Incidence and costs of multifetal pregnancies in Andalusia (2000-2010).

In the past 50 years the incidence of multiple pregnancies has increased dramatically due almost exclusively to two factors: delayed childbearing and assisted reproductive techniques. In this paper we analyze the variations in the incidence of multiple gestations in Andalusia, one of the biggest administrative regions in Spain, over the last decade. Assisted reproduction techniques are very often evaluated only in terms of implantation and pregnancy rates per cycle, ignoring everything related to complications of multiple births, prematurity or economic overload. The rate of twins in Andalusia has increased from 10.9 per thousand in 2000 to 16.2 per thousand in 2009. The rate of triplet births has also increased in recent years. After a decline in 2003, motivated by promulgation of the first Human Assisted Reproduction Law, there was an increase after a second law came into effect in 2006. Health care spending attributable to the excess of multiple pregnancies reported in the decade 2000-2010 may have been much higher than € 25 million.

New York State Creates New Governance of Commercial Gestational Surrogacy.

United States law recognizes adult reproductive liberty and many states view surrogacy services through that lens. During the COVID-19 pandemic in March, 2020, New York State enacted the Child-Parent Surrogacy Act (CPSA) into law, after feminists and their allies had caused its defeat in 2019. Just before approval of the CPSA, a group of legislators introduced the Alternative Surrogacy Bill (ASB). This article is a case study that examines how the CPSA and not the ASB became law, examining surrogate rights, the best interests of the child, and the ethical issues related to adult donor-conceived and surrogacy born children's rights to information about their ancestry.

[Fertility treatments: possibilities for fewer multiple births and lower costs--the 'Umbrella' study]. / Vruchtbaarheidsbehandelingen: mogelijkheden voor minder meerlingen en lagere kosten--de 'Paraplustudie'.

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.

The efficacy and cost effectiveness of embryo cryopreservation compared with other assisted reproductive techniques.

OBJECTIVE: To evaluate the efficacy and cost effectiveness of embryo cryopreservation compared with other assisted reproductive techniques (ARTs). DESIGN: Retrospective review of medical records and health care costs. SETTING: Tertiary care academic medical school ART program. PATIENTS: For determination of the efficacy of cryopreserved ET, we analyzed 610 patients undergoing the first 1,000 oocyte retrievals in our program. For determination of cost effectiveness, we analyzed the costs associated with 334 initiated ART cycles in 1992. MAIN OUTCOME MEASURES: The ongoing pregnancy rate (PR) per initiated cycle and per oocyte retrieval. The medical costs associated with each procedure. RESULTS: The transfer of cryopreserved embryos increased the ongoing PR per oocyte retrieval by 6.6%. Transfer of cryopreserved embryos was cost effective compared with other ARTs. The cost per delivery for cryopreserved ETs was between 25% and 45% that of a fresh cycle. CONCLUSIONS: Including embryo cryopreservation in an ART program can improve PRs and lower the ultimate cost per delivery.

Patient dropout in an assisted reproductive technology program: implications for pregnancy rates.

OBJECTIVE: To study patient dropout and its impact on crude and cumulative pregnancy rates (PRs) after assisted reproductive technology (ART). DESIGN: Retrospective cohort study. SETTING: University hospital-based tertiary care fertility clinic. PATIENT(S): Two hundred two couples applying for their first ART treatment cycle. MAIN OUTCOME MEASURE(S): Drop-out rate and PR per cycle, cumulative drop-out rate and cumulative PR. RESULT(S): After three treatment cycles, the cumulative drop-out rate was 126 of 202 (62.4%); 13.9% (n = 28) was due to active censoring. Active censoring was shown to flatter cumulative PRs by life-table analysis. CONCLUSION: Dropout from ART is high, even when ART costs are covered by health cost insurance. Life-table analysis overestimates cumulative PRs in ART.

Preprogrammed, unmonitored ovarian stimulation reduces expense without compromising the outcome of assisted reproduction.

OBJECTIVE: To determine if a novel, preprogrammed, unmonitored stimulation protocol could reduce the cost of assisted reproductive technology (ART) without compromising outcome or safety. DESIGN: Prospective, nonrandomized study of unmonitored ART versus traditional monitoring. SETTING: University ART program. PATIENT(S): Infertile women aged < 39 years, with a basal FSH level < 15 mIU/mL (conversion factor to SI unit, 1.00) and regular menstrual cycles, undergoing ART. INTERVENTION(S): Oocyte retrieval was performed at a predetermined time in 72 unmonitored cycles based on age and basal FSH level. No monitoring of any type was performed before retrieval. There were 86 monitored control cycles. MAIN OUTCOME MEASURE(S): The number of oocytes, and embryos; complications including ovarian hyperstimulation. RESULT(S): The total cost for unmonitored ART was significantly less than for monitored cycles. There was no difference between groups for patient age, number of oocytes obtained, or number of metaphase II oocytes. For non-male-factor patients, the number of oocytes fertilized, number of embryos transferred, and the clinical pregnancy rates were comparable. There was one case of severe hyperstimulation requiring hospitalization in the unmonitored group. CONCLUSION(S): This novel, unmonitored ovarian stimulation protocol provides ART at a significantly lower cost than is incurred with traditional monitoring, with no apparent compromise in outcome.

A cost and outcome model of fertility treatment in a managed care environment.

OBJECTIVE: To build a financial model of a fertility practice operating under managed care. DESIGN: Financial model in Microsoft Excel (Redmond, Washington). SETTING: University-affiliated infertility practice, assuming primary care referral of patients and total revenue a function of the capitation contract. PATIENT(S): Female infertility patients and their partners with assumed mean age of 35 years. MAIN OUTCOME MEASURE(S): Breakeven capitation rate. RESULT(S): Every other month ovulation induction produced the lowest breakeven capitation rates in the model. Breakeven capitation rates increased from $0.85 up to $4.70 per member per month as utilization increased from 0.1% to 1% of health plan members. Decreasing the cost of an IVF-ET cycle $2,050 decreased breakeven capitation rates from $0.05 up to $0.80 per member per month as utilization of fertility services increases from 0.1% to 1% of health plan members. Decreasing average yearly pregnancy rate from 56% to 41% increased breakeven capitation rate from $0.10 to $0.80 per member per month across similar utilization. The average cost of pregnancy per year ranged from $6,787 to $21,075. CONCLUSION(S): As utilization of fertility services increases, cost reductions no longer exist to offset increasing breakeven capitation rates. Financial modeling, using actual data, can evaluate any medical decision in terms of outcome and the cost of that outcome. Modeling is an effective means for physicians to educate themselves concerning the cost of their fertility and medical decisions.

Leuprolide acetate-prepared in vitro fertilization-gamete intrafallopian transfer cycles: efficacy versus controls and cost analysis.

OBJECTIVE: To evaluate the effect of gonadotropin-releasing hormone agonist (GnRH-a) when given through stimulation with gonadotropins versus stopping it as stimulation was initiated versus a control group unprepared in this manner. Also, to construct a cost analysis for this type of therapy in an in vitro fertilization-gamete intrafallopian transfer program (IVF-GIFT). DESIGN: Prospective, consecutive, randomized, with a control group. SETTING: An out-patient IVF-GIFT program. PATIENTS: One hundred new patients entering an IVF-GIFT program. INTERVENTIONS: In vitro fertilization or GIFT cycles with or without preparation (pituitary suppression) by GnRH-a administration in which suppression was continued or halted as gonadotropins were begun. MAIN OUTCOME MEASURES: Cancellation rates, ampules, and days of gonadotropin use, costs, estradiol (E2) level, egg numbers and quality, and pregnancy rates. RESULTS: Stopping GnRH-a (leuprolide acetate) therapy as stimulation was begun did not lessen the suppressive effect in reduction of spontaneous luteinizing hormone surge as seen with continued use of agonist. In contrast, the control group had a 30.3% cancellation rate before ovum retrieval. The E2 and egg data among the groups were similar, but as expected, agonist use led to the need for more and longer duration of gonadotropin stimulation. Pregnancy rates were not different by group. Costs were approximately even by the third initiated cycle.

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.

Cost-effectiveness of infertility treatments: a cohort study.

OBJECTIVE: To determine the cost-effectiveness of infertility treatments. DESIGN: Retrospective cohort study. SETTING: Academic medical center infertility practice. PATIENT(S): All patients treated for infertility in a 1-year time span. INTERVENTION(S): Intrauterine inseminations, clomiphene citrate and IUI (CC-IUI), hMG and IUI (hMG-IUI), assisted reproductive techniques (ART), and neosalpingostomy by laparotomy. MAIN OUTCOME MEASURE(S): All medical charges and pregnancy outcomes associated with the treatments were obtained. Cost-effectiveness ratios defined as cost per delivery were determined for each procedure. The effects of a woman's age and the number of spermatozoa inseminated on cost-effectiveness of the procedures was also determined. RESULT(S): Intrauterine inseminations, CC-IUI, and hMG-IUI have a similar cost per delivery of between $7,800 and $10,300. All of these were more cost-effective than ART, which had a cost per delivery of $37,000. Assisted reproductive techniques in women with blocked fallopian tubes was more cost-effective than tubal surgery performed by laparotomy, which had a cost per delivery of $76,000. Increasing age in women and lower numbers of spermatozoa inseminated were factors leading to higher costs per delivery for IUI, CC-IUI, hMG-IUI, and ART. Use of donor oocytes reduced the cost per delivery of older women to the range seen in younger women with ART. CONCLUSION(S): Our analysis supports, in general, the use of IUI, CC-IUI, and hMG-IUI before ART in women with open fallopian tubes. For women with blocked fallopian tubes, IVF-ET appears to be the best treatment from a cost-effectiveness standpoint.

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.

Reproductive issues for men with cancer: technology and nursing management.

PURPOSE/OBJECTIVES: To review the current medical technologies available to protect the reproductive potential of adult males undergoing sterilizing cancer treatments; to describe the attributes and limitations of these technologies and how oncology nurses can access them for the patient; and to discuss psychosocial elements, including the legal considerations of oncology nurses who counsel patients. DATA SOURCES: Quantitative data from personal clinical records; personal clinical experience; published articles, abstracts, and books identified by bibliographic data base searches; and consultation with lawyers. DATA SYNTHESIS: Cancer treatment can have severe and adverse long-term iatrogenic effects on male fertility. Medical technologies that protect male reproduction potential from sterilizing procedures have progressed from unreliable to clinically practical over a period of 20 years. The present clinical means for preserving the potential reproductive capacity of men at risk is cryopreservation of sperm before treatment begins, followed by assisted reproductive technology when pregnancy is desired. Medical, legal, and religious issues relevant to counseling are involved. CONCLUSIONS: Current reproductive technology provides realistic hope for future procreation by men facing sterilizing cancer treatment. IMPLICATIONS FOR NURSING PRACTICE: Nursing intervention primarily involves providing patient counseling and arranging patient access to cryopreservation facilities. Oncology nurses can assist men making these types of reproductive decisions by assessing their medical and psychological need for information and by counseling them in regard to human sexuality, the fertility risk of oncologic therapy, the availability of reproductive interventions, and the social ramifications of using stored semen.

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.

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.

Genetic material donation: sperm, oocyte, pre-embryo.

Genetic material donation has become an integral part of the management of infertility. Sperm, oocyte and pre-embryo donation are medical and technical successful procedures, undertaken to deliberately procure the creation of a child. By application of the modern assisted reproductive technologies (ART), it is the adult's interests which are upheld. This does not necessarily imply that those interests apply also to the resulting offspring. Therefore, practice of genetic material donation raises ethical, legal, religious and social issues, which are discussed. The practice of gametes and pre-embryo donation is opposed by the main religions. The medical problems are related mainly to selection of donors, evaluation of recipients and quality control of the genetic material. The relationship between the biological and social parents and safeguarding the interest of the offspring, may be resolved by legislation pertaining to the individual country. Sperm and pre-embryo banks should be subjected to licensing and should not be run by a commercial system. The donated genetic material should not be used to extend the natural reproductive life span. By practicing sperm, oocyte and pre-embryo donation the medical profession and society should consider not only the interests of the infertile couple but the interests of the offspring as well.

ART in women 40 and over. Is the cost worth it?

OBJECTIVE: To determine the efficacy and cost of assisted reproductive techniques in older women (40 years or older) in comparison to younger women (less than 30 years old). STUDY DESIGN: Retrospective review of records from one university-based infertility practice. RESULTS: Women 40 years or older were significantly less likely to achieve pregnancy with human menopausal gonadotropin (hMG)/intrauterine insemination as compared to women under age 30. The older women were also significantly less likely to achieve pregnancy with in vitro fertilization (IVF). The use of donor oocytes resulted in the highest pregnancy rates in older women. Costs per cycle were similar, however, for both groups. CONCLUSION: Older women will consume an equal amount of medical resources per cycle in infertility treatment as compared to younger women (aged < 30 years). However, older women utilizing assisted reproductive techniques are four to five times less likely to achieve pregnancy than the younger group. This poor prognosis for success in older women adds significantly to the mean cost per pregnancy as compared to younger women. Donor oocytes may be the most cost-effective option for achieving pregnancy in older women.