Infertility

Infertility Infertility Weighing Cost Versus Efficacy in Assisted Reproductive Technology Reviewed by Michael P. O’Leary, MD, MPH Division of Urology, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA [Rev Urol. 2003;5(4):251] © 2003 MedReviews, LLC reat strides have been made in assisted reproductive technology (ART) in the last decade. Couples who, 10 years ago, would have had to consider adoption are now able to conceive and carry to term utilizing techniques such as intracytoplasmic sperm injection. What role does the urologist play in the evaluation and management of infertility? Do we still have a role in the era of ART? G The Cost-Effectiveness of Treatment for Varicocele Related Infertility Penson DF, Paltiel AD, Krumholz HM, Palter S J Urol. 2002;168:2490-2494. A recent study by Penson and colleagues compared the cost-effectiveness of various treatments of varicocelerelated infertility. Varicocele is perhaps the most surgically correctable cause of male factor infertility. However, in many states, health insurance does not reimburse the cost of the procedure, leading some couples to choose alternative forms of ART, such as in vitro fertilization (IVF). The study investigators evaluated 4 treatment strategies: varicocelectomy followed by as many as 3 cycles of IVF if the couple did not conceive within a year postoperatively; 3 cycles of gonadotropin stimulation and intrauterine insemination (IUI) followed by 3 cycles of IVF if this was unsuccessful; 3 cycles of immediate IVF; and observation alone. The primary outcome measure was cost per live birth. Using published literature on the effectiveness of varicocelectomy and IUI/IVF and cost estimates from the Yale Center for Reproductive Medicine, probability estimates and sensitivity analyses were calculated for each of the treatments. The results indicated that up-front IVF is the least cost-effective strategy. Each additional birth achieved through the use of varicocelectomy/IVF as opposed to observation alone cost $52,152, whereas each birth that resulted from choosing IUI/IVF over varicocelectomy/IVF cost $561,423. The marginal cost-effectiveness of IUI/IVF compared with observation was $27,371, whereas it was $27,618 for varicocelectomy/IVF compared with observation. The effectiveness probability for varicocelectomy was estimated to be 0.297, compared with 0.254 for each IVF cycle. Although these numbers are conservative, based on data from 1997 and earlier, the point is clear. Up-front IVF for men with varicocele-related infertility is difficult to justify, as it costs more and has less favorable outcomes than other treatment strategies. Even if they require more time, surgery followed by IVF if necessary or IUI followed by IVF if necessary are the logical treatment choices, with comparable rates of success. VOL. 5 NO. 4 2003 REVIEWS IN UROLOGY 251