11 September 2017
Alan Trounson is an emeritus professor, and Dr Karin Hammarberg a senior research fellow at Monash University.Appeared in BioNews 917
In Australia, almost four percent of children are born as a result of assisted reproductive technologies (ART). The comparatively high rate of ART use is in part due to costs being covered by the taxpayer-funded health insurance scheme, Medicare. However, IVF clinics can set fees above the Medicare rebate, and this difference becomes an out-of-pocket expense for the patient. This has progressively increased in the last decade and in many clinics, the out-of-pocket cost is now AU $4,000-5,000 for each treatment cycle. Demand has been gradually eroding, and larger established IVF providers are now seeing a decrease in infertile couples enrolling for ART treatment.
As a result, alternative providers that simply charge the rebate fee with minimal out-of-pocket expenses have entered the fertility industry. These 'no-frills' clinics rely on high throughput, have little face-to-face contact with patients, and offer treatments without 'add-on' technologies. Such clinics can be suitable for young couples with uncomplicated infertility. However, when the prospective mother is over 38, more clinical work and more advanced technology is needed to find developmentally sound eggs and embryos. This is also the case for couples with more complex infertility, such as caused by polycystic ovaries, genetic abnormalities or reduced egg or sperm supply. Solving these problems is expensive and time-consuming, and generally beyond the capabilities of the rebate-only clinics.
Nevertheless, this new low-cost model has put a downward pressure on prices that will see established clinics inevitably attempt to regain lost market share (see BioNews 915). Overall, this should benefit patients. Younger couples with uncomplicated infertility can access affordable treatment in low-cost clinics, and older couples and those with more complex infertility are likely to see prices drop in the established high-technology clinics.
In addition to lower ART treatment cost, there are other ways to reduce the cost of infertility to the individual and society. A group of experts have argued that unnecessary ART treatment and expense could be avoided if IVF clinics had a more prognosis-based approach, based on real life data that predicts natural and ART conception. In their view, some couples with so-called unexplained infertility are offered ART despite no evidence that this increases their chance of having a baby, but does expose them to inherent risks and costs.
It is also argued that technology over-servicing happens frequently. For example, ICSI (intracytoplasmic sperm injection) is now performed in almost 70 percent of IVF treatment cycles globally, in spite of evidence that it is effective only if the male partner has very poor semen quality. ICSI adds to the cost of treatment and there may be even some evidence of increased adverse birth outcomes. Furthermore, some clinics offer other unnecessary 'add-ons' that have little evidence for benefit but increase costs, and there are now calls for more scrutiny to ensure that the safety and efficacy of an adjunct treatment is established before it is recommended to patients.
Knowing what the chance is of having a baby and thus being able to estimate 'value-for-money' is of fundamental interest to patients. But, understanding information about success rates can be difficult because it depends on how it is presented. One clinic can look much more successful than another because of the way 'success' is reported. For example, if 100 women start a treatment cycle, 75 have an embryo transfer, 25 have a clinical pregnancy and 20 give birth, the 'pregnancy per embryo transfer' figure is 33 percent, but the 'live birth per started treatment cycle' figure is only 20 percent. In 2017, an audit of clinic websites in the UK concluded that they were used as advertisements to patients and that the risk of selective reporting therefore was considerable. The authors suggested that binding guidelines are needed to 'ensure consistent and informative reporting'.
Finally, a number of potentially modifiable factors reduce the chance of having a baby with ART. Of these, the woman's age is the most significant. Among women in Australia and New Zealand who used their own eggs in 2014, the live delivery rate per initiated stimulated cycle (excluding the chance offered by any frozen embryos) was almost 32 percent for women aged less than 30 years but only 6.2 percent for those aged 40-44 years. Chance is also reduced if one or both partners smoke or are obese. Fertility health promotion that increases awareness of these factors could potentially reduce the number of treatment cycles needed to achieve a live birth.
Downward trends in costs in IVF benefit patients, and will continue as low-cost providers enter the fertility industry. However, whether in low-cost and high-technology clinical settings, every couple's infertility profile must be matched with the right treatment.