Direct and Indirect Costs
In addition to direct medical costs, cost-effectiveness analyses often include direct nonmedical costs, indirect costs, and intangible costs. Direct nonmedical expenses include expenditures for food, lodging, and transportation connected with seeking such medical treatment. These expenses can be substantial, particularly when services are not readily accessible, as is often the case for highly specialized procedures (eg, IVF, which is offered at a limited number of centers).
Indirect costs are those that occur because of a loss of life or livelihood and may result from morbidity or mortality arising from infertility treatment. Indirect costs include lost wages or decreased earning potential, which may occur while seeking treatment or because of disability.
Finally, intangible costs include the pain, suffering, and grief that may occur as the result of disease or medical care. Intangible costs are very difficult to measure and have not been included in most cost-effectiveness analyses of infertility treatments.
Cost-effectiveness Analysis of IVF
IVF is becoming an increasingly common treatment for all causes of infertility. IVF involves stimulating multiple ovarian follicles to develop by injecting the woman with gonadotropin medications. The eggs within these follicles are retrieved using a needle under ultrasound guidance. The eggs are fertilized in the laboratory, and the resulting embryos are then transferred to the uterus through the cervix.
Typically, 3 of 4 embryos are placed into the uterus in order to improve the chances for pregnancy. As might be expected, this practice also increases the risk of multiple births. Embryos not used for transfer at the time of retrieval are often cryopreserved for later procedures. Some programs use variations of IVF such as gamete intrafallopian tube transfer (GIFT), which involves retrieved eggs and sperm, or zygote intrafallopian tube transfer (ZIFT), which involves embryos. Both procedures require laparoscopy for placing the material in the fallopian tube. IVF, GIFT, and ZIFT are sometimes collectively referred to as assisted reproductive techniques (ART).
The cost-effectiveness of IVF in the US has been examined in a number of reports (Table 1). Neumann and colleagues were the first to report on this topic; they obtained costs of performing IVF by polling 6 IVF centers in the eastern US. Direct costs of the treatment were estimated to be $8000 per cycle for medical charges. They also estimated the costs of complications, including multiple births. Indirect costs of the cycle were included in the analysis by calculating lost wages at $11 per hour.
Outcomes of the treatment cycles were obtained from published reports, and the investigators estimated from those data that pregnancy rates varied from 12% for the first cycle of treatment to 7% for the sixth cycle of treatment. By this analysis, the estimated cost per delivery for the first cycle was $66,667 and increased to $114,286 per delivery after the sixth treatment cycle.