Time costs of fertility care: the hidden hardship of building a family

IMPORTANCE Intracytoplasmic sperm injection (ICSI) is increasingly used in patients without severe male factor infertility without clear evidence of a benefit over conventional in vitro fertilization (IVF). OBJECTIVE To assess national trends and reproductive outcomes for fresh IVF cycles (embryos transferred without being frozen) following the use of ICSI compared with conventional IVF with respect to clinical indications for ICSI use. DESIGN, SETTING, AND POPULATION Retrospective cohort study using data on fresh IVF and ICSI cycles reported to the US National Assisted Reproductive Technology Surveillance System during 1996-2012. MAIN OUTCOMES AND MEASURES Trends in ICSI use during 1996-2012 with respect to male factor infertility, unexplained infertility, maternal age 38 years or older, low oocyte yield, and 2 or more prior assisted reproductive technology cycles; reproductive outcomes for conventional IVF and ICSI cycles during 2008-2012, stratified by the presence or absence of male factor infertility. RESULTS Of the 1 395 634 fresh IVF cycles from 1996 through 2012, 908 767 (65.1%) used ICSI and 499 135 (35.8%) reported male factor infertility. Among cycles with male factor infertility, ICSI use increased from 76.3% (10 876/14 259) to 93.3% (32 191/34 506) (P < .001) during 1996-2012; for those without male factor infertility, ICSI use increased from 15.4% (4197/27 191) to 66.9% (42 321/63 250) (P < .001). During 2008-2012, male factor infertility was reported for 35.7% (176 911/494 907) of fresh cycles. Among those cycles, ICSI use was associated with a lower multiple birth rate compared with conventional IVF (30.9% vs 34.2%; adjusted relative risk [RR], 0.87; 95% CI, 0.83-0.91). Among cycles without male factor infertility (n = 317 996), ICSI use was associated with lower rates of implantation (23.0% vs 25.2%; adjusted RR, 0.93; 95% CI, 0.91-0.95), live birth (36.5% vs 39.2%; adjusted RR, 0.95; 95% CI, 0.93-0.97), and multiple live birth (30.1% vs 31.0%; adjusted RR, 0.93; 95% CI, 0.91-0.95) vs conventional IVF. CONCLUSIONS AND RELEVANCE Among fresh IVF cycles in the United States, ICSI use increased from 36.4% in 1996 to 76.2% in 2012, with the largest relative increase among cycles without male factor infertility. Compared with conventional IVF, ICSI use was not associated with improved postfertilization reproductive outcomes, irrespective of male factor infertility diagnosis.

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“…14,15 The higher reimbursement associated with ICSI has been postulated as one possible reason for the increasing use of this technology.…”

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confidence: 99%

Trends in Use of and Reproductive Outcomes Associated With Intracytoplasmic Sperm Injection

Boulet

Mehta

Kissin

et al. 2015

JAMA

283

127

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“…Infertility is an insidious condition that impacts not only the ability to have biological children, but has broader implications for psychological well-being, relationships, finances (assisted reproduction and adoption can be expensive), general health and life expectancy 164–166,163,167 . Assisted reproductive technologies are available for men that produce even a small number of sperm in their ejaculates or testes.…”

Section: Discussionmentioning

confidence: 99%

Experimental methods to preserve male fertility and treat male factor infertility

Gassei

Orwig

2016

Fertility and Sterility

120

103

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Infertility is a prevalent condition that has insidious impacts on the infertile individuals, their families and society that extend far beyond the inability to have a biological child. Lifestyle changes, fertility treatments and assisted reproductive technologies are available to help many infertile couples achieve their reproductive goals. All of these technologies require that the infertile individual is able to produce at least a small number of functional gametes (eggs or sperm). It is not possible for a person who does not produce gametes to have a biological child. This review focuses on the infertile man and describes several stem cell-based methods and gene therapy approaches that are in the research pipeline and may lead to new fertility treatment options for azoospermic men.

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“…Though patients seeking reproductive assistance are highly likely to have decision making capacity and clear wishes, they may also be emotionally vulnerable and under stress [27]. They may be so desperate to become pregnant that they do not evaluate risks rationally.…”

Section: Informed Consentmentioning

confidence: 99%

Are IVF Risk-Sharing Programs Ethical?

Francis

2014

Virtual Mentor

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ETHICS CASEAre IVF Risk-Sharing Programs Ethical? Commentary by Leslie P. Francis, PhD, JD Dr. Rearden, the head of a fertility clinic in Philadelphia, called a meeting with his staff to discuss budgeting for the coming year. During the meeting, Dr. Rearden proposed implementing a "risk-sharing" program. Patients selected for such programs would initially pay a higher fee to the clinic. If a patient had a successful pregnancy, then the clinic would keep her entire fee. If the patient did not become pregnant, a previously specified proportion of the fee would be returned to her.In his presentation to the staff, Dr. Rearden explained that the program would be beneficial to both the clinic and patients. The program represents a safety net for patients who pay for IVF out of pocket by leaving them money to pursue other options should their treatment fail. Moreover, the higher fee paid by patients who become pregnant ensures that the clinic will have money to reimburse the patients for whom treatment is unsuccessful.At the conclusion of Dr. Rearden's presentation, Dr. Whipple, a long-time ob-gyn physician in the clinic, asked to speak. "I can appreciate wanting to offer a safety net for patients, especially given that IVF is not covered by insurance," Dr. Whipple began. "But I have some serious reservations about implementing such a program. First, it seems that those who would be selected as candidates for the program are also those most likely to become pregnant, so we would be taking advantage of patients in a moment of substantial emotional stress by essentially overcharging them. Second, and more importantly, if medical payment is based on outcome, our focus will inevitably shift from doing what is best for our patients to trying to get the desired outcome, in this case pregnancy, regardless of what that means for the people we're treating. I just don't think we should go down this road." CommentaryAs use of IVF continues to increase, risk sharing [1] has emerged as a potential financing method, with some commentators estimating that such programs are in fact quite common [2]. A survey of the websites of the 10 fertility clinics top ranked for achieving pregnancy by Parents magazine indicated that 3-

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Time costs of fertility care: the hidden hardship of building a family

Cited by 127 publications

References 18 publications

Trends in Use of and Reproductive Outcomes Associated With Intracytoplasmic Sperm Injection

Trends in Use of and Reproductive Outcomes Associated With Intracytoplasmic Sperm Injection

Experimental methods to preserve male fertility and treat male factor infertility

Are IVF Risk-Sharing Programs Ethical?

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