Correspondence
Economic Implications of Assisted Reproductive Technology
N Engl J Med 1994; 331:1588-1589December 8, 1994
- Article
To the Editor:
Neumann et al. (July 28 issue)1 indicate that the cost of having one child with in vitro fertilization begins at $66,667 and can rise as high as $800,000. This cost analysis is inappropriate. It includes such variables as travel time to appointments and time lost at work because of the treatment. It does not take into account the incidence of depression and the additional cost of mental health visits and days lost from work that would be saved if infertility was treated appropriately and the treatment was covered by insurance. The analysis also does not consider the savings accrued from the decreased use of less effective therapy, such as tubal surgery. Furthermore, a couple rarely goes through six cycles of in vitro fertilization even if there is insurance coverage. In these cases there are an average of 2.5 cycles. The authors also use outdated statistics for the success rate (9 to 12 percent) that are much lower than the 1992 national average of 16.8 percent.2
Even an unsuccessful attempt at in vitro fertilization can provide critical diagnostic information for both the patient and the physician to guide future therapy. Cost effectiveness is achieved by pinpointing the cause of the problem and providing specific treatment. Although it is true that the cost of in vitro fertilization treatment for an individual patient can be quite high, the cost to society for its coverage is relatively small. According to an actuarial study conducted by McMaster University and the American Fertility Society (unpublished data), the current cost of including coverage for in vitro fertilization is $2.36 per year per family policy.
2 ReferencesRobert D. Visscher, M.D.
American Fertility Society, Birmingham, AL 35216-28091
Neumann PJ ,Gharib SD ,Weinstein MC . The cost of a successful delivery with in vitro fertilization. N Engl J Med 1994;331:239-243
Full Text | Web of Science | Medline2
The American Fertility Society, Society for Assisted Reproductive Technology, Birmingham, Alabama
Web of Science | Medline
To the Editor:
Neumann et al. present an injudicious view of in vitro fertilization by ignoring recent advances in the technique. New strategies to optimize success rates are continuing to evolve. More effective approaches to controlled ovarian hyperstimulation are being developed to treat women with “low” and “high” responses. Assessments of ovarian reserve can now be reliably predicted by measuring basal serum follicle-stimulating hormone (FSH) levels early in the follicular phase. An elevated FSH level (higher than 20 mU per milliliter) portends a substantially poorer prognosis for pregnancy after in vitro fertilization, and for this reason patients may be encouraged to pursue other options, such as receiving donor oocytes, which have better success rates.1 Enhancing embryonic implantation by selective assisted hatching has shown that a routine clinical pregnancy rate of over 40 percent per transfer is a distinct possibility.2 Even the treatment of couples with severe male-factor infertility can be greatly facilitated by micromanipulation techniques, such as intracytoplasmic injection of sperm, which has resulted in promising initial success rates.3
3 ReferencesMark A. Damario, M.D.
Maureen Moomjy, M.D.
Zev Rosenwaks, M.D.
Center for Reproductive Medicine and Infertility, New York, NY 100211
Burton G ,Abdalla HI ,Kirkland A ,Studd JW . The role of oocyte donation in women who are unsuccessful with in-vitro fertilization treatment. Hum Reprod 1992;7:1103-1105
Web of Science | Medline2
Cohen J ,Alikani M ,Trowbridge J ,Rosenwaks Z . Implantation enhancement by selective assisted hatching using zona drilling of human embryos with poor prognosis. Hum Reprod 1992;7:685-691
Web of Science | Medline3
Van Steirteghem AC ,Nagy Z ,Joris H , et al. High fertilization and implantation rates after intracytoplasmic sperm injection. Hum Reprod 1993;8:1061-1066
Web of Science | Medline
To the Editor:
Neumann et al. claim that establishing a cost for having a child is “the least we can do... to improve the discourse over policy by a better understanding of the costs and results involved.” Health is defined by the World Health Organization as a complete state of physical and mental well-being.1 Health is more than the absence of disease; it is the harmonious development of the human being. Infertility affects the person adversely both mentally and physically, thereby justifying treatment with in vitro fertilization. Viewing infertility as a health problem in the social context makes its treatment a health-enhancing act.1 Not providing available treatment with in vitro fertilization is therefore discriminatory. In this great country, a person's guarantee of life, liberty, and the pursuit of happiness should include medical care in order to achieve pregnancy.
1 ReferencesMachelle M. Seibel, M.D.
Faulkner Centre for Reproductive Medicine, Boston, MA 021301
Knoppers BM ,Le Bris S . Ethical and legal concerns: reproductive technologies 1990-1993. Clin Opin Obstet Gynecol 1993;5:630-635
Web of Science | Medline
To the Editor:
The study by Neumann et al. of the cost of achieving a birth through in vitro fertilization would have been more powerful had the authors compared the various charges for assisted reproductive technology with the charges for the same services delivered in a fee-controlled environment, such as that of Medicare. For example, three programs in the Northeast charge from $315 to $405 for cognitive consulting services that would bring a reimbursement of $100 to $125 for a Medicare patient in my office. Quick ultrasound studies to evaluate follicle size cost up to $250. In comparison, were the vascular laboratory in our office to perform a more detailed duplex scan of the lower-extremity veins of a Medicare patient, the maximal revenue would be approximately $168. Egg retrieval is billed at $1,000. I can only imagine what the allowable charge would be if it was calculated according to the Medicare resource-based relative-value scale. The current charge to the patient for one ampule of menotropins ranges from $55 to $65. There is only one manufacturer of these drugs, and the price has increased more than 25 percent from 1989 to 1994. One program in the northeastern United States charges $2,500 for ovum micromanipulation, with extra fees for partial dissection of the zona or subzonal insertion of sperm. One must conclude that assisted reproductive technology is grossly overpriced at every level -- hospitals, physicians' services, and pharmaceuticals. To put it bluntly, assisted reproductive technology is a cash cow.
Jeffrey L. Kaufman, M.D.
Baystate Medical Center, Springfield, MA 01199To the Editor:
Our program has developed a novel option for couples requiring in vitro fertilization treatment if the woman is under 38 years old (and therefore has a good prognosis). The couple places $19,000 in an escrow account and can do up to six cycles of stimulated in vitro fertilization, as well as any cycles of cryopreservation that may result. When a healthy baby is delivered, we earn this escrow money; if not, all the escrow money is returned to the couple. They buy their own medication and pay a nonrefundable fee of $1,000 per cycle. This may mean that a couple without a successful delivery goes through multiple cycles of in vitro fertilization at relatively low cost. This couple would be subsidized by the couple that has a delivery after one or two cycles and is required to pay the full escrow amount. We based these fees on our delivery rate of 30 percent per egg retrieval (78 deliveries out of 275 initiated cycles and 264 egg retrievals). The onus is therefore on the in vitro fertilization program to be cost effective and successful.
Michael J. Levy, M.D.
Shady Grove Fertility Center, Rockville, MD 20850Author/Editor Response
The authors reply:
To the Editor: Visscher asserts that our analysis ignores the cost savings from factors such as the decreased number of mental health visits, the avoidance of surgery. We are not aware of any data to document such savings, although our paper noted their potential importance. To the extent that success rates are rising, as Visscher maintains, they should be incorporated into future analyses. We note, however, that his data define success as deliveries per egg retrieval, not per initiated cycle, as in our paper. We believe that the initiated cycle represents a more appropriate starting point for measurement.
Damario et al. indicate that newer techniques of assisted reproduction have higher success rates. However, they ignore the fact that these techniques are probably associated with increased costs. Moreover, these techniques are not yet widely available.
Levy and his colleagues have devised an interesting system of financing in vitro fertilization treatment. Because this plan creates an incentive to select patients with an excellent prognosis, the success rates should be higher, and the costs per delivery lower, than the national averages. As a result, such programs may become more widespread.
We agree with Seibel that infertility adversely affects a person's mental and physical health. Since society does not have unlimited resources, however, we are forced to make difficult decisions about allocating resources among desired alternatives. Do we, for example, choose to save the lives of people who are now alive or to create new lives? In our paper we attempted to provide objective data so that such decisions can be as informed as possible.
Finally, we reiterate that the goal of our paper was neither to support nor to oppose reimbursement for in vitro fertilization. We did not state or intend to imply a value judgment about whether the costs we calculated should be considered high or low. As we noted, such an interpretation would require information about how people value the procedure. People may or may not be willing to pay the costs involved. We cited one study finding that survey respondents were willing to pay from $170,000 to $1.7 million per delivery with in vitro fertilization, depending on how the question was framed.1 Future studies need to continue improving our understanding of the benefits and costs associated with the procedure.
1 ReferencesPeter J. Neumann, Sc.D.
Project HOPE Center for Health Affairs, Bethesda, MD 20814Soheyla D. Gharib, M.D.
Brigham and Women's HospitalMilton C. Weinstein, Ph.D.
Harvard School of Public Health, Boston, MA 021151
Neumann PJ ,Johannesson M . Willingness to pay for in vitro fertilization: a pilot study using contingent valuation. Med Care 1994;32:686-699
CrossRef | Web of Science | Medline
- Citing Articles (2)
Citing Articles
1
Kaylen Silverberg, Salim Daya, Jean Paul Auray, Gerald Duru, William Ledger, Matts Wikland, Renda Bouzayen, Mark O’Brien, Barri Falk, Ariel Beresniak. (2002) Analysis of the cost effectiveness of recombinant versus urinary follicle-stimulating hormone in in vitro fertilization/intracytoplasmic sperm injection programs in the United States. Fertility and Sterility 77:1, 107-113
CrossRef2
Richard P. Porreco. (1998) A Guest Editorial. Obstetrical & Gynecological Survey 53:7, 393-394
CrossRef
