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Audrey A.A. Fiddelers, Aafke P.A. van Montfoort, Carmen D. Dirksen, John C.M. Dumoulin, Jolande A. Land, Gerard A.J. Dunselman, J.Marij Janssen, Johan L. Severens, Johannes L.H. Evers, Single versus double embryo transfer: cost-effectiveness analysis alongside a randomized clinical trial, Human Reproduction, Volume 21, Issue 8, 1 August 2006, Pages 2090–2097, https://doi.org/10.1093/humrep/del112
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Abstract
BACKGROUND: Twin pregnancies after IVF are still frequent and are considered high-risk pregnancies leading to high costs. Transferring one embryo can reduce the twin pregnancy rate. We compared cost-effectiveness of one fresh cycle elective single embryo transfer (eSET) versus one fresh cycle double embryo transfer (DET) in an unselected patient population. METHODS: Patients starting their first IVF cycle were randomized between eSET and DET. Societal costs per couple were determined empirically, from hormonal stimulation up to 42 weeks after embryo transfer. An incremental cost-effectiveness ratio (ICER) was calculated, representing additional costs per successful pregnancy. RESULTS: Successful pregnancy rates were 20.8% for eSET and 39.6% for DET. Societal costs per couple were significantly lower after eSET (€ 7334) compared with DET (€10 924). The ICER of DET compared with eSET was €19 096, meaning that each additional successful pregnancy in the DET group will cost €19 096 extra. CONCLUSIONS: One cycle eSET was less expensive, but also less effective compared to one cycle DET. It depends on the society’s willingness to pay for one extra successful pregnancy, whether one cycle DET is preferred from a cost-effectiveness point of view.
Introduction
One of the most important complications of infertility treatments is the high percentage of multiple pregnancies. In 2001, of all IVF pregnancies in Europe, 24.0% were twin pregnancies (Andersen et al., 2005) compared with 1.2% twin pregnancies after natural conception (ESHRE Capri Workshop Group, 2000). Twin pregnancies are considered high-risk pregnancies for both mother and infants because of the relative high incidence in obstetric, perinatal and neonatal complications, which at the same time lead to high health care costs. Up till now, five studies have been performed on the cost-effectiveness of elective single embryo transfer (eSET) versus double embryo transfer (DET) (Wolner-Hanssen and Rydhstroem, 1998; De Sutter et al., 2002; Gerris et al., 2004; Lukassen et al., 2005; Thurin Kjellberg et al., 2006).
One study from Sweden used a hypothetical take-home baby rate after SET and empirical pregnancy rates after DET to compare costs per successful pregnancy (Wolner-Hanssen and Rydhstroem, 1998). Another study from Belgium (De Sutter et al., 2002) used a Markov model to estimate cost-effectiveness of eSET versus DET, in which pregnancy probabilities for eSET and DET were based on results from other studies, and costs were based on data from a local hospital. In a study by Gerris et al. (2004), also from Belgium, the cost-effectiveness of eSET and DET was compared by offering patients the choice of eSET, in case one good quality embryo was available, and DET, irrespective of embryo quality. Furthermore, in a Dutch study by Lukassen et al. (2005), the cost-effectiveness of two cycles eSET was compared with one cycle DET after randomization, in case two embryos were available of which one was of good quality. Finally, in a Scandinavian study by Thurin Kjellberg (Thurin Kjellberg et al., 2006), the cost-effectiveness of one cycle eSET and one cycle DET was compared, in case two good quality embryos were available in patients <36 years of age before randomization for eSET or DET. In a proportion of the patients, three good quality embryos had to be available in patients <35 years of age.
What the former studies have in common is that eSET was performed in a sub-sample of good prognosis patients. A radical approach to reduce the twin pregnancy rate would be to apply eSET in all patients, irrespective of their age and whether a good quality embryo is present. We have performed a randomized clinical trial (RCT), in which couples were randomized to having either eSET or DET in their first IVF treatment cycle, irrespective of age and embryo quality (Van Montfoort et al., 2006). Alongside the RCT, a cost-effectiveness analysis was performed. The aim of this article is to compare the costs and cost-effectiveness of one fresh cycle eSET and one fresh cycle DET in an unselected sample of patients.
Materials and methods
Study design
From January 2002 to December 2004, all couples who entered our IVF programme had their eligibility assessed for participation in this study (Van Montfoort et al., 2006); 308 couples who started their first IVF cycle were included in the study. Provided that at least two embryos (2PN) were available, couples were randomized between eSET and DET, irrespective of age and embryo quality. For a detailed overview of the patients and study design, see Van Montfoort et al. (2006).
Cost analysis
The cost analysis was performed from the societal perspective, according to the Dutch guidelines for cost calculations, and included health care costs and costs outside the health care sector (Oostenbrink et al., 2002, 2004). Health care costs consisted of hospital costs, and other health care costs related to the IVF procedure and resulting pregnancies. Hospital costs consisted of personnel costs, costs of material, costs of equipment, medication and overheads. Other health care costs included costs of visits to a General Practitioner (GP) or midwife care. Costs outside the health care system consisted of productivity costs and out of pocket costs for the couples (such as travel costs and over-the-counter medication) associated with the IVF treatment cycle and resulting pregnancies. Costs were determined empirically for each couple entering the study from the start of the first IVF treatment cycle (i.e. hormonal stimulation) up to 42 weeks after embryo transfer (ET). For the subgroup of pregnant patients, this means that costs were determined up to 4 weeks after giving birth. For couples with a negative pregnancy test, we assumed no costs related to the first IVF treatment cycle were made after the first IVF cycle. Costs were calculated by multiplying volumes of use with unit prices. Subtotal costs were determined for hospital costs, other health care costs and costs outside health care made during the IVF treatment cycle, pregnancy as well as delivery and up to 4 weeks after delivery. All costs were determined for the year 2003.
Volumes of use
Cost diaries were used to determine volumes of use during the IVF treatment cycle, during pregnancy (from 13 weeks onwards, i.e. ongoing pregnancy), delivery and up to 4 weeks after delivery. In these diaries, we asked for visits to a GP or midwife, for hospital visits, for hospital admissions, for over-the-counter medication, for the distance to several health care provisions, for absence of work and other costs related to the IVF treatment cycle, pregnancy or post-natal period (including delivery). The couples completed each cost diary prospectively for four successive weeks. The first cost diary was used to determine costs during the IVF treatment cycle, from hormonal stimulation (2 weeks before ET) until pregnancy test (2 weeks after ET), to reflect care directly related to IVF. For patients with a positive pregnancy test, no cost diary was administered to determine volumes of care until 13 weeks of pregnancy. Therefore, we assumed that they had one hospital visit, including an ultrasound at 7 weeks of pregnancy. With respect to patients who miscarried before 13 weeks of pregnancy, we assumed that they had another hospital visit including an ultrasound at the hospital (a total of two hospital visits and two ultrasounds). To determine volumes of use during pregnancy from 13 weeks onwards, patients with a singleton pregnancy were asked to complete two cost diaries for two randomly selected periods, whereas patients with a twin pregnancy completed three cost diaries for three randomly selected periods. Patients who were pregnant with twins were asked to complete three instead of two cost diaries, because only 20% of the pregnant patients in the DET strategy had a twin pregnancy (Van Montfoort et al., 2006). In that way, we still received sufficient information of medical consumption and other costs during pregnancy. To calculate the total costs per patient, the costs per period were added, assuming that the subgroup of patients (13–26 patients per period, of whom two to five patients were pregnant with twins) was representative for the total group of pregnant patients. The last cost diary was used to determine volumes of use of delivery and after delivery, starting from delivery up to 4 weeks later.
Unit prices
Unit prices were obtained from the hospital financial department, by cost price calculation and using guideline prices. All hospital costs during the IVF treatment cycle, except the costs of the laboratory phase, were calculated using unit prices by the financial department of the University Hospital, Maastricht. These unit prices include the general overhead costs. Unit prices were linked to the volumes of use obtained from the cost diaries to determine the mean hospital costs per couple. The cost of the laboratory phase was determined by a detailed cost price calculation (Oostenbrink et al., 2004). First, the total costs for the year 2003 of all equipment used for IVF (depreciation, interest and maintenance costs of invested capital) were determined. Furthermore, material costs related to IVF (such as needles and chemicals) and personnel costs were determined for the year 2003. The total direct costs were raised with 35% to include the general overhead of the hospital (Oostenbrink et al., 2004). To calculate the mean laboratory costs per IVF cycle per couple, total costs were divided by the number of ovum pick ups (OPUs) performed in 1 year.
For calculation of costs outside the hospital, guideline prices were used. Productivity losses were valued using the friction cost method, which assumes that within a productivity process, everybody is replaceable. Productivity costs only appear during the friction period which is defined as the average period that a vacancy exists in a society (Oostenbrink et al., 2004; Brouwer and Koopmanschap, 2005).
Cost-effectiveness analysis
A cost-effectiveness analysis was performed based on the incremental costs per extra successful pregnancy. A successful pregnancy was defined as a pregnancy resulting in at least one live-born child. The incremental cost-effectiveness ratio (ICER) was calculated using the following formula: [(mean total costs DET – mean total costs eSET)/(proportion of successful pregnancies DET – proportion of successful pregnancies eSET)].
Sensitivity analyses
Recently, an integrative study was performed in which the cost-effectiveness of several IVF treatment strategies in the Netherlands was determined, based on six IVF-related studies financed by the Dutch Organisation for Health Research and Development (ZonMw). For this, mean unit prices were determined, based on unit price information from all participating centres (ZonMw, 2005). These ‘Dutch’ unit prices were available for a limited number of cost units. First, a sensitivity analysis was performed in which these ‘Dutch’ unit prices were used instead of the Maastricht unit prices, to investigate the influence on the cost-effectiveness of eSET versus DET. Second, a sensitivity analysis was performed in which the costs of IVF medication were set on the lowest and highest values (€1046 and €1550). Third, as costs from 5 to 12 weeks of pregnancy were based on an assumption, sensitivity analyses were performed in which a ‘low-care’ and ‘high-care’ assumption was made for estimation of the costs of that period. In the ‘low-care’ assumption, only half of the pregnant patients had one visit including an ultrasound and only half of the patients who miscarried had one visit including an ultrasound. Furthermore, in the ‘high-care’ assumption, all pregnant patients had two hospital visits including an ultrasound and one visit to a GP, and all patients who miscarried had two hospital visits including an ultrasound. Fourth, for the post-natal costs, cost data from Lukassen et al. (2004) were used, because in our study, we had information only on these costs from 29% of the pregnant patients (25% of the twin pregnancies and 31% of the singleton pregnancies) who completed the last cost diary. However, in the study of Lukassen and co-workers, only hospital costs were calculated. Therefore, only these costs were changed in the sensitivity analysis. Fifth, hospital admissions during the IVF treatment cycle were excluded from the cost calculation, because the difference in costs of hospital admissions during the IVF treatment cycle between eSET and DET could not be attributed to the ET policy. Sixth, the unit price of a hospital admission day was changed into guideline prices according to Oostenbrink et al. (2004) (€337 and €476 per day for general hospital and university hospital, respectively). Finally, as the cost analysis was based on couples, in a secondary analysis, costs were determined for female patients only, i.e. those actually undergoing the first IVF treatment cycle, excluding male partners from the cost analysis.
Statistical analysis
The statistical analysis was performed according to the intention-to-treat principle. A Missing Value Analysis [Statistics Package for Social Sciences (SPSS)] was performed to estimate missing items in the cost diaries. To estimate ‘missing’ cost diaries, the overall groups’ mean of eSET and DET was calculated, and resulting values were imputed (mean substitution). To quantify uncertainty around the cost-differences between eSET and DET, subtotal IVF costs, pregnancy costs and post-natal costs and total societal costs for eSET and DET were bootstrapped. The bootstrap method estimates the sampling distribution of a statistic through a large number of simulations, based on sampling with replacement from the original data (Briggs et al., 1997). The results based on 1000 bootstrap replications of the costs for eSET and DET were used to calculate 95% uncertainty intervals (UI) around the cost-differences, based on the 2.5th and 97.5th percentiles. Also, bootstrap simulations were conducted to get insight into the uncertainty around the ICER (Efron and Tobshirani, 1993), yielding information about the joint distribution of the cost and effect differences. The results based on 1000 successive bootstrap replications were presented in a cost-effectiveness plane. The horizontal axis of the cost-effectiveness plane shows the difference in effect between the groups, and the vertical axis shows the difference in costs. The choice of a treatment strategy depends on the maximum amount of money that the society is prepared to pay for a gain in effectiveness, which is called the ceiling ratio. A ceiling ratio can vary from zero to infinity and can be represented by an imaginary straight line through the origin of the cost-effectiveness plane, starting with a slope of zero (representing a ceiling ratio of zero) and increasing the slope to 90 degrees (representing a ceiling ratio of infinity). For any given ceiling ratio, the proportion of bootstrap replications with an ICER equal to or lower than that particular ceiling ratio was determined. The probability that an intervention is cost-effective in relation to different values of the ceiling ratio was reflected in a cost-effectiveness acceptability curve (Van Hout et al., 1994). Also, a cost-effectiveness acceptability curve was derived using the results of the sensitivity analysis in which post-natal cost data of Lukassen et al. (2004) were used. All analyses were performed in SPSS 12.0 with the exception of the bootstrap analysis which was performed in Excel 2000.
Results
In Table I, baseline socio-economic characteristics are given for both the groups. All characteristics were comparable for eSET and DET. Other patients’ and cycle characteristics such as female age and fertilization rate were also comparable for both the groups. For a detailed overview of the latter, we refer to our previous publication (Van Montfoort et al., 2006).
. | Single embryo transfer [n (%)] N = 154 . | Double embryo transfer [n (%)] N = 154 . | ||||
---|---|---|---|---|---|---|
. | . | . | ||||
. | Female . | . | Male . | Female . | . | Male . |
Marital state | ||||||
Married | 98 (63.6) | 97 (63.0) | ||||
Not married or living together | 2 (1.3) | 2 (1.3) | ||||
Living together | 25 (16.2) | 25 (16.2) | ||||
Information missing | 29 (18.8) | 30 (19.5) | ||||
Having a housekeeper | ||||||
Yes | 19 (12.3) | 17 (11.0) | ||||
No | 108 (70.1) | 101 (65.6) | ||||
Information missing | 27 (17.5) | 36 (23.4) | ||||
Education | ||||||
Lower education | 19 (12.3) | 22 (14.3) | 20 (13.0) | 18 (11.7) | ||
Secondary education | 27 (17.5) | 15 (9.7) | 22 (14.3) | 19 (12.3) | ||
Higher education | 72 (46.8) | 62 (40.3) | 70 (45.5) | 62 (40.3) | ||
University | 7 (4.5) | 10 (6.5) | 12 (7.8) | 12 (7.8) | ||
Information missing | 29 (18.8) | 45 (29.2) | 30 (19.5) | 43 (27.9) | ||
Paid work | ||||||
Yes | 110 (71.4) | 105 (68.2) | 107 (69.5) | 112 (72.7) | ||
No | 17 (11.0) | 13 (8.4) | 19 (12.3) | 4 (2.6) | ||
Information missing | 27 (17.5) | 36 (23.4) | 28 (18.2) | 38 (24.7) | ||
Voluntary work | ||||||
Yes | 5 (3.2) | 4 (2.6) | 5 (3.2) | 4 (2.6) | ||
No | 122 (79.2) | 114 (74.0) | 121 (78.6) | 112 (72.7) | ||
Information missing | 27 (17.5) | 36 (23.4) | 28 (18.2) | 38 (24.7) | ||
Studying | ||||||
Yes | 6 (3.9) | 2 (1.3) | 5 (3.2) | 2 (1.3) | ||
No | 121 (82.5) | 116 (75.3) | 121 (78.6) | 114 (74.0) | ||
Information missing | 27 (17.5) | 36 (23.4) | 28 (18.2) | 38 (24.7) | ||
Unemployed | ||||||
Yes | 4 (2.6) | 4 (2.6) | 6 (3.9) | 1 (0.6) | ||
No | 123 (79.9) | 114 (74.0) | 120 (77.9) | 115 (74.7) | ||
Information missing | 27 (17.5) | 36 (23.4) | 28 (18.2) | 38 (24.7) | ||
Work-disabled | ||||||
Yes | 7 (4.5) | 3 (1.9) | 5 (3.2) | 1 (0.6) | ||
No | 120 (77.9) | 115 (74.7) | 121 (78.6) | 115 (74.7) | ||
Information missing | 27 (17.5) | 36 (23.4) | 28 (18.2) | 38 (24.7) | ||
Housekeeping | ||||||
Yes | 53 (34.4) | 13 (8.4) | 52 (33.8) | 10 (6.5) | ||
No | 74 (48.1) | 105 (68.2) | 74 (48.1) | 106 (68.8) | ||
Information missing | 27 (17.5) | 36 (23.4) | 28 (18.2) | 38 (24.7) |
. | Single embryo transfer [n (%)] N = 154 . | Double embryo transfer [n (%)] N = 154 . | ||||
---|---|---|---|---|---|---|
. | . | . | ||||
. | Female . | . | Male . | Female . | . | Male . |
Marital state | ||||||
Married | 98 (63.6) | 97 (63.0) | ||||
Not married or living together | 2 (1.3) | 2 (1.3) | ||||
Living together | 25 (16.2) | 25 (16.2) | ||||
Information missing | 29 (18.8) | 30 (19.5) | ||||
Having a housekeeper | ||||||
Yes | 19 (12.3) | 17 (11.0) | ||||
No | 108 (70.1) | 101 (65.6) | ||||
Information missing | 27 (17.5) | 36 (23.4) | ||||
Education | ||||||
Lower education | 19 (12.3) | 22 (14.3) | 20 (13.0) | 18 (11.7) | ||
Secondary education | 27 (17.5) | 15 (9.7) | 22 (14.3) | 19 (12.3) | ||
Higher education | 72 (46.8) | 62 (40.3) | 70 (45.5) | 62 (40.3) | ||
University | 7 (4.5) | 10 (6.5) | 12 (7.8) | 12 (7.8) | ||
Information missing | 29 (18.8) | 45 (29.2) | 30 (19.5) | 43 (27.9) | ||
Paid work | ||||||
Yes | 110 (71.4) | 105 (68.2) | 107 (69.5) | 112 (72.7) | ||
No | 17 (11.0) | 13 (8.4) | 19 (12.3) | 4 (2.6) | ||
Information missing | 27 (17.5) | 36 (23.4) | 28 (18.2) | 38 (24.7) | ||
Voluntary work | ||||||
Yes | 5 (3.2) | 4 (2.6) | 5 (3.2) | 4 (2.6) | ||
No | 122 (79.2) | 114 (74.0) | 121 (78.6) | 112 (72.7) | ||
Information missing | 27 (17.5) | 36 (23.4) | 28 (18.2) | 38 (24.7) | ||
Studying | ||||||
Yes | 6 (3.9) | 2 (1.3) | 5 (3.2) | 2 (1.3) | ||
No | 121 (82.5) | 116 (75.3) | 121 (78.6) | 114 (74.0) | ||
Information missing | 27 (17.5) | 36 (23.4) | 28 (18.2) | 38 (24.7) | ||
Unemployed | ||||||
Yes | 4 (2.6) | 4 (2.6) | 6 (3.9) | 1 (0.6) | ||
No | 123 (79.9) | 114 (74.0) | 120 (77.9) | 115 (74.7) | ||
Information missing | 27 (17.5) | 36 (23.4) | 28 (18.2) | 38 (24.7) | ||
Work-disabled | ||||||
Yes | 7 (4.5) | 3 (1.9) | 5 (3.2) | 1 (0.6) | ||
No | 120 (77.9) | 115 (74.7) | 121 (78.6) | 115 (74.7) | ||
Information missing | 27 (17.5) | 36 (23.4) | 28 (18.2) | 38 (24.7) | ||
Housekeeping | ||||||
Yes | 53 (34.4) | 13 (8.4) | 52 (33.8) | 10 (6.5) | ||
No | 74 (48.1) | 105 (68.2) | 74 (48.1) | 106 (68.8) | ||
Information missing | 27 (17.5) | 36 (23.4) | 28 (18.2) | 38 (24.7) |
. | Single embryo transfer [n (%)] N = 154 . | Double embryo transfer [n (%)] N = 154 . | ||||
---|---|---|---|---|---|---|
. | . | . | ||||
. | Female . | . | Male . | Female . | . | Male . |
Marital state | ||||||
Married | 98 (63.6) | 97 (63.0) | ||||
Not married or living together | 2 (1.3) | 2 (1.3) | ||||
Living together | 25 (16.2) | 25 (16.2) | ||||
Information missing | 29 (18.8) | 30 (19.5) | ||||
Having a housekeeper | ||||||
Yes | 19 (12.3) | 17 (11.0) | ||||
No | 108 (70.1) | 101 (65.6) | ||||
Information missing | 27 (17.5) | 36 (23.4) | ||||
Education | ||||||
Lower education | 19 (12.3) | 22 (14.3) | 20 (13.0) | 18 (11.7) | ||
Secondary education | 27 (17.5) | 15 (9.7) | 22 (14.3) | 19 (12.3) | ||
Higher education | 72 (46.8) | 62 (40.3) | 70 (45.5) | 62 (40.3) | ||
University | 7 (4.5) | 10 (6.5) | 12 (7.8) | 12 (7.8) | ||
Information missing | 29 (18.8) | 45 (29.2) | 30 (19.5) | 43 (27.9) | ||
Paid work | ||||||
Yes | 110 (71.4) | 105 (68.2) | 107 (69.5) | 112 (72.7) | ||
No | 17 (11.0) | 13 (8.4) | 19 (12.3) | 4 (2.6) | ||
Information missing | 27 (17.5) | 36 (23.4) | 28 (18.2) | 38 (24.7) | ||
Voluntary work | ||||||
Yes | 5 (3.2) | 4 (2.6) | 5 (3.2) | 4 (2.6) | ||
No | 122 (79.2) | 114 (74.0) | 121 (78.6) | 112 (72.7) | ||
Information missing | 27 (17.5) | 36 (23.4) | 28 (18.2) | 38 (24.7) | ||
Studying | ||||||
Yes | 6 (3.9) | 2 (1.3) | 5 (3.2) | 2 (1.3) | ||
No | 121 (82.5) | 116 (75.3) | 121 (78.6) | 114 (74.0) | ||
Information missing | 27 (17.5) | 36 (23.4) | 28 (18.2) | 38 (24.7) | ||
Unemployed | ||||||
Yes | 4 (2.6) | 4 (2.6) | 6 (3.9) | 1 (0.6) | ||
No | 123 (79.9) | 114 (74.0) | 120 (77.9) | 115 (74.7) | ||
Information missing | 27 (17.5) | 36 (23.4) | 28 (18.2) | 38 (24.7) | ||
Work-disabled | ||||||
Yes | 7 (4.5) | 3 (1.9) | 5 (3.2) | 1 (0.6) | ||
No | 120 (77.9) | 115 (74.7) | 121 (78.6) | 115 (74.7) | ||
Information missing | 27 (17.5) | 36 (23.4) | 28 (18.2) | 38 (24.7) | ||
Housekeeping | ||||||
Yes | 53 (34.4) | 13 (8.4) | 52 (33.8) | 10 (6.5) | ||
No | 74 (48.1) | 105 (68.2) | 74 (48.1) | 106 (68.8) | ||
Information missing | 27 (17.5) | 36 (23.4) | 28 (18.2) | 38 (24.7) |
. | Single embryo transfer [n (%)] N = 154 . | Double embryo transfer [n (%)] N = 154 . | ||||
---|---|---|---|---|---|---|
. | . | . | ||||
. | Female . | . | Male . | Female . | . | Male . |
Marital state | ||||||
Married | 98 (63.6) | 97 (63.0) | ||||
Not married or living together | 2 (1.3) | 2 (1.3) | ||||
Living together | 25 (16.2) | 25 (16.2) | ||||
Information missing | 29 (18.8) | 30 (19.5) | ||||
Having a housekeeper | ||||||
Yes | 19 (12.3) | 17 (11.0) | ||||
No | 108 (70.1) | 101 (65.6) | ||||
Information missing | 27 (17.5) | 36 (23.4) | ||||
Education | ||||||
Lower education | 19 (12.3) | 22 (14.3) | 20 (13.0) | 18 (11.7) | ||
Secondary education | 27 (17.5) | 15 (9.7) | 22 (14.3) | 19 (12.3) | ||
Higher education | 72 (46.8) | 62 (40.3) | 70 (45.5) | 62 (40.3) | ||
University | 7 (4.5) | 10 (6.5) | 12 (7.8) | 12 (7.8) | ||
Information missing | 29 (18.8) | 45 (29.2) | 30 (19.5) | 43 (27.9) | ||
Paid work | ||||||
Yes | 110 (71.4) | 105 (68.2) | 107 (69.5) | 112 (72.7) | ||
No | 17 (11.0) | 13 (8.4) | 19 (12.3) | 4 (2.6) | ||
Information missing | 27 (17.5) | 36 (23.4) | 28 (18.2) | 38 (24.7) | ||
Voluntary work | ||||||
Yes | 5 (3.2) | 4 (2.6) | 5 (3.2) | 4 (2.6) | ||
No | 122 (79.2) | 114 (74.0) | 121 (78.6) | 112 (72.7) | ||
Information missing | 27 (17.5) | 36 (23.4) | 28 (18.2) | 38 (24.7) | ||
Studying | ||||||
Yes | 6 (3.9) | 2 (1.3) | 5 (3.2) | 2 (1.3) | ||
No | 121 (82.5) | 116 (75.3) | 121 (78.6) | 114 (74.0) | ||
Information missing | 27 (17.5) | 36 (23.4) | 28 (18.2) | 38 (24.7) | ||
Unemployed | ||||||
Yes | 4 (2.6) | 4 (2.6) | 6 (3.9) | 1 (0.6) | ||
No | 123 (79.9) | 114 (74.0) | 120 (77.9) | 115 (74.7) | ||
Information missing | 27 (17.5) | 36 (23.4) | 28 (18.2) | 38 (24.7) | ||
Work-disabled | ||||||
Yes | 7 (4.5) | 3 (1.9) | 5 (3.2) | 1 (0.6) | ||
No | 120 (77.9) | 115 (74.7) | 121 (78.6) | 115 (74.7) | ||
Information missing | 27 (17.5) | 36 (23.4) | 28 (18.2) | 38 (24.7) | ||
Housekeeping | ||||||
Yes | 53 (34.4) | 13 (8.4) | 52 (33.8) | 10 (6.5) | ||
No | 74 (48.1) | 105 (68.2) | 74 (48.1) | 106 (68.8) | ||
Information missing | 27 (17.5) | 36 (23.4) | 28 (18.2) | 38 (24.7) |
Effectiveness
Table II summarizes the clinical outcomes of one cycle eSET versus one cycle DET. After one cycle eSET and one cycle DET, 33.1 and 47.4% of the patients had a positive pregnancy test, respectively, and 21.4 and 40.3% achieved an ongoing pregnancy (more than 12 weeks of pregnancy). In both the groups, one late abortion (after 12 weeks of pregnancy) occurred, resulting in 20.8% successful pregnancies in the SET group and 39.6% in the DET group. Of the successful pregnancies, 0 and 19.6% were twins after one cycle eSET and DET, respectively (Van Montfoort et al., 2006).
. | Single embryo transfer n = 154 (%) . | Double embryo transfer n = 154 (%) . |
---|---|---|
Positive HCG test (% per ET) | 51 (33.1) | 73 (47.4) |
Abortion <13 weeks (% per positive HCG test) | 18 (35.3) | 11 (15.1) |
Ongoing pregnancies (% per ET) | 33 (21.4) | 62 (40.3) |
Successful pregnancies (% per ET) | 32 (20.8) | 61 (39.6) |
Twin pregnancies (% per successful pregnancy) | 0 (0) | 12 (19.6) |
Number of children born (% per ET) | 32 (20.8) | 73 (47.4) |
. | Single embryo transfer n = 154 (%) . | Double embryo transfer n = 154 (%) . |
---|---|---|
Positive HCG test (% per ET) | 51 (33.1) | 73 (47.4) |
Abortion <13 weeks (% per positive HCG test) | 18 (35.3) | 11 (15.1) |
Ongoing pregnancies (% per ET) | 33 (21.4) | 62 (40.3) |
Successful pregnancies (% per ET) | 32 (20.8) | 61 (39.6) |
Twin pregnancies (% per successful pregnancy) | 0 (0) | 12 (19.6) |
Number of children born (% per ET) | 32 (20.8) | 73 (47.4) |
ET, embryo transfer; HCG, human chorionic gonadotrophin.
Adapted from Van Montfoort et al. (2006). Outcomes expressed per ET, because eSET and DET are the comparators in this study.
. | Single embryo transfer n = 154 (%) . | Double embryo transfer n = 154 (%) . |
---|---|---|
Positive HCG test (% per ET) | 51 (33.1) | 73 (47.4) |
Abortion <13 weeks (% per positive HCG test) | 18 (35.3) | 11 (15.1) |
Ongoing pregnancies (% per ET) | 33 (21.4) | 62 (40.3) |
Successful pregnancies (% per ET) | 32 (20.8) | 61 (39.6) |
Twin pregnancies (% per successful pregnancy) | 0 (0) | 12 (19.6) |
Number of children born (% per ET) | 32 (20.8) | 73 (47.4) |
. | Single embryo transfer n = 154 (%) . | Double embryo transfer n = 154 (%) . |
---|---|---|
Positive HCG test (% per ET) | 51 (33.1) | 73 (47.4) |
Abortion <13 weeks (% per positive HCG test) | 18 (35.3) | 11 (15.1) |
Ongoing pregnancies (% per ET) | 33 (21.4) | 62 (40.3) |
Successful pregnancies (% per ET) | 32 (20.8) | 61 (39.6) |
Twin pregnancies (% per successful pregnancy) | 0 (0) | 12 (19.6) |
Number of children born (% per ET) | 32 (20.8) | 73 (47.4) |
ET, embryo transfer; HCG, human chorionic gonadotrophin.
Adapted from Van Montfoort et al. (2006). Outcomes expressed per ET, because eSET and DET are the comparators in this study.
Cost analysis
Table III summarizes the costs divided into IVF treatment costs, costs of pregnancy, delivery and up to 4 weeks later, resulting in the total societal costs per randomized couple. Subtotal costs of the IVF treatment cycle were €4431 for one cycle eSET and €4513 for one cycle DET. The bootstrapped difference of these costs was not statistically significant (95% UI: €–88 – €268). The cost difference was mainly caused by higher hospital costs after ET, because of costs of six hospital admissions in the DET group following OPU. In five of six patients, hospital admission occurred immediately after the OPU, before ET and randomization. These admissions can therefore not be attributed to having DET. However, one patient was admitted because of ovarian hyperstimulation syndrome (OHSS) which occurred 9 days after ET. This could possibly be contributed to the fact that this patient was pregnant with twins, although a possible relationship between multiple pregnancy and OHSS has not been convincingly established in the literature. During pregnancy, all cost components were about twice as high in the DET group compared with the eSET group, and the cost difference was mainly caused by differences in productivity costs and hospital costs. The bootstrapped difference of the costs during pregnancy was statistically significant (95% UI: €928 – €2622). From delivery until 4 weeks later, the higher costs of DET compared with eSET were mainly caused by differences in hospital costs and productivity costs. The bootstrapped difference of the costs after delivery was also statistically significant (95% UI: €966 – €2637). The total societal costs per couple were €7334 for one cycle eSET compared with €10 924 for one cycle DET, which was statistically significantly different (95% UI: €2060 – €5290). Most costs during the IVF treatment cycle, pregnancy and post-natal period were due to female patients (97% of the total societal costs in both the groups). The male partners were mainly responsible for the ‘leave of absence’ costs during the IVF treatment cycle (70%), pregnancy (27%) and from delivery up to 4 weeks later (100%).
. | Unit price (€) . | Elective single embryo transfer (eSET) (n = 154) . | Double embryo transfer (DET) (n = 154) . | Bootstrapped difference in costsb (€) (95% UI)DET – eSET . | ||
---|---|---|---|---|---|---|
. | . | . | . | . | ||
. | . | Volumes of use . | Costs per couplea (€)Mean (SD) . | Volumes of use . | Costs per couplea (€)Mean (SD) . | . |
IVF treatment cycled | ||||||
Hospital costs | ||||||
Hormonal stimulation phase | ||||||
Medicatione | 1298 (1046–1550) | 1 | 1298 (NA) | 1 | 1298 (NA) | |
Hospital care | 272 (250) | 1 | 272 (NA) | 1 | 272 (NA) | |
Ovum pick-up | 490 (300) | 1 | 490 (NA) | 1 | 490 (NA) | |
Laboratory phase | 1100 (350) | 1 | 1100 (NA) | 1 | 1100 (NA) | |
Embryo transfer | 260 (200) | 1 | 260 (NA) | 1 | 260 (NA) | |
Other | NAc | NA | 242.11 (81.46) | NA | 246.18 (82.99) | |
Hospital admission days | 265–336/day | 0 | 4.38 (9.97) | 0.11 | 49.53 (290.97) | |
Subtotal | 3666 (82) | 3716 (317) | 51 (7 – 109) | |||
Other health care costs | ||||||
General Practitioner | 20.20/visit | 0.12 | 2.51 (7.31) | 0.13 | 2.60 (7.14) | |
Other | NA | NA | 10.73 (39.99) | NA | 9.29 (34.36) | |
Subtotal | 13 (43) | 12 (35) | –1(–11 – 7) | |||
Costs outside health care | ||||||
Productivity cost | ||||||
Sick leave | 29.88–40.86/hour | NA | 467.56 (600.52) | NA | 444.73 (518.62) | |
Leave of absence | 9.00/hour | 12.9 | 116.26 (136.45) | 13.6 | 121.99 (130.78) | |
Loss of leisure time | 9.00/hour | 6.6 | 59.71 (157.90) | 11.5 | 103.67 (576.97) | |
Out of pocket cost | NA | NA | 63.22 (41.56) | NA | 73.46 (50.39) | |
Informal care | 9.00/hour | 3.0 | 26.69 (61.82) | 3.0 | 27.01 (59.77) | |
Other | NA | NA | 18.03 (90.86) | NA | 14.56 (72.21) | |
Subtotal | 751 (710) | 785 (780) | 35 (–118 – 210) | |||
Subtotal IVF treatment cycle | 4431 (731) | 4513 (880) | 87 (–88 – 268) | |||
Pregnancy (5–40 weeks) | ||||||
Hospital costs | ||||||
Ultrasound and consultation | 80.58 | 0.33 | 26.78 (38.17) | 0.48 | 38.85 (40.53) | |
Miscarriage | 80.58 | 0.13 | 9.98 (26.68) | 0.08 | 6.30 (21.74) | |
Other | NAc | NA | 120.54 (253.50) | NA | 274.86 (386.38) | |
Hospital admission days | 265–336/day | 0.62 | 123.49 (340.20) | 1.32 | 273.23 (788.79) | |
Subtotal | 281(563) | 593 (1050) | 312 (129 – 528) | |||
Other health care costs | ||||||
General Practitioner | 20.20/visit | 0.19 | 3.85 (8.35) | 0.35 | 6.99 (11.69) | |
Midwife care | 21.43/visit | 0.97 | 20.77 (42.70) | 1.47 | 31.40 (48.10) | |
Other | NA | NA | 65.51 (165.37) | NA | 104.65 (181.92) | |
Subtotal | 90 (205) | 143 (223) | 53 (1 – 103) | |||
Costs outside health care | ||||||
Productivity cost | ||||||
Sick leave | 29.88–40.86/hour | NA | 494.60 (1053.85) | NA | 1236.38 (1910.63) | |
Maternity leave | 29.88–40.86/hour | NA | 406.90 (868.89) | NA | 725.52 (1001.49) | |
Leave of absence | 9.00/hour | 6.63 | 59.69 (320.00) | 14.35 | 129.13 (446.19) | |
Loss of leisure time | 9.00/hour | 0.67 | 6.02 (18.06) | 2.26 | 20.30 (59.13) | |
Out of pocket cost | NA | NA | 19.63 (44.06) | NA | 35.86 (47.22) | |
Informal care | 9.00/hour | 8.54 | 76.83 (206.87) | 18.89 | 170.00 (276.90) | |
Other | NA | NA | 85.59 (188.95) | NA | 198.32 (316.25) | |
Subtotal | 1149 (2349) | 2516 (3378) | 1287 (704 – 1865) | |||
Subtotal pregnancyf | 1520 (3047) | 3252 (4304) | 1761 (928 – 2622) | |||
Delivery up to 4 weeks after delivery | ||||||
Hospital costs | ||||||
Other | NA | NA | 11.22 (44.93) | NA | 28.36 (72.76) | |
Hospital admission days | 336–804/day | 0.56 | 551.76 (1228.18) | 4.61 | 1590.51 (2826.54) | |
Subtotal | 563 (1245) | 1619 (2852) | 1067 (632 – 1603) | |||
Other health care costs | ||||||
General Practitioner | 20.20/visit | 0.13 | 2.69 (7.32) | 0.20 | 4.03 (7.98) | |
Midwife care | 41.99/visit | 0.20 | 8.41 (22.18) | 0.27 | 11.40 (28.72) | |
Other | NAc | NA | 315.36 (789.34) | NA | 419.63 (712.97) | |
Subtotal | 326 (806) | 435 (732) | 111 (–71–275) | |||
Costs outside health care | ||||||
Productivity cost | ||||||
Maternity leave | 29.88–40.86/hour | NA | 390.52 (846.38) | NA | 831.40 (1178.93) | |
Leave of absence | 9.00/hour | 2.84 | 25.58 (80.91) | 6.28 | 56.50 (130.44) | |
Loss of leisure time | 9.00/hour | 0.53 | 4.79 (11.90) | 2.00 | 17.96 (80.64) | |
Out of pocket cost | NA | NA | 4.06 (10.67) | NA | 7.76 (17.36) | |
Informal care | 9.00/hour | 5.28 | 47.49 (115.54) | 17.23 | 155.07 (470.33) | |
Other | NA | NA | 20.50 (72.87) | NA | 36.35 (119.09) | |
Subtotal | 493 (1049) | 1105 (1649) | 614 (313 – 928) | |||
Subtotal after deliveryg | 1382 (2910) | 3159 (4549) | 1785 (966 – 2637) | |||
Total societal costs per couple | 7334 (5780) | 10924 (8560) | 3510 (2060 – 5290) |
. | Unit price (€) . | Elective single embryo transfer (eSET) (n = 154) . | Double embryo transfer (DET) (n = 154) . | Bootstrapped difference in costsb (€) (95% UI)DET – eSET . | ||
---|---|---|---|---|---|---|
. | . | . | . | . | ||
. | . | Volumes of use . | Costs per couplea (€)Mean (SD) . | Volumes of use . | Costs per couplea (€)Mean (SD) . | . |
IVF treatment cycled | ||||||
Hospital costs | ||||||
Hormonal stimulation phase | ||||||
Medicatione | 1298 (1046–1550) | 1 | 1298 (NA) | 1 | 1298 (NA) | |
Hospital care | 272 (250) | 1 | 272 (NA) | 1 | 272 (NA) | |
Ovum pick-up | 490 (300) | 1 | 490 (NA) | 1 | 490 (NA) | |
Laboratory phase | 1100 (350) | 1 | 1100 (NA) | 1 | 1100 (NA) | |
Embryo transfer | 260 (200) | 1 | 260 (NA) | 1 | 260 (NA) | |
Other | NAc | NA | 242.11 (81.46) | NA | 246.18 (82.99) | |
Hospital admission days | 265–336/day | 0 | 4.38 (9.97) | 0.11 | 49.53 (290.97) | |
Subtotal | 3666 (82) | 3716 (317) | 51 (7 – 109) | |||
Other health care costs | ||||||
General Practitioner | 20.20/visit | 0.12 | 2.51 (7.31) | 0.13 | 2.60 (7.14) | |
Other | NA | NA | 10.73 (39.99) | NA | 9.29 (34.36) | |
Subtotal | 13 (43) | 12 (35) | –1(–11 – 7) | |||
Costs outside health care | ||||||
Productivity cost | ||||||
Sick leave | 29.88–40.86/hour | NA | 467.56 (600.52) | NA | 444.73 (518.62) | |
Leave of absence | 9.00/hour | 12.9 | 116.26 (136.45) | 13.6 | 121.99 (130.78) | |
Loss of leisure time | 9.00/hour | 6.6 | 59.71 (157.90) | 11.5 | 103.67 (576.97) | |
Out of pocket cost | NA | NA | 63.22 (41.56) | NA | 73.46 (50.39) | |
Informal care | 9.00/hour | 3.0 | 26.69 (61.82) | 3.0 | 27.01 (59.77) | |
Other | NA | NA | 18.03 (90.86) | NA | 14.56 (72.21) | |
Subtotal | 751 (710) | 785 (780) | 35 (–118 – 210) | |||
Subtotal IVF treatment cycle | 4431 (731) | 4513 (880) | 87 (–88 – 268) | |||
Pregnancy (5–40 weeks) | ||||||
Hospital costs | ||||||
Ultrasound and consultation | 80.58 | 0.33 | 26.78 (38.17) | 0.48 | 38.85 (40.53) | |
Miscarriage | 80.58 | 0.13 | 9.98 (26.68) | 0.08 | 6.30 (21.74) | |
Other | NAc | NA | 120.54 (253.50) | NA | 274.86 (386.38) | |
Hospital admission days | 265–336/day | 0.62 | 123.49 (340.20) | 1.32 | 273.23 (788.79) | |
Subtotal | 281(563) | 593 (1050) | 312 (129 – 528) | |||
Other health care costs | ||||||
General Practitioner | 20.20/visit | 0.19 | 3.85 (8.35) | 0.35 | 6.99 (11.69) | |
Midwife care | 21.43/visit | 0.97 | 20.77 (42.70) | 1.47 | 31.40 (48.10) | |
Other | NA | NA | 65.51 (165.37) | NA | 104.65 (181.92) | |
Subtotal | 90 (205) | 143 (223) | 53 (1 – 103) | |||
Costs outside health care | ||||||
Productivity cost | ||||||
Sick leave | 29.88–40.86/hour | NA | 494.60 (1053.85) | NA | 1236.38 (1910.63) | |
Maternity leave | 29.88–40.86/hour | NA | 406.90 (868.89) | NA | 725.52 (1001.49) | |
Leave of absence | 9.00/hour | 6.63 | 59.69 (320.00) | 14.35 | 129.13 (446.19) | |
Loss of leisure time | 9.00/hour | 0.67 | 6.02 (18.06) | 2.26 | 20.30 (59.13) | |
Out of pocket cost | NA | NA | 19.63 (44.06) | NA | 35.86 (47.22) | |
Informal care | 9.00/hour | 8.54 | 76.83 (206.87) | 18.89 | 170.00 (276.90) | |
Other | NA | NA | 85.59 (188.95) | NA | 198.32 (316.25) | |
Subtotal | 1149 (2349) | 2516 (3378) | 1287 (704 – 1865) | |||
Subtotal pregnancyf | 1520 (3047) | 3252 (4304) | 1761 (928 – 2622) | |||
Delivery up to 4 weeks after delivery | ||||||
Hospital costs | ||||||
Other | NA | NA | 11.22 (44.93) | NA | 28.36 (72.76) | |
Hospital admission days | 336–804/day | 0.56 | 551.76 (1228.18) | 4.61 | 1590.51 (2826.54) | |
Subtotal | 563 (1245) | 1619 (2852) | 1067 (632 – 1603) | |||
Other health care costs | ||||||
General Practitioner | 20.20/visit | 0.13 | 2.69 (7.32) | 0.20 | 4.03 (7.98) | |
Midwife care | 41.99/visit | 0.20 | 8.41 (22.18) | 0.27 | 11.40 (28.72) | |
Other | NAc | NA | 315.36 (789.34) | NA | 419.63 (712.97) | |
Subtotal | 326 (806) | 435 (732) | 111 (–71–275) | |||
Costs outside health care | ||||||
Productivity cost | ||||||
Maternity leave | 29.88–40.86/hour | NA | 390.52 (846.38) | NA | 831.40 (1178.93) | |
Leave of absence | 9.00/hour | 2.84 | 25.58 (80.91) | 6.28 | 56.50 (130.44) | |
Loss of leisure time | 9.00/hour | 0.53 | 4.79 (11.90) | 2.00 | 17.96 (80.64) | |
Out of pocket cost | NA | NA | 4.06 (10.67) | NA | 7.76 (17.36) | |
Informal care | 9.00/hour | 5.28 | 47.49 (115.54) | 17.23 | 155.07 (470.33) | |
Other | NA | NA | 20.50 (72.87) | NA | 36.35 (119.09) | |
Subtotal | 493 (1049) | 1105 (1649) | 614 (313 – 928) | |||
Subtotal after deliveryg | 1382 (2910) | 3159 (4549) | 1785 (966 – 2637) | |||
Total societal costs per couple | 7334 (5780) | 10924 (8560) | 3510 (2060 – 5290) |
Cost per couple = unit price × volumes of use.
Bootstrapped difference of costs DET – costs eSET.
NA means not applicable. Presentation of separate volumes and cost prices was not possible because they were constructed of several medical activities. For example, other hospital costs consist of consultations, laboratory tests etc. Each medical activity has its own volume and cost price.
Two weeks before ovum pick up (OPU) until 2 weeks after OPU.
For the costs of medication, mean costs were used per couple.
Mean subtotal costs after pregnancy were €7315 for pregnant patients in the eSET group and €8210 for pregnant patients in the DET group.
Mean subtotal costs after delivery were €6651 for pregnant patients in the eSET group and €7975 for pregnant patients in the DET group.
. | Unit price (€) . | Elective single embryo transfer (eSET) (n = 154) . | Double embryo transfer (DET) (n = 154) . | Bootstrapped difference in costsb (€) (95% UI)DET – eSET . | ||
---|---|---|---|---|---|---|
. | . | . | . | . | ||
. | . | Volumes of use . | Costs per couplea (€)Mean (SD) . | Volumes of use . | Costs per couplea (€)Mean (SD) . | . |
IVF treatment cycled | ||||||
Hospital costs | ||||||
Hormonal stimulation phase | ||||||
Medicatione | 1298 (1046–1550) | 1 | 1298 (NA) | 1 | 1298 (NA) | |
Hospital care | 272 (250) | 1 | 272 (NA) | 1 | 272 (NA) | |
Ovum pick-up | 490 (300) | 1 | 490 (NA) | 1 | 490 (NA) | |
Laboratory phase | 1100 (350) | 1 | 1100 (NA) | 1 | 1100 (NA) | |
Embryo transfer | 260 (200) | 1 | 260 (NA) | 1 | 260 (NA) | |
Other | NAc | NA | 242.11 (81.46) | NA | 246.18 (82.99) | |
Hospital admission days | 265–336/day | 0 | 4.38 (9.97) | 0.11 | 49.53 (290.97) | |
Subtotal | 3666 (82) | 3716 (317) | 51 (7 – 109) | |||
Other health care costs | ||||||
General Practitioner | 20.20/visit | 0.12 | 2.51 (7.31) | 0.13 | 2.60 (7.14) | |
Other | NA | NA | 10.73 (39.99) | NA | 9.29 (34.36) | |
Subtotal | 13 (43) | 12 (35) | –1(–11 – 7) | |||
Costs outside health care | ||||||
Productivity cost | ||||||
Sick leave | 29.88–40.86/hour | NA | 467.56 (600.52) | NA | 444.73 (518.62) | |
Leave of absence | 9.00/hour | 12.9 | 116.26 (136.45) | 13.6 | 121.99 (130.78) | |
Loss of leisure time | 9.00/hour | 6.6 | 59.71 (157.90) | 11.5 | 103.67 (576.97) | |
Out of pocket cost | NA | NA | 63.22 (41.56) | NA | 73.46 (50.39) | |
Informal care | 9.00/hour | 3.0 | 26.69 (61.82) | 3.0 | 27.01 (59.77) | |
Other | NA | NA | 18.03 (90.86) | NA | 14.56 (72.21) | |
Subtotal | 751 (710) | 785 (780) | 35 (–118 – 210) | |||
Subtotal IVF treatment cycle | 4431 (731) | 4513 (880) | 87 (–88 – 268) | |||
Pregnancy (5–40 weeks) | ||||||
Hospital costs | ||||||
Ultrasound and consultation | 80.58 | 0.33 | 26.78 (38.17) | 0.48 | 38.85 (40.53) | |
Miscarriage | 80.58 | 0.13 | 9.98 (26.68) | 0.08 | 6.30 (21.74) | |
Other | NAc | NA | 120.54 (253.50) | NA | 274.86 (386.38) | |
Hospital admission days | 265–336/day | 0.62 | 123.49 (340.20) | 1.32 | 273.23 (788.79) | |
Subtotal | 281(563) | 593 (1050) | 312 (129 – 528) | |||
Other health care costs | ||||||
General Practitioner | 20.20/visit | 0.19 | 3.85 (8.35) | 0.35 | 6.99 (11.69) | |
Midwife care | 21.43/visit | 0.97 | 20.77 (42.70) | 1.47 | 31.40 (48.10) | |
Other | NA | NA | 65.51 (165.37) | NA | 104.65 (181.92) | |
Subtotal | 90 (205) | 143 (223) | 53 (1 – 103) | |||
Costs outside health care | ||||||
Productivity cost | ||||||
Sick leave | 29.88–40.86/hour | NA | 494.60 (1053.85) | NA | 1236.38 (1910.63) | |
Maternity leave | 29.88–40.86/hour | NA | 406.90 (868.89) | NA | 725.52 (1001.49) | |
Leave of absence | 9.00/hour | 6.63 | 59.69 (320.00) | 14.35 | 129.13 (446.19) | |
Loss of leisure time | 9.00/hour | 0.67 | 6.02 (18.06) | 2.26 | 20.30 (59.13) | |
Out of pocket cost | NA | NA | 19.63 (44.06) | NA | 35.86 (47.22) | |
Informal care | 9.00/hour | 8.54 | 76.83 (206.87) | 18.89 | 170.00 (276.90) | |
Other | NA | NA | 85.59 (188.95) | NA | 198.32 (316.25) | |
Subtotal | 1149 (2349) | 2516 (3378) | 1287 (704 – 1865) | |||
Subtotal pregnancyf | 1520 (3047) | 3252 (4304) | 1761 (928 – 2622) | |||
Delivery up to 4 weeks after delivery | ||||||
Hospital costs | ||||||
Other | NA | NA | 11.22 (44.93) | NA | 28.36 (72.76) | |
Hospital admission days | 336–804/day | 0.56 | 551.76 (1228.18) | 4.61 | 1590.51 (2826.54) | |
Subtotal | 563 (1245) | 1619 (2852) | 1067 (632 – 1603) | |||
Other health care costs | ||||||
General Practitioner | 20.20/visit | 0.13 | 2.69 (7.32) | 0.20 | 4.03 (7.98) | |
Midwife care | 41.99/visit | 0.20 | 8.41 (22.18) | 0.27 | 11.40 (28.72) | |
Other | NAc | NA | 315.36 (789.34) | NA | 419.63 (712.97) | |
Subtotal | 326 (806) | 435 (732) | 111 (–71–275) | |||
Costs outside health care | ||||||
Productivity cost | ||||||
Maternity leave | 29.88–40.86/hour | NA | 390.52 (846.38) | NA | 831.40 (1178.93) | |
Leave of absence | 9.00/hour | 2.84 | 25.58 (80.91) | 6.28 | 56.50 (130.44) | |
Loss of leisure time | 9.00/hour | 0.53 | 4.79 (11.90) | 2.00 | 17.96 (80.64) | |
Out of pocket cost | NA | NA | 4.06 (10.67) | NA | 7.76 (17.36) | |
Informal care | 9.00/hour | 5.28 | 47.49 (115.54) | 17.23 | 155.07 (470.33) | |
Other | NA | NA | 20.50 (72.87) | NA | 36.35 (119.09) | |
Subtotal | 493 (1049) | 1105 (1649) | 614 (313 – 928) | |||
Subtotal after deliveryg | 1382 (2910) | 3159 (4549) | 1785 (966 – 2637) | |||
Total societal costs per couple | 7334 (5780) | 10924 (8560) | 3510 (2060 – 5290) |
. | Unit price (€) . | Elective single embryo transfer (eSET) (n = 154) . | Double embryo transfer (DET) (n = 154) . | Bootstrapped difference in costsb (€) (95% UI)DET – eSET . | ||
---|---|---|---|---|---|---|
. | . | . | . | . | ||
. | . | Volumes of use . | Costs per couplea (€)Mean (SD) . | Volumes of use . | Costs per couplea (€)Mean (SD) . | . |
IVF treatment cycled | ||||||
Hospital costs | ||||||
Hormonal stimulation phase | ||||||
Medicatione | 1298 (1046–1550) | 1 | 1298 (NA) | 1 | 1298 (NA) | |
Hospital care | 272 (250) | 1 | 272 (NA) | 1 | 272 (NA) | |
Ovum pick-up | 490 (300) | 1 | 490 (NA) | 1 | 490 (NA) | |
Laboratory phase | 1100 (350) | 1 | 1100 (NA) | 1 | 1100 (NA) | |
Embryo transfer | 260 (200) | 1 | 260 (NA) | 1 | 260 (NA) | |
Other | NAc | NA | 242.11 (81.46) | NA | 246.18 (82.99) | |
Hospital admission days | 265–336/day | 0 | 4.38 (9.97) | 0.11 | 49.53 (290.97) | |
Subtotal | 3666 (82) | 3716 (317) | 51 (7 – 109) | |||
Other health care costs | ||||||
General Practitioner | 20.20/visit | 0.12 | 2.51 (7.31) | 0.13 | 2.60 (7.14) | |
Other | NA | NA | 10.73 (39.99) | NA | 9.29 (34.36) | |
Subtotal | 13 (43) | 12 (35) | –1(–11 – 7) | |||
Costs outside health care | ||||||
Productivity cost | ||||||
Sick leave | 29.88–40.86/hour | NA | 467.56 (600.52) | NA | 444.73 (518.62) | |
Leave of absence | 9.00/hour | 12.9 | 116.26 (136.45) | 13.6 | 121.99 (130.78) | |
Loss of leisure time | 9.00/hour | 6.6 | 59.71 (157.90) | 11.5 | 103.67 (576.97) | |
Out of pocket cost | NA | NA | 63.22 (41.56) | NA | 73.46 (50.39) | |
Informal care | 9.00/hour | 3.0 | 26.69 (61.82) | 3.0 | 27.01 (59.77) | |
Other | NA | NA | 18.03 (90.86) | NA | 14.56 (72.21) | |
Subtotal | 751 (710) | 785 (780) | 35 (–118 – 210) | |||
Subtotal IVF treatment cycle | 4431 (731) | 4513 (880) | 87 (–88 – 268) | |||
Pregnancy (5–40 weeks) | ||||||
Hospital costs | ||||||
Ultrasound and consultation | 80.58 | 0.33 | 26.78 (38.17) | 0.48 | 38.85 (40.53) | |
Miscarriage | 80.58 | 0.13 | 9.98 (26.68) | 0.08 | 6.30 (21.74) | |
Other | NAc | NA | 120.54 (253.50) | NA | 274.86 (386.38) | |
Hospital admission days | 265–336/day | 0.62 | 123.49 (340.20) | 1.32 | 273.23 (788.79) | |
Subtotal | 281(563) | 593 (1050) | 312 (129 – 528) | |||
Other health care costs | ||||||
General Practitioner | 20.20/visit | 0.19 | 3.85 (8.35) | 0.35 | 6.99 (11.69) | |
Midwife care | 21.43/visit | 0.97 | 20.77 (42.70) | 1.47 | 31.40 (48.10) | |
Other | NA | NA | 65.51 (165.37) | NA | 104.65 (181.92) | |
Subtotal | 90 (205) | 143 (223) | 53 (1 – 103) | |||
Costs outside health care | ||||||
Productivity cost | ||||||
Sick leave | 29.88–40.86/hour | NA | 494.60 (1053.85) | NA | 1236.38 (1910.63) | |
Maternity leave | 29.88–40.86/hour | NA | 406.90 (868.89) | NA | 725.52 (1001.49) | |
Leave of absence | 9.00/hour | 6.63 | 59.69 (320.00) | 14.35 | 129.13 (446.19) | |
Loss of leisure time | 9.00/hour | 0.67 | 6.02 (18.06) | 2.26 | 20.30 (59.13) | |
Out of pocket cost | NA | NA | 19.63 (44.06) | NA | 35.86 (47.22) | |
Informal care | 9.00/hour | 8.54 | 76.83 (206.87) | 18.89 | 170.00 (276.90) | |
Other | NA | NA | 85.59 (188.95) | NA | 198.32 (316.25) | |
Subtotal | 1149 (2349) | 2516 (3378) | 1287 (704 – 1865) | |||
Subtotal pregnancyf | 1520 (3047) | 3252 (4304) | 1761 (928 – 2622) | |||
Delivery up to 4 weeks after delivery | ||||||
Hospital costs | ||||||
Other | NA | NA | 11.22 (44.93) | NA | 28.36 (72.76) | |
Hospital admission days | 336–804/day | 0.56 | 551.76 (1228.18) | 4.61 | 1590.51 (2826.54) | |
Subtotal | 563 (1245) | 1619 (2852) | 1067 (632 – 1603) | |||
Other health care costs | ||||||
General Practitioner | 20.20/visit | 0.13 | 2.69 (7.32) | 0.20 | 4.03 (7.98) | |
Midwife care | 41.99/visit | 0.20 | 8.41 (22.18) | 0.27 | 11.40 (28.72) | |
Other | NAc | NA | 315.36 (789.34) | NA | 419.63 (712.97) | |
Subtotal | 326 (806) | 435 (732) | 111 (–71–275) | |||
Costs outside health care | ||||||
Productivity cost | ||||||
Maternity leave | 29.88–40.86/hour | NA | 390.52 (846.38) | NA | 831.40 (1178.93) | |
Leave of absence | 9.00/hour | 2.84 | 25.58 (80.91) | 6.28 | 56.50 (130.44) | |
Loss of leisure time | 9.00/hour | 0.53 | 4.79 (11.90) | 2.00 | 17.96 (80.64) | |
Out of pocket cost | NA | NA | 4.06 (10.67) | NA | 7.76 (17.36) | |
Informal care | 9.00/hour | 5.28 | 47.49 (115.54) | 17.23 | 155.07 (470.33) | |
Other | NA | NA | 20.50 (72.87) | NA | 36.35 (119.09) | |
Subtotal | 493 (1049) | 1105 (1649) | 614 (313 – 928) | |||
Subtotal after deliveryg | 1382 (2910) | 3159 (4549) | 1785 (966 – 2637) | |||
Total societal costs per couple | 7334 (5780) | 10924 (8560) | 3510 (2060 – 5290) |
Cost per couple = unit price × volumes of use.
Bootstrapped difference of costs DET – costs eSET.
NA means not applicable. Presentation of separate volumes and cost prices was not possible because they were constructed of several medical activities. For example, other hospital costs consist of consultations, laboratory tests etc. Each medical activity has its own volume and cost price.
Two weeks before ovum pick up (OPU) until 2 weeks after OPU.
For the costs of medication, mean costs were used per couple.
Mean subtotal costs after pregnancy were €7315 for pregnant patients in the eSET group and €8210 for pregnant patients in the DET group.
Mean subtotal costs after delivery were €6651 for pregnant patients in the eSET group and €7975 for pregnant patients in the DET group.
Cost-effectiveness analysis
The ICER of one cycle DET compared to one cycle eSET was €19 096 for the base-case analysis (Table IV). This means that the incremental costs are €19 096 for one extra successful pregnancy if one cycle DET will be performed instead of one cycle eSET.
. | Single embryo transfer . | Double embryo transfer . | ICER (% change in ICER) . | ||||
---|---|---|---|---|---|---|---|
. | . | . | . | ||||
. | Mean total costs (€) . | Effectiveness (%) . | Mean total costs/effect (€) . | Mean total costs (€) . | Effectiveness (%) . | Mean total costs/effect (€) . | . |
Base-case analysis | 7334 | 20.8 | 35 260 | 10 924 | 39.6 | 27 586 | 19 096 |
‘Dutch’ unit prices | 6312 | 20.8 | 30 346 | 9902 | 39.6 | 25 005 | 19 096 (0) |
Medication costs | |||||||
Low estimate | 7082 | 20.8 | 34 048 | 10 672 | 39.6 | 26 949 | 19 096 (0) |
High estimate | 7586 | 20.8 | 36 471 | 11 176 | 39.6 | 28 222 | 19 096 (0) |
Pregnancy costs 5–12 weeks | |||||||
Low-care assumption | 7315 | 20.8 | 35 168 | 10 901 | 39.6 | 27 528 | 19 074 (–0.1) |
High-care assumption | 7373 | 20.8 | 35 447 | 10 970 | 39.6 | 27 702 | 19 133 (+0.2) |
Post-natal hospital costs Lukassen and co-workersa | 7204 | 20.8 | 34 635 | 10 448 | 39.6 | 26 384 | 17 255 (–9.6) |
Exclusion of hospital admissions during IVF treatment cycle from cost calculation | 7329 | 20.8 | 35 236 | 10 874 | 39.6 | 27 460 | 18 856 (–1.3) |
Unit price of hospital admission day | |||||||
€337/day | 7197 | 20.8 | 34 601 | 10 599 | 39.6 | 26 765 | 18 096 (–5.2) |
€476/day | 7383 | 20.8 | 35 495 | 11 156 | 39.6 | 28 172 | 20 069 (+5.1) |
Only female patients in analysis | 7099 | 20.8 | 34 130 | 10 567 | 39.6 | 26 684 | 18 447 (–3.4) |
. | Single embryo transfer . | Double embryo transfer . | ICER (% change in ICER) . | ||||
---|---|---|---|---|---|---|---|
. | . | . | . | ||||
. | Mean total costs (€) . | Effectiveness (%) . | Mean total costs/effect (€) . | Mean total costs (€) . | Effectiveness (%) . | Mean total costs/effect (€) . | . |
Base-case analysis | 7334 | 20.8 | 35 260 | 10 924 | 39.6 | 27 586 | 19 096 |
‘Dutch’ unit prices | 6312 | 20.8 | 30 346 | 9902 | 39.6 | 25 005 | 19 096 (0) |
Medication costs | |||||||
Low estimate | 7082 | 20.8 | 34 048 | 10 672 | 39.6 | 26 949 | 19 096 (0) |
High estimate | 7586 | 20.8 | 36 471 | 11 176 | 39.6 | 28 222 | 19 096 (0) |
Pregnancy costs 5–12 weeks | |||||||
Low-care assumption | 7315 | 20.8 | 35 168 | 10 901 | 39.6 | 27 528 | 19 074 (–0.1) |
High-care assumption | 7373 | 20.8 | 35 447 | 10 970 | 39.6 | 27 702 | 19 133 (+0.2) |
Post-natal hospital costs Lukassen and co-workersa | 7204 | 20.8 | 34 635 | 10 448 | 39.6 | 26 384 | 17 255 (–9.6) |
Exclusion of hospital admissions during IVF treatment cycle from cost calculation | 7329 | 20.8 | 35 236 | 10 874 | 39.6 | 27 460 | 18 856 (–1.3) |
Unit price of hospital admission day | |||||||
€337/day | 7197 | 20.8 | 34 601 | 10 599 | 39.6 | 26 765 | 18 096 (–5.2) |
€476/day | 7383 | 20.8 | 35 495 | 11 156 | 39.6 | 28 172 | 20 069 (+5.1) |
Only female patients in analysis | 7099 | 20.8 | 34 130 | 10 567 | 39.6 | 26 684 | 18 447 (–3.4) |
ICER, incremental cost-effectiveness ratio.
€182 for eSET and €852 for DET (Lukassen et al., 2004).
. | Single embryo transfer . | Double embryo transfer . | ICER (% change in ICER) . | ||||
---|---|---|---|---|---|---|---|
. | . | . | . | ||||
. | Mean total costs (€) . | Effectiveness (%) . | Mean total costs/effect (€) . | Mean total costs (€) . | Effectiveness (%) . | Mean total costs/effect (€) . | . |
Base-case analysis | 7334 | 20.8 | 35 260 | 10 924 | 39.6 | 27 586 | 19 096 |
‘Dutch’ unit prices | 6312 | 20.8 | 30 346 | 9902 | 39.6 | 25 005 | 19 096 (0) |
Medication costs | |||||||
Low estimate | 7082 | 20.8 | 34 048 | 10 672 | 39.6 | 26 949 | 19 096 (0) |
High estimate | 7586 | 20.8 | 36 471 | 11 176 | 39.6 | 28 222 | 19 096 (0) |
Pregnancy costs 5–12 weeks | |||||||
Low-care assumption | 7315 | 20.8 | 35 168 | 10 901 | 39.6 | 27 528 | 19 074 (–0.1) |
High-care assumption | 7373 | 20.8 | 35 447 | 10 970 | 39.6 | 27 702 | 19 133 (+0.2) |
Post-natal hospital costs Lukassen and co-workersa | 7204 | 20.8 | 34 635 | 10 448 | 39.6 | 26 384 | 17 255 (–9.6) |
Exclusion of hospital admissions during IVF treatment cycle from cost calculation | 7329 | 20.8 | 35 236 | 10 874 | 39.6 | 27 460 | 18 856 (–1.3) |
Unit price of hospital admission day | |||||||
€337/day | 7197 | 20.8 | 34 601 | 10 599 | 39.6 | 26 765 | 18 096 (–5.2) |
€476/day | 7383 | 20.8 | 35 495 | 11 156 | 39.6 | 28 172 | 20 069 (+5.1) |
Only female patients in analysis | 7099 | 20.8 | 34 130 | 10 567 | 39.6 | 26 684 | 18 447 (–3.4) |
. | Single embryo transfer . | Double embryo transfer . | ICER (% change in ICER) . | ||||
---|---|---|---|---|---|---|---|
. | . | . | . | ||||
. | Mean total costs (€) . | Effectiveness (%) . | Mean total costs/effect (€) . | Mean total costs (€) . | Effectiveness (%) . | Mean total costs/effect (€) . | . |
Base-case analysis | 7334 | 20.8 | 35 260 | 10 924 | 39.6 | 27 586 | 19 096 |
‘Dutch’ unit prices | 6312 | 20.8 | 30 346 | 9902 | 39.6 | 25 005 | 19 096 (0) |
Medication costs | |||||||
Low estimate | 7082 | 20.8 | 34 048 | 10 672 | 39.6 | 26 949 | 19 096 (0) |
High estimate | 7586 | 20.8 | 36 471 | 11 176 | 39.6 | 28 222 | 19 096 (0) |
Pregnancy costs 5–12 weeks | |||||||
Low-care assumption | 7315 | 20.8 | 35 168 | 10 901 | 39.6 | 27 528 | 19 074 (–0.1) |
High-care assumption | 7373 | 20.8 | 35 447 | 10 970 | 39.6 | 27 702 | 19 133 (+0.2) |
Post-natal hospital costs Lukassen and co-workersa | 7204 | 20.8 | 34 635 | 10 448 | 39.6 | 26 384 | 17 255 (–9.6) |
Exclusion of hospital admissions during IVF treatment cycle from cost calculation | 7329 | 20.8 | 35 236 | 10 874 | 39.6 | 27 460 | 18 856 (–1.3) |
Unit price of hospital admission day | |||||||
€337/day | 7197 | 20.8 | 34 601 | 10 599 | 39.6 | 26 765 | 18 096 (–5.2) |
€476/day | 7383 | 20.8 | 35 495 | 11 156 | 39.6 | 28 172 | 20 069 (+5.1) |
Only female patients in analysis | 7099 | 20.8 | 34 130 | 10 567 | 39.6 | 26 684 | 18 447 (–3.4) |
ICER, incremental cost-effectiveness ratio.
€182 for eSET and €852 for DET (Lukassen et al., 2004).
Figure 1 shows the cost-effectiveness plane for the base-case analysis, in which the results based on 1000 successive bootstrap replications are given, comparing one cycle DET to one cycle eSET. The incremental cost-effectiveness acceptability curve of the base-case analysis in Figure 2 shows that until the ceiling ratio reaches €15 000, the probability that one cycle DET is cost-effective is 0%, as all bootstrapped ICERs were equal to or higher than €15 000. When the ceiling ratio is between €15 000 and €32 500, the probability that one cycle DET is cost-effective increases and the probability that one cycle eSET is most cost-effective decreases. If the ceiling ratio is above €32 500, the probability that one cycle DET is most cost-effective is 100%, as all bootstrapped ICERs were equal to or lower than €32 500.
Sensitivity analyses
Results of the sensitivity analyses are summarized in Table IV. The ICERs of one cycle DET compared with one cycle eSET changed only marginally if several cost parameters were altered. Using post-natal hospital costs of Lukassen et al. (2004) in a sensitivity analysis had the largest effect on the ICER. Therefore, results from this analysis were bootstrapped, and a cost-effectiveness acceptability curve was derived. Again, 100% of the cost-effectiveness pairs are located in the quadrant where one cycle DET is more effective but more costly compared with one cycle eSET (northeast quadrant; results not graphically presented). Figure 2 (Lukassen data) shows that the cost‐effectiveness acceptability curve is slightly shifted to the left compared with the base-case curve in Figure 2 meaning that the results became slightly more favourable for DET. Until the ceiling ratio reaches €12 500, the probability that one cycle eSET is most cost-effective is 100%. When the ceiling ratio is between €12 500 and €25 000, the probability that one cycle eSET is most cost-effective decreases and the probability that one cycle DET is most cost-effective increases. If the ceiling ratio is above €25 000, the probability that one cycle DET is most cost-effective is 100%. As costs of pregnancy were based on a small number of pregnant couples, we also compared our hospital costs during pregnancy with the hospital costs found in the study of Lukassen et al. (2004). These costs (€238 for eSET and €595 for DET) were highly comparable with the hospital costs we calculated in our study (€281 for eSET and €593 for DET). Therefore, we decided not to perform a sensitivity analysis on these costs.
Discussion
This study is distinct from other studies, because a cost-effectiveness analysis was performed in an unselected group of patients receiving eSET or DET, based on the couple’s perspective instead of only the female patient’s perspective. Socio-economic characteristics were comparable for both the groups, indicating that the difference in costs between eSET and DET (such as productivity costs and out-of-pocket costs) was not affected by differences in socio-economic characteristics. The successful pregnancy rate after eSET was approximately half of that obtained after DET (20.8% after eSET versus 39.6% after DET). Total societal costs per couple were significantly lower after one cycle eSET (€7334) compared with one cycle DET (€10 924). The cost difference was mainly caused by the hospital costs after ET (40% of the cost difference) and productivity costs (32% of the cost difference). Female patients were mainly responsible for the costs in both the groups. The ICER of DET compared to that of eSET was €19 096, indicating that the incremental costs are €19 096 for one extra successful pregnancy if one cycle DET will be performed instead of one cycle eSET. Sensitivity analyses showed that our results were very robust for changing several cost parameters. Using post-natal hospital costs of Lukassen et al. (2004) caused a minor shift to the left in the cost-effectiveness acceptability curve, indicating that results became slightly more favourable for DET.
There are some limitations in the cost-effectiveness analysis that need to be addressed. First, all data with respect to the volumes of use were collected from cost diaries, because most patients dispersed to other hospitals in the south of the Netherlands during pregnancy. Because we relied on couple-reported data and made no use of official registrations, possibly under- or over-reporting may have occurred. However, it is expected that the bias resulting from it is probably equal for both the groups, so it will not influence our conclusions. Although several assumptions were made and some data were missing, our results proved to be reliable for changing several cost parameters. In addition, cost diaries have proven to be reliable (Goossens et al., 2000) and are commonly used in cost-effectiveness analysis. Second, in our cost-effectiveness analysis, only results of the first IVF cycle were compared. Nowadays, there is increasing support to compare two consecutive cycles of eSET with one cycle of DET, to gain equal pregnancy probabilities. In our study, assuming that all couples without a successful pregnancy in the first eSET cycle would receive eSET for a second time, that the successful pregnancy rate of a second cycle eSET would be exactly the same as in the first cycle and that the total costs would also be the same, 37.0% [32 (20.8% × 154) + 25 (20.8% × 122)/154] of the patients would have a successful pregnancy after two cycles of eSET. The total costs would be €12 728 [(€7102 × 154) + (€7102 × 122)/154]. On the basis of ICER, two cycles eSET would be dominated by one cycle DET, because costs are higher and the effect is lower compared with one cycle DET. Furthermore, in a comprehensive cost-effectiveness analysis, several DET and eSET strategies should be compared, evaluating the full IVF procedure. For this, a Markov model is currently being developed, reflecting the ‘real-world’ situation as accurate as possible, taking into account cancelled cycles, availability of only one embryo (compulsory SET), declining pregnancy rates in subsequent cycles, transfers of cryopreserved embryos and treatment dropouts. In this model, several eSET and DET strategies based on continued cycles were compared to determine which one was preferable.
Former studies have shown that cost differences between eSET and DET are mainly caused by high costs because of complications during twin pregnancies and deliveries and by high neonatal costs for twins in the DET group (Wolner-Hanssen and Rydhstroem, 1998; De Sutter et al., 2002; Gerris et al., 2004; Lukassen et al., 2005; Thurin Kjellberg et al., 2006). In our study, the cost difference between eSET and DET was also because of twin pregnancies and more pregnancies occurring in the DET group. Contrary to most other cost-effectiveness studies (Wolner-Hanssen and Rydhstroem, 1998; De Sutter et al., 2002; Gerris et al., 2004; Lukassen et al., 2005), in our study, an ICER was calculated. Other studies have only calculated the mean costs per successful pregnancy (i.e. birth of at least one live-born child) for each strategy separately. According to Drummond et al. (2005), regarding a full economic evaluation, two criteria have to be met. First, in the study, two or more alternatives have to be compared. Second, an economic evaluation must deal with the consequences (outcome) and the costs (investment) of the treatment alternatives being compared using an incremental approach. Therefore, it is not comprehensive to only determine the mean costs per effect for each strategy separately, but the incremental cost-effectiveness should be reported as well. Moreover, as these studies used a selected patient group, results cannot directly be compared to those of the present study. Only in the study of (Thurin Kjellberg et al., 2006), an ICER was calculated. Using a societal perspective, their ICER comparing DET with SET was €91 702 per extra successful pregnancy, which is about 4.5 times higher than the ICER of our study. On the basis of ICER, Thurin and co-workers concluded that DET is not cost-effective.
The choice between offering couples one cycle eSET or one cycle DET depends on what the society is prepared to pay for one extra live-born child. Currently, there is no universally accepted ceiling ratio for cost-effectiveness, and to date (Eichler et al., 2004), most cost-effectiveness researchers only provide policymakers with cost-effectiveness acceptability curves, showing for a wide range of ceiling ratios, the probability that a particular health care commodity is cost-effective. Also within the field of IVF, there is currently no agreement on an appropriate ceiling ratio for one extra successful pregnancy. Therefore, based on the results of this study, it cannot be concluded whether DET or eSET in the first cycle is more cost‐effective. On the contrary, because DET seems to be the current practice, the ratio from our study indicates that substituting DET by eSET in an unselected patient group would lead to cost savings but effectiveness loss as well. A reluctance to lose a proportion of successful pregnancies would consequently indicate acceptability of the ICER we found in this study (Severens et al., 2005). Nevertheless, in deciding on the preferred strategy, the long-term consequences of eSET and DET should also be considered. Inclusion of the long-term costs in the cost-effectiveness analysis, such as costs because of premature births, would probably result in a substantially higher ICER, making DET less attractive from a long-term economic point of view. However, a ‘successful pregnancy’ is considered an intermediate outcome measure. A commonly used outcome measure in economic evaluation is the number of quality adjusted life years (QALYs), combining the number of life years gained with the quality of that life. To obtain a balanced estimate of the long-term cost-effectiveness of eSET versus DET, both long-term costs and effects in terms of QALYs should be considered. For practical reasons, this has not been included in any study so far. Therefore, it is difficult to provide a fair estimate of the long-term cost-effectiveness.
In conclusion, our study shows that in an unselected group of patients qualifying for IVF treatment, one cycle eSET is less expensive but also less effective compared with one cycle DET. It depends on the society’s willingness to pay for one extra successful pregnancy, whether one cycle eSET or one cycle DET is preferred from a cost-effectiveness point of view. The Markov model currently in development by our research group should provide insight into the ‘real-world’ cost-effectiveness of several SET and DET strategies.
Acknowledgements
The authors thank Fred Nieman (Department of Clinical Epidemiology and Medical Technology Assessment, University Hospital, Maastricht) for his statistical assistance. This study was supported by a research grant (number 945-12-014) from the Dutch Organisation for Health Research and Development (ZonMw) and the Dutch Health Insurance Board (CvZ) in a joint research programme on health technology assessment of infertility.