title: Modified natural cycle versus controlled ovarian hyperstimulation IVF: a cost-effectiveness evaluation of three simulated treatment scenarios.
abstract: OBJECTIVE
  Can modified natural cycle IVF or ICSI (MNC) be a cost-effective alternative for controlled ovarian hyperstimulation IVF or ICSI (COH)?
  
  
  CONCLUSIONS
  The comparison of simulated scenarios indicates that a strategy of three to six cycles of MNC with minimized medication is a cost-effective alternative for one cycle of COH with strict application of single embryo transfer (SET).
  
  
  BACKGROUND
  MNC is cheaper per cycle than COH but also less effective in terms of live birth rate (LBR). However, strict application of SET in COH cycles reduces effectiveness and up to three MNC cycles can be performed at the same costs as one COH cycle.
  
  
  METHODS
  The cost-effectiveness of MNC versus COH was evaluated in three simulated treatment scenarios: three cycles of MNC versus one cycle of COH with SET or double embryo transfer (DET) and subsequent transfer of cryopreserved embryos (Scenario 1); six cycles of MNC versus one cycle of COH with strictly SET and subsequent transfer of cryopreserved embryos (Scenario 2); six cycles of MNC with minimized medication (hCG ovulation trigger only) versus one cycle of COH with SET or DET and subsequent transfer of cryopreserved embryos (Scenario 3). We used baseline data obtained from two retrospective cohorts of consecutive patients (2005-2008) undergoing MNC in the University Medical Center Groningen (n = 499, maximum six cycles per patient) or their first COH cycle with subsequent transfer of cryopreserved embryos in the Academic Medical Center Amsterdam (n = 392).
  
  
  METHODS
  Data from 1994 MNC cycles (958 MNC-IVF and 1036 MNC-ICSI) and 392 fresh COH cycles (one per patient, 196 COH-IVF and 196 COH-ICSI) with subsequent transfer of cryopreserved embryos (n = 72 and n = 94 in MNC and COH cycles, respectively) in ovulatory, subfertile women <36 years of age served as baseline for the three simulated scenarios. To compare the scenarios, the incremental cost-effectiveness ratio (ICER) was calculated, defined as the ratio of the difference in IVF costs up to 6 weeks postpartum to the difference in LBR. Live birth was the primary outcome measure and was defined as the birth of at least one living child after a gestation of ≥25 weeks.
  
  
  RESULTS
  In the baseline data, MNC was not cost-effective, as COH dominated MNC with a higher cumulative LBR (27.0 versus 24.0%) and lower cost per patient (€3694 versus €5254). The simulations showed that in scenario 1 three instead of six cycles lowered the costs of MNC to below the level of COH (€3390 versus €3694, respectively), but also lowered the LBR per patient (from 24.0 to 16.2%, respectively); Scenario 2: COH with strict SET was less effective than six cycles MNC (LBR 17.5 versus 24.0%, respectively), but also less expensive per patient (€2908) than MNC (€5254); Scenario 3: improved the cost-effectiveness of MNC but COH still dominated MNC when medication was minimized in terms of costs, i.e. €855 difference in favor of COH and 3% difference in LBR in favor of COH (ICER: €855/-3.0%).
  
  
  CONCLUSIONS
  Owing to the retrospective nature of the study, the analyses required some assumptions, for example regarding the costs of pregnancy and delivery, which had to be based on the literature rather than on individual data. Furthermore, costs of IVF treatment were based on tariffs and not on actual costs. Although this may limit the external generalizability of the results, the limitations will influence both treatments equally, and would therefore not bias the comparison of MNC versus COH.
  
  
  CONCLUSIONS
  The combined results suggest that MNC with minimized medication might be a cost-effective alternative for COH with strict SET. The scenarios reflect realistic alternatives for daily clinical practice. A preference for MNC depends on the willingness to trade off effectiveness in terms of LBR against the benefits of a milder stimulation regimen, including a very low rate of multiple pregnancies and hyperstimulation syndrome and ensuing lower costs per live birth.
  
  
  BACKGROUND
  The study was supported by research grants from Merck Serono and Ferring Pharmaceuticals. The authors declare no conflicts of interest.
  
  
  BACKGROUND
  Not applicable.
authors.affiliation: Department of Epidemiology, HPC FA40, University of Groningen, University Medical Center Groningen, PO Box 30001, 9700 RB Groningen, The Netherlands.
authors.forename: Henk
authors.initials: H
authors.lastname: Groen
authors.forename: Nino
authors.initials: N
authors.lastname: Tonch
authors.forename: Arnold H M
authors.initials: AH
authors.lastname: Simons
authors.forename: Fulco
authors.initials: F
authors.lastname: van der Veen
authors.forename: Annemieke
authors.initials: A
authors.lastname: Hoek
authors.forename: Jolande A
authors.initials: JA
authors.lastname: Land
mesh_terms: D000328:Adult; D001723:Birth Rate; D006063:Chorionic Gonadotropin / Q000627:therapeutic use*; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D004624:Embryo Transfer / Q000191:economics / Q000379:methods; D005260:Female; D005307:Fertilization in Vitro / Q000191:economics*; D006801:Humans; D054315:Oocyte Retrieval / Q000191:economics / Q000379:methods*; D016471:Ovarian Hyperstimulation Syndrome / Q000517:prevention & control; D010062:Ovulation Induction / Q000191:economics / Q000379:methods*; D011247:Pregnancy; D012189:Retrospective Studies; D056826:Single Embryo Transfer / Q000191:economics; D020554:Sperm Injections, Intracytoplasmic / Q000191:economics
chemical_list: D006063:Chorionic Gonadotropin
keywords: ICSI; IVF; cost-effectiveness analysis; live birth rate; single embryo transfer