Access to infertility care in a low-resource setting: bridging the gap through resident and fellow education in a New York City public hospital.

PURPOSE: Improving access to care is an issue at the forefront of reproductive medicine. We sought to describe how one academic center, set in the background of a large and diverse metropolitan city, cares for patients with extremely limited access to reproductive specialists. METHODS: The NYU Reproductive Endocrinology and Infertility (REI) Fellowship program provides a "fellow-run clinic" within Manhattan's Bellevue Hospital Center, which is led by the REI fellows and supervised by the REI attendings of the NYU Langone Health system. A description of the history of the hospital as well as the logistics of the fertility clinic is provided as a logistical template for implementation. RESULTS: The fellow-run fertility clinic at Bellevue hospital is held on two half days per month seeing approximately 150 new patients per year. The fertility workup, counseling, surgery, as well as ovulation induction, and early pregnancy management are offered within the construct of the fellowship and residency at NYU. Barriers to care and ways to circumvent those barriers are discussed in detail. CONCLUSION: By utilizing the ambition and construct of the OB/GYN programs, we greatly improve care for an otherwise underserved patient population by offering an efficient and optimal infertility workup and treatment in a population that would otherwise be without care. We utilize the framework of graduate medical education to provide autonomy, experience, and mentorship to both residents and fellows in our programs in an effort to provide a solution to combating inequity in infertility care.

Increasing access to fertility care through private foundations.

OBJECTIVE: To characterize the available support for infertility treatment and populations served by private foundations across the United States. DESIGN: Web-based cross-sectional survey. SETTING: Not applicable. PATIENT(S): Not applicable. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Geographies and populations served, dollar-amount and scope of financial assistance provided by private foundations for individuals seeking financial assistance for infertility treatment. RESULT(S): Thirty-seven private foundations were identified, 25 responded (68% response rate). More than one-half of the foundations had awarded grants to lesbian, gay, and transgender individuals, as well as single men and women. Forty percent of the foundations serve only a single state or geographic region. Foundations have provided 9,996 grants for infertility treatment, 1,740 in 2016 alone, with an average value of $8,191 per grant. The Livestrong foundation has provide more than 90% of these grants, and only to patients with a history of cancer. Twelve percent of foundations provide assistance for fertility preservation in patients with cancer, and 20% provide assistance for elective oocyte cryopreservation. CONCLUSION(S): Private foundations significantly increase access to infertility care for individuals and couples affected by cancer who could otherwise not afford treatment. Significant heterogeneity exists regarding the populations served and the services available for grant support by these foundations, and the landscape of options for patients unaffected by cancer is severely limited.

Cost-effectiveness of preimplantation genetic testing for aneuploidies.

OBJECTIVE: To evaluate the economical benefit of preimplantation genetic testing of aneuploidies (PGT-A) when applied in an extended culture and stringent elective single ET framework. DESIGN: Theoretical cost-effectiveness study. SETTING: Not applicable. PATIENTS/ANIMAL(S): None. INTERVENTION(S): Comparison of the cost-effectiveness between two IVF treatment strategies: serial transfer of all available blastocysts without genetic testing (first fresh transfer and subsequent frozen-thawed transfer); and systematic use of genetic testing (trophectoderm biopsy, freeze-all, and frozen-thawed transfers of euploid blastocysts). The costs considered for this analysis are based on regional public health system provider. MAIN OUTCOME MEASURE(S): Costs per live birth. RESULT(S): Cost-effectiveness profile of PGT-A improves with female age and number of available blastocysts. Sensitivity analyses varying the costs of ET, the costs of genetic analyses, the magnitude of the detrimental impact of PGT-A on live birth rate, and the crude live birth rates change to some extent the thresholds for effectiveness but generally confirm the notion that PGT-A can be economically advantageous in some specific subgroups. CONCLUSION(S): PGT-A can be cost-effective in specific clinical settings and population groups. Economic considerations deserve attention in the debate regarding the clinical utility of PGT-A.

"Creating a family after battling cancer is exhausting and maddening": Exploring real-world experiences of young adult cancer survivors seeking financial assistance for family building after treatment.

OBJECTIVE: Young adult (YA) cancer survivors who received gonadotoxic therapy are at risk for impaired fertility and/or childbearing difficulties. This study explored the experiences and financial concerns of survivors pursuing family building through assisted reproductive technology (ART) and adoption. METHODS: Retrospective study of data collected from grant applications for financial assistance with family building. Grounded theory methodology using an inductive data-driven approach guided qualitative data analysis. RESULTS: Participants (N = 46) averaged 32 years old (SD = 3.4) were primarily female (81%) and married/partnered (83%). Four main themes were identified representing the (1) emotional experiences and (2) financial barriers to family building after cancer, (3) perceived impact on partners, and (4) disrupted life trajectory. Negative emotions were pervasive but were balanced with hope and optimism that parenthood would be achieved. Still, the combination of high ART/adoption costs, the financial impact of cancer, and limited sources for support caused extreme financial stress. Further, in the face of these high costs, many survivors reported worry and guilt about burdening partners, particularly as couples failed to meet personal and societal expectations for parenthood timelines. CONCLUSION: After cancer, YAs face numerous psychosocial and financial difficulties in their pursuits of family building when ART/adoption is needed to achieve parenthood. Survivors interested in future children may benefit from follow-up fertility counseling post-treatment including discussion of ART options, surrogacy, and adoption, as appropriate, and potential barriers. Planning for the financial cost and burden in particular may help to avoid or mitigate financial stress later on.

Hysteroscopic polypectomy prior to infertility treatment: A cost analysis and systematic review.

The cost of fertility treatment is expensive and interventions that reduce cost can lead to greater efficiency and fewer embryos transferred. Endometrial polyps contribute to infertility and are frequently removed prior to infertility treatment. It is unclear whether polypectomy reduces fertility treatment cost and if so, the magnitude of cost reduction afforded by the procedure. The aim of this study was to determine whether performing office or operative hysteroscopic polypectomy prior to infertility treatment would be cost-effective. PubMed, Embase, and Cochrane libraries were used to identify publications reporting pregnancy rates after hysteroscopic polypectomy. Studies were required to have a polypectomy treatment group and control group of patients with polyps that were not resected. The charges of infertility treatments and polypectomy were obtained through infertility organizations and a private healthcare cost reporting website. These charges were applied to a decision tree model over the range of pregnancy rates observed in the representative studies to calculate an average cost per clinical or ongoing pregnancy. A sensitivity analysis was conducted to assess cost savings of polypectomy over a range of pregnancy rates and polypectomy costs. Pre-treatment office or operative hysteroscopic polypectomy ultimately saved €6658 ($7480) and €728 ($818), respectively, of the average cost per clinical pregnancy in women treated with four cycles of intrauterine insemination. Polypectomy prior to intrauterine insemination was cost-effective for clinical pregnancy rates greater than 30.2% for office polypectomy and 52.6% for operative polypectomy and for polypectomy price <€4414 ($4959). Office polypectomy or operative polypectomy saved €15,854 ($17,813) and €6644 ($7465), respectively, from the average cost per ongoing pregnancy for in vitro fertilization/intracytoplasmic sperm injection treated women and was cost-effective for ongoing pregnancy rates greater than 26.4% (office polypectomy) and 31.7% (operative polypectomy) and polypectomy price <€6376 ($7164). These findings suggested that office or operative hysteroscopic polypectomy was cost-effective when performed prior to both intrauterine insemination and in vitro fertilization over a range of plausible pregnancy rates and procedural costs.

A doação compartilhada de óvulos no Brasil sob enfoque do Direito e da Bioética / Egg sharing in Brazil from the legal and bioethical point of view

Este artigo analisa os aspectos jurídicos e bioéticos da prática médica da doação compartilhada de óvulos no contexto da Reprodução Assistida no Brasil. Trata-se de uma prática criada pela classe médica para auxiliar na obtenção de gametas femininos e beneficiar as pacientes que buscam alcançar a gravidez com assistência profissional (AU)

This paper examines the legal and bioethical aspects of medical practice of shared egg donation in the context of Assisted Reproduction in Brazil. This is a practice created by physicians to aid in obtaining female gametes and benefit patients seeking to achieve pregnancy with professional assistance (AU)

Infertility in reproductive-age female cancer survivors.

Improved survival rates among reproductive-age females diagnosed with cancer have increased the focus on long-term quality of life, including maintenance of the ability to conceive biological children. Cancer-directed therapies such as high-dose alkylating agents and radiation to the pelvis, which deplete ovarian reserve, radiation to the brain, which affects the hypothalamic-pituitary-gonadal axis, and surgical resection of reproductive structures can decrease the likelihood of having biological children. Standard fertility preservation strategies such as embryo and oocyte cryopreservation before the onset of therapy offer the opportunity to conserve fertility, but they may not be feasible because of the urgency to start cancer therapy, financial limitations, and a lack of access to reproductive endocrinologists. Ovarian tissue freezing is considered experimental, with limited data related to pregnancies, but it minimizes treatment delay. Studies evaluating gonadotropin-releasing hormone analogues have had mixed results, although a recent randomized, prospective study in women with breast cancer demonstrated a protective effect. Fertility preservation programs are increasingly being developed within cancer programs. In this article, we describe risks to infertility and options for preservation, raise psychosocial and ethical issues, and propose elements for establishing an effective fertility preservation program.

A comparative analysis of assisted reproductive technology cycles in Australia and New Zealand 2004-2007.

BACKGROUND: There are different funding arrangements for fertility treatments between New Zealand (NZ) and Australia. In NZ, there are two options for patients accessing treatment: either meeting specified criteria for age, no smoking and BMI for publicly funding or funding their own treatment. This differs from Australia, which has no explicit eligibility criteria restricting access to fertility treatment. An analysis of assisted reproductive technology (ART) in Australia and NZ was undertaken to consider the impact of these different funding approaches. METHODS: Data were extracted from the Australian and New Zealand Assisted Reproduction Database between 2004 and 2007. A total of 116 111 autologous fresh cycles were included. RESULTS: In Australia, more cycles were in women aged 40 years or older compared with those in NZ (23.5 versus 16.0%, P < 0.01). Single embryo transfer was more common in NZ than that in Australia, in women < 35 years of age (75.1 versus 59.6%, P < 0.01). In women <35 years, the crude rates of clinical pregnancy (37.5 versus 31.2%, P < 0.01) and live delivery (31.6 versus 26%, P < 0.01) following fresh ART cycles were significantly higher in NZ than that in Australia. These differences in outcomes persisted in older age groups. CONCLUSIONS: The purpose of the criteria used in NZ to access public funding for fertility treatments is to optimize pregnancy outcomes. This approach has resulted in a healthier population of women undergoing treatment and may explain the improved pregnancy outcomes seen in NZ couples who undergo fertility treatments.

Who should pay for assisted reproductive techniques? Answers from patients, professionals and the general public in Germany.

BACKGROUND: Financing ART is variously regulated in the different countries of Europe. In Germany, coverage of assisted reproduction by statutory health insurances was restricted to 50% in 2004. We conducted a national survey among patients, professionals (physicians and other academics in IVF centres, psychosocial counsellors, medical ethicists, social lawyers, health politicians) and the general public in Germany regarding their opinions on financing ART. METHODS: Standard questionnaire techniques (paper and pencil interviewing, computer-aided web interviewing, computer-aided telephone interviewing) were used. RESULTS: The vast majority of all groups supported public coverage of ART. Co-payments by patients were considered appropriate by about one-third of the patients, two-third of the physicians and three quarters of all other groups. According to the respondents, the amount of co-payment should cover 15-25% of the costs, considerably less than what patients actually have to pay (50%). Support for public coverage was strongly correlated with the views (i) of infertility as a disease, (ii) that there is a need for assisted reproduction for infertile couples and (iii) that every human should have the opportunity to have children. The respondents had varying opinions on whether to increase medical insurance premiums in order to cover ART. Reducing services in other areas of health care in favour of reproductive medicine was supported only by the group of reproductive physicians. Financial incentives for oocyte sharing were rejected by most groups as was a money-back guarantee for unsuccessful treatments. CONCLUSIONS: Experts and the general public in Germany accept moderate co-payments for ART. No clear pattern of opinion emerged regarding the question of how public co-funding should be financed.

Partnership for Families Program: philanthropy for in vitro fertilization patients.

OBJECTIVE: To describe our Partnership for Families Program, which was established to provide second in vitro fertilization (IVF) cycles for couples who pay for one IVF cycle, do not get pregnant and cannot afford a second IVF cycle. In addition, this program provides funding for fertility-sparing procedures for financially needy cancer patients. STUDY DESIGN: Retrospective description of the Partnership for Families' first 5 years of operation. RESULTS: In its 5 years of operation, the Partnership for Families Program has provided 137 infertile couples with a second IVF cycle, resulting in 68 ongoing or delivered pregnancies. It has also provided funding for 19 fertility-sparing procedures for cancer patients. CONCLUSION: Because of the high costs of IVF, alternative funding sources, specifically philanthropy, must be explored to provide increased access to IVF. The Partnership for Families Program, started by patients in a single practice, has in 5 years provided over 151 infertile and cancer patients IVF or egg-freezing cycles that they otherwise could not have afforded. This is a program that can be emulated by other fertility centers.

A Abordagem do casal infértil / The infertile couple assessment

As escolhas que definem a pesquisa e o tratamento da infertilidade fazem parte de um desenvolvimento sistemático de procedimentos. Em breve revisão, procurou-se identificar as melhores opções disponíveis entre dados da Medicina Baseada em Evidências. A partir da definição da infertilidade, foram identificadas as situações causais que permitem o início da pesquisa, assim como justificam sua antecipação temporal. Buscaram-se considerações sobre a etiologia e o diagnóstico; a importância dos principais exames utilizados; a infertilidade sem causa aparente; o casal infértil e a reprodução assistida; e o direito dos casais de receber informações claras e objetivas sobre os procedimentos, participando das decisões de terapêuticas. De forma geral, embora se tenha ganhado exames e procedimentos, a indicação de alguns, outrora considerados clássicos e indispensáveis, hoje não encontra mais sustentação, enquanto outros, novos, ainda permanecem sem níveis de evidência definidos.

The infertile couple routine assessments include a wide range of exams. In this review we look for the best options following the criteria of Evidenced Based Medicine. We review the definition of infertility and the data from anamnesis and physical exam that can lead to the investigation. Situations in which exams are anticipated are discussed. The most common ethiology and diagnosis are reviewed, as well as the most significant tests. In addition, unexplained infertility, the infertile couple and the assisted reproductive techniques, the right of the couples to be informed and to participate of the therapeutical decisions about their fertility were discussed. Classical exams like the post coital test and the endometrium biopsy are almost useless, while many available new tests based on technology, remain without defined strength on evidence levels.

Actuarial analysis of private payer administrative claims data for women with endometriosis.

BACKGROUND: Endometriosis is a painful, chronic disease affecting 5.5 million women and girls in the United States and Canada and millions more worldwide. The usual age range of women diagnosed with endometriosis is 20 to 45 years. Endometriosis has an estimated prevalence of 10% among women of reproductive age, although estimates of prevalence vary greatly. Endometriosis is the most common gynecological cause of chronic pelvic pain, but published information on its associated medical care costs is scarce. OBJECTIVE: The aim of this study was to determine (1) the prevalence of endometriosis in the United States, (2) the amount of health care services used by women coded with endometriosis in a commercial medical claims database during 1999 to 2003, and (3) the endometriosis-related costs for 2003, the most recent data available at the time the study was performed. METHODS: This study was a retrospective review of administrative data for commercial payers, which included enrollment, eligibility, and claims payment data contained in the Medstat Marketscan database for approximately 4 million commercial insurance members. All claims and membership data were extracted for each woman aged 18 to 55 years who had at least 1 medical or hospital claim with a diagnosis code for endometriosis (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 617.00-617.99) for 1999 through 2003. Claims data from 1999 through 2003 were used to determine prevalence and health care resource utilization (i.e., annual admission rate, annual surgical rate, distribution of endometriosis-related surgeries, and prevalence of comorbid conditions). The cost analysis was based on claims from 2003 only. Cost was defined as the payer-allowed charge, which equals the net payer cost plus member cost share. RESULTS: The prevalence of women with medical claims (inpatient and/or outpatient) containing ICD-9-CM codes for endometriosis was 1.1% for the age band of 30 to 39 years and 0.7% over the entire age span of 18 to 55 years. The medical costs per patient per month (PPPM) for women with endometriosis were 63% greater ($706 PPPM) than those of the average woman per member per month ($433) in 2003; inpatient hospital costs accounted for 32% of total direct medical costs. Between 1999 and 2003, these women with endometriosis who were identified by either inpatient and/or outpatient claims had high rates of hospital admission (53% for any reason; 38% for an endometriosis-related reason) and a high annual surgical procedure rate (64%). Additionally, women with endometriosis frequently suffered from comorbid conditions, and these conditions were associated with greater PPPM costs of 15% to 50% for women with an endometriosis diagnosis code, depending on the condition. Interstitial cystitis was associated with 50% greater cost ($1,061 PPPM); depression, 41% ($997 PPPM); migraine, 40% ($988 PPPM); irritable bowel syndrome, 34% ($943 PPPM); chronic fatigue syndrome, 29% ($913 PPPM); abdominal pain, 20% ($846 PPPM); and infertility, 15% ($813 PPPM). CONCLUSIONS: Women with endometriosis have a high hospital admission rate and surgical procedure rate and a high incidence of comorbid conditions. Consequently, these women incur total medical costs that are, on average, 63% higher than medical costs for the average woman in a commercially insured group.

Diagnosing infertility in a district general hospital: a case-note and cost analysis.

This study aimed to observe diagnostic work-up and cost evaluation of infertile couples to identify opportunities for improvement. One hundred and seventy-four new referrals to the gynaecology clinic in a District General Hospital during 1996 and 1997 provided the cohort for analysis. Data from case notes were transferred on to data collection sheets. Data were inputted into SPSS for analysis. Primary infertility accounted for 62% of couples. One hundred and forty-two couples (81.6%) had a definitive diagnosis, and the analyses relate to these couples only. There was no single investigation performed on the whole cohort studied. Semen analysis was undertaken in 80.3% of the couples; couples with suspected male infertility were over four times more likely to have had more than two semen tests (P = 0.0005); 77.5% of couples had FSH and LH tests; and midluteal progesterone was tested in 76.1%. An increased intensity of FSH-LH hormone testing was associated with couples with anovulation (chi(2) = 6.79, P = 0.03). Serial repeat progesterone tended to be given to women with irregular or prolonged cycles (35 days or more), although this tendency was not statistically significant. The most common test for tubal patency was hysterosalpingography. Higher costs are generally associated with diagnosing endometriosis and tubal factor because of the relatively high cost of laparoscopy. The average cost of diagnosis for each patient was pound 365 and ranged from pound 64 to pound 851. In conclusion, a standard protocol of basic investigative procedures should be offered in secondary centres to all couples. Avoiding duplication and unnecessary investigations (for example, serial progesterone) may reduce costs, although offering all couples a standard protocol of tests would probably offset this observation.

Health inequality and users' risk-taking: a longitudinal analysis in a French reproductive technology centre.

This article sets out to provide a demographic analysis of the production of social inequality through IVF trajectories in a reproductive technology centre of a French hospital. However specific this example may be, it reveals one of the paradoxes of social inequalities in health: lay experience of risk in reproductive technology shows profound inequalities related to social status, despite the fact that equality would seem to be guaranteed in France, since the social security system covers the full cost of the treatments. We will try to understand this paradox through a lifecourse approach. Thus, it will be shown that social inequality in reproductive health is deeply rooted in social scenarios of infertility that lead to differentiated medical experience: there is little benefit and even a worsening in the situation of lower class women, who were faced with unpredictable risks related to the collective testing of these new technologies. Conversely, the possibility of inventing new lifestories, which may or may not include motherhood, was given to upper class women who take calculated risks to delay the scheduling of their pregnancies. In short, this study confirms that the production of social inequality in reproductive health can only be understood in connection with the social dynamics of lifestyles, resulting in specific medical patterns. This paper also leads to the assumption that these social scenarios are related to attempts to enhance the different forms of capital: economic, cultural and social capital. In addition, the presence of risks aggravates this inequality process. This raises another question: do reproductive technologies result in reinforcing social inequality?