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Infertility & Childlessness Future healthcare policies. Willem Ombelet Genk Institute for Fertility Technology Belgium Kheel lecture Jones Institute Norfolk, 01-03-2011. ESHRE Capri Workshop Group, Hum Reprod Update, 16, 590, 2010.

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Infertility & Childlessness Future healthcare policies


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    1. Infertility & ChildlessnessFuture healthcare policies Willem Ombelet Genk Institute for Fertility Technology Belgium Kheel lecture Jones Institute Norfolk, 01-03-2011

    2. ESHRE Capri Workshop Group, Hum Reprod Update, 16, 590, 2010 Figure 2 Adjusted total fertility rate (TFR) for European countries (Lutz et al., 2008b). (The values have been adjusted for the tempo effect arising from postponement of childbearing which depresses the values of the conventional period TFR) The lowest fertility rates in 2004 were registered in Eastern Europe, Italy, Greece and Spain.

    3. Patient’s urgent wish to become pregnant Cost infertile couple Low ongoing pregnancy rate per treatment cycle Cost society Infertility treatment programs Complications of multiple pregnancies Other complications: OHSS … Influence of Industry Need for regulations Need for public information

    4. Connolly et al., Hum Reprod Update, 16, 603, 2010 Figure 1 Estimates of the direct cost of one fresh ART treatment cycle (euro 2006). (1) Henne et al., 2008; (2) Chambers et al., 2009; (3) Chambers et al., 2009; (4) Chambers et al., 2009; (5) Chambers et al., 2009; (6) Strandell et al., 2005; (7) NICE, 2004; (8) Maheshwari et al., 2009; (9) Koivurova et al., 2004; (10) Chambers et al., 2009; (11) Thurin Kjellberg et al., 2006; (12) de Mouzon et al., 2004; (13) Bouwmans et al., 2008 and (14) De Sutter et al., 2002. Note: costs are indexed to 2006 using medical consumer price indexes, and converted to euros using average 2006 interbank exchange rates.

    5. Connolly et al., Hum Reprod Update, 16, 603, 2010 Figure 2 Average cost of a standard IVF cycle as a percentage of annual disposable income in selected developed countries in 2006. Notes: 1. Reproduced from Chambers et al., 2009 with permission from Elsevier Publishing. 2. Annual disposable income is based on a single person at 100% of average earnings with no dependents. 3. The estimated percentage reduction in the average price of a standard IVF cycle due to government subsidization was 11% for Canada, 25% for the UK, 50% for Scandinavia, 0% for Japan and 71% for Australia. 4. In the USA, there is negligible government subsidization for ART, however, the central role of private insurance in the USA was included in the analysis, reducing the average price of a standard cycle by 12%.

    6. Family sizes Observed and desired Births per woman 1989

    7. Macro-economical estimates

    8. Analysis of costs IVF – 6 wks 48,000 40+

    9. IVF outcome and age UK 2002 USA 2002

    10. NNT for one live birth

    11. Multiple pregnancies = Complication of ART

    12. Foetal mortality Foetal morbidity Perinatal mortality Perinatal morbidity Childhood morbidity Maternal mortality Maternal morbidity Economic impact Psychological impact ... Multiple pregnancies = Complication of ART

    13. ART: ESHRE- resultsEurope 1999 : 22 countries 74 42.0 37.2 24 11.5 9.4 Overall multiple pregnancy rate = 26.3% Iceland 18.9 % Czech 38 % Slovenia 16.7 % Hungary 39.2 %

    14. USA 2001 MPR 40 % Schieve & Reynolds Hum Reprod, 2004

    15. Prevention of multiple pregnancies Projected costs of IVF/ICSI for the USA (2000) Collins & Graves, Hum Fert (Camb), 3, 275, 2000

    16. SPE – results 1993-2003perinatalrisks Birth weight at delivery grams singl.(%) twins(%) triplets(%) (n=17.761) (n=8.096) (n=799) 500-9990.73.1 (x4)10.0 (x14) 1000-14990.8 4.8 (x6)19.0 (x23) 1500-24996.1 48.2 63.8  2500 92.4 43.8 7.1

    17. SPE – results 1993-2003perinatalrisks Neonatal interventions & complications singletons(%) twins(%) triplets(%) Endotracheal ventilation1.87.5 x422.1 x12 Intracranial bleeding 0.51.9 x45.6 x11 Convulsions 0.20.4 x21.5 x7 Lung disease 1.8 8.0 x420.4 x11

    18. Costs neonatal care (Euro) Review 40 studies (Petrou S, BJOG 2003,110,17) US Non-US Genk grams (70 twins & triplets) < 1000 38700 20830 23900 1000-1499 23710 1049011540  1500 / 6444 7553

    19. SPE: ART-pregnancies - perinatal risks

    20. Conclusion Perinatal mortality & morbidity Singletons: IVF/ICSI > non-IVF > NC Twins: IVF/ICSI = non-IVF = NC Unlike-sex twins: non-IVF = IVF/ICSI > NC

    21. The Spectrum of Care ICSI TI IVF Infertility COH IUI

    22. Patient // Society - friendly ART • Cost – effectiveness • Access • Risk minimisation • Burden minimisation

    23. Patient-friendly ARTcost-effectiveness Fertility potential of a couple Dunson et al (2002) Hum Reprod 17:1399

    24. Patient-friendly ARTcost-effectiveness • Fertility awareness methods • 80 % pregnant within 6 months • IVF: HP-hMG versus rec-FSH • IUI: clomiphene versus hMG / rec FSH • Male subfertility: 3 IUI’s versus IVF

    25. IVF // ICSI versus 3 x IUI Philips et al., Hum Reprod 15, 95, 2000 Stone et al., AJOG, 180, 1522, 1999 Garceau et al., Hum Reprod 17, 3090, 2002

    26. W. Ombelet et al., Hum Reprod, 12,1458,1997 IMC < 1 106 MORPH < 4% Take Baby Home rateAfter 3 IUI’s No pregnancy % All patients < 1 106 < 1 106 MORPH >= 4% All patients >1 106

    27. Algorithm for male subfertility treatment Tubal Factor No Tubal Factor Initial Semen Sample Washing procedure Washing procedure IMC IMC IMC IMC IMC IMC < 1 million < 1 million >= 1 million < 1 million < 1 million >= 1 million Morphology < 4% Morphology >= 4% Morphology < 4% Morphology >= 4% IUI 4 x IVF < 30% or no fertilisation IVF ICSI < 30% or no fertilisation ICSI ICSI

    28. Mol, 2009, the Netherlands

    29. Flanders IUI results 2008

    30. Flanders IUI results 2008

    31. Van Voorhis, Genk, 2009

    32. www.fvvo.be

    33. Questionnaire → All secretariats “Fertility Societies” (IFFS - 15) → 2 clinicians per country → 2 embryologists per country → Repeat after 2 weeks → 2 newclinicians per country – repeat after 1 week

    34. AID • AID not allowed : 2 / 22 • AID reimbursement: 9 / 20 • Imported semen allowed: 14 / 20 • AID registration: 7 / 20

    35. AID • AID for genetic disease: 19 / 19 • AID for lesbic couples: 9 / 19 • AID for singles: 9 / 19 • only anonymous: 13 / 19 • only non-anonymous: 3 / 19 • both: 3 / 19

    36. AIH • AIH for all: 14 / 22 • AIH reimbursement: 11 / 22 • Posthumous AIH : 5 / 22 • AIH registration: 9 / 22

    37. Cross-border infertility care

    38. Patient-friendly ARTaccess • High costs  concerns about equity • Private versus public • Reimbursement strategy risk :  IVF procedures &  IUI’s • Limited number of reimbursed cycles risk :  SET, more multiples

    39. Problem of accessibility Assumed need for IVF / ICSI=1500 / year / millionFauser et al, Hum Reprod Update, 8, 1, 2002

    40. Belgian project of ART-reimbursement Conditions  35 yrs SET cycle 1 SET or DET cycle 2 max DET cycle 3 - 6 > 35 and  39 yrs max DET cycle 1 - 2 max TET cycle 3 - 6 > 39 and  42 yrs No limit cycle 1 - 6 Non-IVF Med: 400 E / cycle 250 Euro IVF/ICSI Med: 1100 E / cycle 1400 Euro Registration non-IVF Less use of medication Online registration Less use of medication 50 % reduction of twins  triplets Quality control

    41. First results Number of cycles:  40 – 50 % Multiple Pregnancy Rate: 26 % → 10 % Number of IVF/ICSI babies:  23 % Total live births:  1 %

    42. Hum. Reprod., 2004, Land