Cost cutting in assisted reproductive techniques (art

1. Cost cutting in assisted reproductive techniques (art) DR SAMINA KHALID SIRM

2. What are art? • Assisted Reproductive Techniques (ART) refers to all techniques involving direct retrieval of oocytes from the ovary • ART procedures include IVF, GIFT, ZIFT, and ICSI. • The simplest ART procedure, IVF has been around for over 20 years and is perhaps the most commonly recognized ART of all procedures.

3. Indications for art • Tubal factor infertility • Endometriosis • Male factor infertility • Unexplained infertility • Ovarian failure • Diminished ovarian reserve • Mullein anomaly • Genetic risk

4. Process of art • Follicle growth • Oocyte maturation/ovulation triggering • Oocyte retrieval • Luteal support • Fertilization by IVF or ICSI • In vitro embryo culture • Transfer of fresh embryos • Cryopreservation of surplus embryos • First trimester pregnancy monitoring

5. Artificial insemination • It is the deliberate introduction of sperms into female's uterus or cervix for the purpose of achieving pregnancy through in vivo fertilization. • It has the following types: • Intracervical insemination • Intrauterine semination • Intratubal insemination

6. Indications of iui • Hostile cervical mucus • Cervical stenosis • Oligospermia • Anatomical defect in male e.g. hypospadias but normal ejaculate can be obtained • Unexplained infertility

7. Invitro fertilization (ivf) • IVF consists of retrieving preovulatory oocyte from ovary by transvaginal ultrasonography guided procedure, with subsequent fertilized egg (embryo) transferred within endometrial cavity • Usually transfer of embryo is done 2-5 days after fertilization through fine flexible soft catheter transcervically. • Not more than 3 embryo is transferred per cycle to minimize multiple pregnancy. • Luteal phase support is provided by progesterone supplementation.

8. Indications for ivf • Failed ovulation induction • Blocked Tubes • Azoo, Severe Oligo, Astheno,Teratozoospermia • Ovarian failure (Donor oocyte IVF) • Women with normal ovaries but • no functional uterus (Müllerian agenesis) • Women with genetic risk • Tubal disease • Endometriosis

9. Intracytoplasmic sperm injection (ICSi) • ICSI was first described by van Steirteghem and colleagues in Belgium (1992). • ICSI is an invitro fertilization procedure in which a single sperm is injected directly into cytoplasm of an oocyte by micropuncture of zona pellucida. • This procedure is carried out under a high quality inverted operating microscope. • Sperm is recovered from ejaculate. Otherwise sperm is retrieved by PESA/TESE (testicular sperm extraction) or by MESA (microsurgical epididymal spermaspiration) procedures. • Result: Fertilization rate is about 60-70%. Pregnancy rate is 20 40% per embryo transfer.

10. Indications for icsi • Azoospermia • Severe oligospermia (5 million sperms/ml) • Asthenospermia, teratospermia • Presence of sperm antiboides • Congenital absence of vas (bilateral)

12. cryopreservation • Its is the process of keeping embryos, sperms and tissues from ovaries at -196C under liquid nitrogen in the lab, for the restoration of fertility in the future. • It is increasingly used as an option to negate the risk of age-related fertility loss. • In a recent retrospective US study conducted by Leung etal, in which 921 women who vitrified their oocytes between 2006 and 2020, women who cryopreserved their oocytes before aged 38 achieved a higher cumulative live birth rate (CLBR) (38.9%) than those who planned their oocytes cryopreservation after age 38 (25%). Doi: 10.1016/j.rbmo.2021.06.024

13. Cryopreservation technique •  Controlled ovarian stimulation (COS) → oocyte retrieval → cryopreservation of mature oocytes • Administration of exogenous gonadotropins during COS with daily injections effectively extends the timeframe of the aforementioned FSH threshold, allowing for multi-follicular development. • Typically, patients will require 7–12 days of ovarian stimulation, during which their progress will be monitoring on a periodic basis using transvaginal ultrasonography and serum hormone levels.

14. CRYOPRESERVATION TECHNIQUE • Typically, once 1–2 follicles are measured to be >18 mm, follicle maturation is “triggered” using medications that mimic the natural LH surge. • The oocyte retrieval is performed around 36 h after the trigger medication to maximize oocyte maturation rates but minimize the risk of spontaneous ovulation. The oocyte retrieval is an outpatient procedure of less than 30 min during which needle aspiration of the ovarian follicle contents is performed under transvaginal ultrasonography guidance. It is within this fluid that oocytes are isolated and selected for cryopreservation by the embryologist. • The entire process can generally be accomplished in two weeks.

15. The need for cost reduction in art • Even though ART has existed for over four decades, it remains either unavailable or inaccessible to most people in resource-poor settings. • Apart from being costly, ART is also often time-consuming, physically and emotionally strenuous, and without certainty about its outcome • Moreover, in many resource-limited settings, such as Pakistan, infertility is often neglected due to many competing health needs, as well as the relatively high fertility rates and large family sizes, which may not only mask infertility in populations. • As a result, in many lower middle-income classes, government-funded infertility treatments are either limited or non-existent which means that many couples pay for their treatment out of pocket, making cost an important barrier to access, likely resulting in treatment inequalities

16. Current challenges • This means that in lower middle-income classes, ART can generally only be accessed by the well-off, paying out of pocket, via predominantly private health facilities. • Nonetheless, the desire for a child often encourages couples to make significant financial sacrifices and even suffer catastrophic financial hardship to obtain infertility care. • A systematic review conducted in 2023 showed that, specifically, in Africa and South-East Asia, the medical costs were on average 2- to 3-fold higher than the average GDP per capita (227.7% and 327.2%, respectively)

17. Current challenges • Expressing medical costs as a share of average annual income shows that patients paid significantly higher than their average annual income for one ART cycle in countries with no financing mechanisms, for example, Zimbabwe (456.8%), Sudan (401.5%), Ecuador (243.9%), India (166.4%), and Vietnam (106.3%) • In addition, when using average income as a marker of affordability, patients spent approximately half of their average annual income on one ART cycle in countries with mechanisms for government financing. In contrast, in countries with no mechanisms for financing, the cost for one cycle was even more than double their average annual income.

18. Current challenges • High Treatment Costs • Expensive medications, equipment, and lab tests • Limited Insurance Coverage • ART is not widely covered by insurance in Pakistan. • Lack of Government Support • Limited regulations and subsidies for fertility treatments.

19. What can we do?

20. Government Support & Policy Advocacy • Advocating for Subsidies and Support • Push for subsidies to make ART more affordable. • Standardization of Pricing • Government regulation to ensure price transparency. • Insurance Coverage • Lobby for ART to be covered under health insurance policies.

21. Affordable Medication & Generic Drugs • Use of Locally Produced Medications Locally made fertility drugs can cut costs significantly. • Generic Alternatives Use of generic drugs instead of brand-name medications to lower expenses. • Bulk Purchasing Clinics could buy medications in bulk to get better rates and reduce costs for patients.

22. Affordable IVF Packages • Discounted IVF Packages Comprehensive packages that include consultations, tests, medications, and procedures. • Group Discounts Collaborative offers between clinics and other healthcare providers. • Payment Plans Clinics can provide financing options to help patients manage costs over time.

23. Optimizing the Treatment Process • Streamlining Procedures Reducing unnecessary tests and treatments can lower overall costs. • Tailoring Stimulation Protocols Individualized protocols to avoid unnecessary cycles and optimize the egg retrieval process.

24. Collaboration and Partnerships • Collaborative Clinics Clinics working together to share resources and negotiate better pricing with suppliers. • Referral Programs Offering discounts to patients who refer others, creating a network of support and savings.

25. Use of Technology and Telemedicine • Telemedicine for Consultations Virtual follow-up consultations to reduce travel and clinic overhead costs. • Digital Patient Records Implementing electronic health records to increase efficiency and reduce administrative costs.

26. Non-invasive Alternatives • IUI as an Alternative to IVF For patients with less severe fertility challenges, IUI is a more affordable option. • Egg Freezing A long-term solution that can reduce future ART costs by preserving eggs for later use. In a recent retrospective US study conducted by Leung etal, in which 921 women who vitrified their oocytes between 2006 and 2020, women who cryopreserved their oocytes before aged 38 achieved a higher cumulative live birth rate (CLBR) (38.9%) than those who planned their oocytes cryopreservation after age 38 (25%). Doi: 10.1016/j.rbmo.2021.06.024

27. Fertility Tourism • Positioning Pakistan as a Fertility Hub Encouraging foreign patients to come to Pakistan for affordable ART treatments. • Package Deals for International Patients Offering travel and accommodation in addition to treatment.

28. Preventive Care & Education • Lifestyle Changes to Improve Fertility Healthy diet, weight management, and reducing stress can help reduce the need for expensive ART treatments. • Public Awareness Campaigns Education to improve awareness and early intervention, preventing the need for costly treatments.

29. Research Grants and Funding • Seeking Research Funding Apply for international grants or collaborations that can subsidize ART costs. • Non-profit Partnerships Working with NGOs to make ART more affordable for low-income families.

30. conclusion • Infertility is a major issue in Pakistan and since more than one third of our population in under the proverty line, access to fertility treatments is nothing short of impossible. • Government support, local alternatives, optimized processes, and non-invasive options can help decrease the cost of ART and make it more financially approachable. • Call to Action: Encouraging collaboration between clinics, the government, and non-profits to lower ART costs. • By implementing these strategies, Pakistan can make ART treatments accessible to a larger segment of the population.

32. Thank youany questions?