P-456 Economic evaluations of assisted reproductive technology in high income countries - a systematic review
Authors: Olive E , Bull C , Gordon A , Davies-Tuck M , Wang R , Callander E 
Published: June 2023

Abstract

Study question
In high-income country settings, what is the evidence supporting economic evaluations of in vitro fertilisation (IVF) interventions?

Summary answer
Most interventions associated with IVF are high cost for minimal improvement in effectiveness, leading to excessively high acceptability thresholds.

What is known already
The economic burden of infertility, and approaches to reduce costs and increase access have been identified in the top 10 research priorities for future infertility research. Meanwhile, there has been exponential growth in use of ART for infertility, especially in high-income countries. Therefore, it is important to map the landscape of economic evaluations in IVF research to inform health policy and future research.

Study design, size, duration
A systematic review of studies of an IVF intervention together with an economic evaluation conducted in high income countries between 2011 and 2022 was completed. Seven electronic databases were searched for eligible studies
(MEDLINE, PUBMED, EMBASE, COCHRANE, ECONLIT, SCOPUS or CINAHL).

Participants/materials, setting, methods
Studies assessing a component of IVF with a cost effectiveness, cost benefit, cost utility or cost minimization assessment were included. Studies were examined to assess their
chosen outcome measure, perspective, completeness of reporting and cost effectiveness of
the intervention studied. Cost data were converted to USD, taking inflation into consideration.

Main results and the role of chance
Of the 40 included studies, 62% evaluated an unselected population and 68% used livebirth as the effectiveness outcome measure. Modelling studies predominated (65%) over those alongside trials. Most (80%) spoke from a health funder perspective.
There were 11 IVF interventions assessed together with an economic evaluation. The incremental cost effectiveness ratio was greatest for those interventions where the intervention did not improve efficacy significantly. The intervention of PGT-A was assessed as either less effective and more expensive, or more effective, but costing up to $600,000 USD for each additional livebirth. Likewise, intracytoplasmic sperm injection for non-male factor infertility, conferred minimal benefit but cost up to $72000 USD per additional livebirth.
Choice of agents for ovarian hyperstimulation were assessed in 15 included papers. Recombinant FSH is more effective and slightly more expensive than biosimilars.
The direction of effect of the cost effectiveness findings was the same for the groups of studies assessing IVF, ICSI, PGT-A and embryo transfer number, increasing confidence in the findings across different settings and funding models.

Limitations, reasons for caution
Systematic reviews of economic evidence rely on assumptions of evidence in included studies. The data on health outcomes (e.g. pregnancy rates) were sometimes optimistic compared with findings in evidence from large trials or systematic reviews. There is variable reporting quality which might increase uncertainty around the cost effectiveness results.

Wider implications of the findings
Economic evaluation of IVF interventions is important for state funders and individuals who pay for treatment. Awareness of the real price per outcome allows consideration for funding to be applied more effectively. Multi-faceted decision making is needed. Cost effectiveness alone should not champion interventions that may otherwise have adverse consequences.

Trial registration number
not applicable