Overuse of IVF risks public funding
G. Bahadur, R Homburg, A. Al-Habib, A Muneer04 May 2017
In a fertility industry, worth over £500 million in the UK alone, IVF cumulative pregnancy rate presentation inflates the actual result from what would otherwise appear as poor success rates to laypersons, hospital administrators and funding agencies such as CCGs (1-3). To suggest such a model would help a patient individually misses the point, since it attempts to sell a `better pregnancy rate’ on a 6-cycle package (1) which some fertility clinics market. While there may be benefits of utilising cumulative rates, a figure of over 80% success does not alter the live birth rate for each IVF treatment cycle which is quoted at 25.8% in 2008 to 25.5% in 2013, when using the female’s own fresh eggs. Clinics differences in success rates are attributed to patient selection. What patients are not informed about is the cheaper and yet effective treatment option of intrauterine insemination (IUI) which can be justified as a first line treatment option for most patients, and the NICE guidelines (2-4) controversially relegated IUI as an option. The UK IVF industry is highly reliant on patients being recommended IVF treatment directly on the basis of one poor RCT with a low IUI success rate of 7%/cycle used by NICE. Against this backdrop the mean HFEA IUI pregnancies success rates is 13%/cycle, which typically translates to around 25% of the cohort. The costing of IUI and IVF are approximately £800 per cycle and over £4000 respectively, against an estimated 33-50% overuse of IVF (2-4).
Cumulative pregnancy rates have academic merits, but using individual patients’ heterogeneous data from fresh and frozen embryo transfer (FER) cycles seems to add complexity and costs. FER has 2 events with added costs for freezing embryos and the patients’ re-attendance. Even the cumulative graphs as presented could be interpreted as having treatment occurring at 2.5 or 3.5 cycles appears scientifically unsound, while all predictors of successful pregnancy are not unique to this model(1). Far too many variables would need to be included in IVF costing and it’s not surprising IUI is still a more cost-effective treatment option than IVF by 43,375 Euro per pregnancy, while the mean cost per live birth rate is 7187 Euros for IVF versus 5070 Euros for IUI (5). Individual and professional interests in utilising more profitable IVF treatments appears an overriding factor in choices of treatment, with heightened risks to public fertility funding (2-4).
1. McLernon DJ, Steyerberg EW, Te Velde ER, Lee AJ, Bhattacharya Predicting the chances of a live birth after one or more complete cycles of in vitro fertilisation: population based study of linked cycle data from 113 873 women. BMJ. 2016 Nov 16;355:i5735. doi: 10.1136/bmj.i5735.
2. Bahadur G, Homburg R, Muneer A, Racich P, Alangaden T, Al-Habib A, Okolo S. First line fertility treatment strategies regarding IUI and IVF require clinical evidence. Hum Reprod. 2016 Jun;31(6):1141-6. doi: 10.1093/humrep/dew075. Epub 2016 Apr 12.
3. Bahadur G, Homburg R, Al-Habib A. 2016. A new dawn for intrauterine insemination: efficient and prudent practice will benefit patients, the fertility industry and the healthcare bodies. The Journal of Obstetrics and Gynecology of India, (), 1-7 DOI 10.1007/s13224-016-0928-5
4. G. Bahadur, B Woodward, R. Homburg, A. Al-Habib, A Muneer NICE guidelines fail to provide evidence on first line fertility treatment, BMJOnline, December 2016 http://bmjopen.bmj.com/content/6/11/e013940/reply#bmjopen_el_10201
5. Tjon-Kon-Fat RI, Bensdorp AJ, Bossuyt PM, Koks C, Oosterhuis GJ, Hoek A, Hompes P, Broekmans FJ, Verhoeve HR, de Bruin JP et al. Is IVF-served two different ways-more cost-effective than IUI with controlled ovarian hyperstimulation? Hum Reprod 2015; 30:2331–2339.
G. Bahadur, R Homburg, A. Al-Habib, A Muneer
Reproductive Medicine Unit, North Middlesex University Hospital, Old Admin Block, Sterling Way, London N18 1QX
Homerton Fertility Centre, Homerton University Hospital, Homerton Row, London, E9 6SR
University College London Hospital, 250 Euston Road, London NW1 2BU