Cost-effectiveness analysis of preimplantation genetic screening and in vitro fertilization versus expectant management in patients with unexplained recurrent pregnancy loss

Gayathree Murugappan; Mika S Ohno; Ruth B Lathi

doi:10.1016/j.fertnstert.2015.02.012

Assisted Reproduction Industry, Cost and Access

Cost-effectiveness analysis of preimplantation genetic screening and in vitro fertilization versus expectant management in patients with unexplained recurrent pregnancy loss

Murugappan G, Ohno MS, Lathi RB

Published May 2015 Fertility and Sterility, 103(5), 1215-1220

DOI 10.1016/j.fertnstert.2015.02.012 PMID 25772770

RRM Academy Synopsis

IVF with screening was not cost effective in a model of recurrent loss

A decision analytic model of women with unexplained recurrent pregnancy loss found that IVF with genetic screening cost 100-fold more per live birth than expectant management. Expectant management means conceiving without treatment. The model gave live birth in about 7 out of 10 women with it and about 5 out of 10 with IVF and screening.

Key Findings

The live-birth rate, calculated per strategy, was 53% with IVF and preimplantation genetic screening and 67% with expectant management.
The clinical miscarriage rate, calculated per pregnancy, was 7% with IVF and screening and 24% with expectant management.
Cost per live birth was $45,300 with IVF and screening and $418 with expectant management, which the authors describe as 100-fold more expensive.
The cost per clinical miscarriage averted with IVF and screening was $135,054, above the $100,000 threshold the authors set for cost effectiveness.
In sensitivity analyses, IVF and screening needed a live-birth rate of at least 91% to be cost effective. With its miscarriage rate set to 0, modeled live birth was 56% against 67%.

Interpretation

The study is a decision analytic model, a calculation built from published outcome rates and cost estimates for two strategies. The authors write that no prospective study or randomized trial has compared them directly. The IVF rates came from a 2012 cohort with an average maternal age of 36.7 years. The expectant management rates came from a 1999 cohort averaging 32 years. Only direct medical costs were counted. Obstetric costs were left out, as were adjustments for the higher rate of multiple births after IVF, which the authors say would likely favor expectant management further. The model applies to unexplained recurrent pregnancy loss only.

RRM Context

Current evaluation finds no cause in at least half of recurrent pregnancy loss cases, so those couples have no diagnosis. IVF with genetic screening bypasses the reproductive system and leaves the reason for the losses unresolved. Restorative reproductive medicine puts evaluation before treatment and searches both partners and the cycle for a cause.

Our editorial summary of this paper, not the article's abstract.

Abstract

Objective

To determine whether in vitro fertilization with preimplantation genetic screening (IVF/PGS) is cost effective compared with expectant management in achieving live birth for patients with unexplained recurrent pregnancy loss (RPL).

Design

Decision analytic model comparing costs and clinical outcomes.

Setting

Academic recurrent pregnancy loss programs.

Patients

Women with unexplained RPL.

Interventions

IVF/PGS with 24-chromosome screening and expectant management.

Main Outcome Measures

Cost per live birth.

Results

The IVF/PGS strategy had a live-birth rate of 53% and a clinical miscarriage rate of 7%. Expectant management had a live-birth rate of 67% and clinical miscarriage rate of 24%. The IVF/PGS strategy was 100-fold more expensive, costing $45,300 per live birth compared with $418 per live birth with expectant management.

Conclusions

In this model, IVF/PGS was not a cost-effective strategy for increasing live birth. Furthermore, the live-birth rate with IVF/PGS needs to be 91% to be cost effective compared with expectant management.

Topics

Assisted Reproduction › Industry, Cost and Access › Cost Effectiveness · Cost and Access › Cost of Care › Cost Effectiveness

Gayathree Murugappan, Mika S Ohno, Ruth B Lathi

G Murugappan, M Ohno, R Lathi

PMID 25772770 25772770 DOI 10.1016/j.fertnstert.2015.02.012 10.1016/j.fertnstert.2015.02.012 Murugappan et al. 2015, Murugappan 2015

Keywords

Abortion, Habitual/diagnosis/economics/genetics/prevention & Control, Cost-Benefit Analysis, Decision Support Techniques, Female, Fertilization in Vitro/adverse Effects/economics, Genetic Testing/economics, Health Care Costs, Humans, Live Birth, Models, Economic, Predictive Value of Tests, Pregnancy, Preimplantation Diagnosis/economics/methods, Treatment Outcome, Cost Effectiveness, In vitro Fertilization, Preimplantation Genetic Screening, Recurrent Pregnancy Loss