Management of the first in vitro fertilization cycle for unexplained infertility cost effectiveness analysis of split in vitro fertilization intracytoplasmic sperm injection

Conventional IVF may be the preferred insemination method in the initial treatment of couples with unexplained infertility, but split IVF-ICSI becomes preferable if more than one IVF cycle is necessary.

Wendy Vitek, M.D., Omar Galarraga, Ph.D., Peter C. Klatsky, M.D., M.P.H., Jared C. Robins, M.D., Sandra A. Carson, M.D., Andrew S. Blazar, M.D.

Volume 100, Issue 5, Pages 1381-1388.e1, November 2013


To determine the cost-effectiveness of split IVF-intracytoplasmic sperm injection (ICSI) for the treatment of couples with unexplained infertility.

Adaptive decision model.

Academic infertility clinic.

A total of 154 couples undergoing a split IVF-ICSI cycle and a computer-simulated cohort of women <35 years old with unexplained infertility undergoing IVF. Intervention(s):
Modeling insemination method in the first IVF cycle as all IVF, split IVF-ICSI, or all ICSI, and adapting treatment based on fertilization outcomes.

Main Outcome Measure(s):
Live birth rate, incremental cost-effectiveness ratio (ICER).

In a single cycle, all IVF is preferred as the ICER of split IVF-ICSI or all ICSI ($58,766) does not justify the increased live birth rate (3%). If two cycles are needed, split IVF/ICSI is preferred as the increased cumulative live birth rate (3.3%) is gained at an ICER of $29,666.

In a single cycle, all IVF was preferred as the increased live birth rate with split IVF-ICSI and all ICSI was not justified by the increased cost per live birth. If two IVF cycles are needed, however, split IVF/ICSI becomes the preferred approach, as a result of the higher cumulative live birth rate compared with all IVF and the lesser cost per live birth compared with all ICSI.

  • Lauren Johnson

    I applaud the authors for their hard work in performing a cost-effectiveness
    analysis to determine if split ICSI should be used for couples with unexplained infertility. The authors concluded that performing split ICSI is not cost effective in the first IVF cycle but is cost effective if two cycles are performed.

    While the model that the authors constructed is appropriate, I do question some of the assumptions that went into the model. Based on SART data, the authors estimated a LBR of 42.3% among couples with adequate fertilization (regardless of insemination method). However, the authors also estimated a 42.3% chance of live birth among couples with poor fertilization. I question whether LBR is the same among couples with poor fertilization simply because there are likely to be fewer high quality embryos available for transfer.

    Additionally, some IVF programs do not charge additional fees for ICSI. For patients in those practices, ICSI would be cost effective in the first cycle since the cost of the cycle would be the same while the chance of pregnancy would be higher.

    • Micah Hill

      I also appreciated this article. As with any cost analysis, the assumptions in the model can have significant effects on the conclusions. I was curious if the authors performed sensitivity analysis on the total fertilization failure rate?
      Lauren, after your recent meta-analysis I have moved to ICSI on all unexplained couples (used to use a time of infertility cutoff of 2 years). From my perspective, this cost analysis reinforces that decision, despite the conclusion of 1 cycle not being cost effective.

      • Lauren Johnson

        We also moved to ICSI for all couples with unexplained infertility based on the results of our meta-analysis. I agree that this cost analysis reinforces that decision. In our practice, we do not charge additional fees for ICSI, so there is no increased cost to the patient.

        • Jason Kovac

          Looking at the numbers on the SART database, in 2011 (the latest date for which national data is available), 66% of IVF cases were done using ICSI. Compared to 2003 (the earliest date available on the SART website), this number was 55%. Have you seen these types of trends in your practices as well ? I would assume that ICSI is being performed with increased frequencies in 2013 – but I wonder to what degree. Any thoughts?

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