiencing infertility. Midwifery assessment and management strategies that can assist women and their partners experiencing infertility to achieve a successful pregnancy are reviewed. In addition to physiologic considerations, the article addresses psychosocial, spiritual, legal, and financial issues essential to understanding the ramifications of infertility care. The authors frame their approach in a feminist perspective that enables the woman to achieve control of fertility and self-determination of care.

Profiling assisted reproductive technology: outcomes and quality of infertility management

OBJECTIVE

To critically appraise the content of the American Society for Reproductive Medicine (ASRM)/Society for Reproductive Technology (SART) Registry.

DESIGN

English-language literature review.

PATIENT(S)

Women undergoing treatment with assisted reproductive technology (ART).

INTERVENTION(S)

Current ART treatments, including IVF, GIFT, zygote intrafollopian transfer (ZIFT), oocyte micromanipulation, and cryopreserved embryo transfers.

MAIN OUTCOME MEASURE(S)

Compliance with clinical practice guidelines, and casemix-adjusted rates of live delivery, clinical pregnancy, ectopic pregnancy, miscarriage, birth defects, implantation, fertilization, and retrieval.

RESULT(S)

Outcomes should be adjusted for variation in patient characteristics known to affect prognosis, including maternal age, the duration of infertility, the presumed cause(s) of infertility, the patient's prior history of treatment for infertility, and diethylstilbestrol exposure. Outcome rates should be reported using the patient as the denominator, as well as cycle, retrieval, and transfer. The statistical significance of observed differences in events rates should be indicated. Because widely accepted clinical practice guidelines related to performance of ART procedures are not available, compliance with practice guidelines cannot currently be assessed.

CONCLUSION(S)

Reports based on ASRM/SART Registry data can be enhanced by refined casemix adjustment, assessing outcome rates per patient, as well as per component of ART procedure, and by providing an indication of the statistical significance of observed differences in event rates. In addition, a critical appraisal of available evidence related to particular aspects of infertility management would help clarify the areas in which there is an evidentiary basis for formulation of practice guidelines, as well as topics requiring additional clinical research.