This reluctance to provide benefits for infertility treatment has two detrimental effects:

1) it discourages patients from seeking effective medical attention;

2) it promotes "gaming" of the reimbursement system (coding for disorders that are present and covered, but ignoring the underlying primary concern-infertility). This leads to a highly inaccurate database, as it is impossible to manage conditions that are not identified.

Infertility actually lends itself very well to disease state management. The goal of disease state management is to provide the best possible outcome at the lowest possible cost. This method "manages" all aspects of the disease (awareness, education, prevention, and intervention).

The endpoint for infertility is clearly defined: pregnancy resulting in childbirth. Life table analysis and the statistical probabilities of pregnancy-limited somewhat by the quality of the studies at the current time-are available in the literature for many of the disease processes causing infertility (eg, endometriosis, tubal factor, male factor).

Confounding factors known to affect outcomes are recognized, including age, smoking, and body weight. And as is pointed out in the article by Dr. Van Voorhis, pregnancy rates resulting from in vitro fertilization have risen steadily over the last few years. Using this body of knowledge, it should be relatively simple to establish rational treatment plans for couples with infertility over a limited period of time.

The current article provides an excellent summary of what we know about cost-effective care for the infertile couple. There are 3 points that should be emphasized:

1) IVF success rates are increasing, making it more cost effective for more diagnoses; several programs in the US have pregnancy rates consistently above 50% per embryo transfer.

2) It is incumbent on providers of infertility services to decrease the rate of high-order (3 or more) multiple pregnancy. Most of the programs mentioned above transfer 3 or fewer embryos in women under the age of 40.

3) It is hoped that the cost of IVF will decrease, either because of competitive pricing of drugs and services or because emerging technologies will lessen the need for expensive, controlled, ovarian hyperstimulation.

All these advancements will result in improvements of the cost-effectiveness of IVF, thereby lowering the cost per delivery for infants conceived by means of advanced technologies.

David A. Grainger, MD
Associate Professor & Director, Division of Reproductive Endocrinology
Department of Obstetrics and Gynecology
University of Kansas School of Medicine-Wichita
Wichita, Kan.

Table of Contents
1. Cost Effective Approach
2. How much will IVF cost me?
3. A 'good prognosis' costs how much less?
4. If you're younger, it works out cheaper
5. Why is IUI more affordable?
6. Over 38? It may cost more.
7. Fertility Economics
8. Discouraged? IVF success rates increasing.
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