title: Cost-effectiveness of 'immediate IVF' versus 'delayed IVF': a prospective study.
abstract: How does the cost-effectiveness (CE) of immediate IVF compared with postponing IVF for 1 year, depend on prognostic characteristics of the couple?
  
  
  
  The CE ratio, i.e. the incremental costs of immediate versus delayed IVF per extra live birth, is the highest (range of €15 000 to >€60 000) for couples with unexplained infertility and for them depends strongly on female age and the duration of infertility, whilst being lowest for endometriosis (range 8000-23 000) and, for such patients, only slightly dependent on female age and duration of infertility.
  
  
  
  A few countries have guidelines for indications of IVF, using the diagnostic category, female age and duration of infertility. The CE of these guidelines is unknown and the evidence base exists only for bilateral tubal occlusion, not for the other diagnostic categories.
  
  
  
  A modelling approach was applied, based on the literature and data from a prospective cohort study among couples eligible for IVF or ICSI treatment, registered in a national waiting list in The Netherlands between January 2002 and December 2003.
  
  
  
  A total of 5962 couples was included. Chances of natural ongoing pregnancy were estimated from the waiting list observations and chances of ongoing pregnancy after IVF from follow-up data of couples with primary infertility that began treatment. Prognostic characteristics considered were female age, duration of infertility and diagnostic category. Costs of IVF were assessed from a societal perspective and determined on a representative sample of patients. A cost-effectiveness comparison was made between two scenarios: (I) wait one more year and then undergo IVF for 1 year and (II) immediate IVF during 1 year, and try to conceive naturally in the following year. Comparisons were made for strata determined by the prognostic factors. The final outcome was a live birth.
  
  
  
  The gain in live birth rate of the immediate IVF scenario versus postponed IVF increased with female age, and was independent from diagnostic category or duration of infertility. By contrast, the corresponding increase in costs primarily depended on diagnostic category and duration of infertility. The lowest CE ratio was just below €10 000 per live birth for endometriosis from age 34 onwards at 1 year duration. The highest CE ratio reached €56 000 per live birth for unexplained infertility at age 30 and 3 years duration, dropping to values below € 30 000 per live birth from age 32 onwards. It reached values below €20 000 per live birth with 3 years duration at age 34 and older. The CE ratio was in between for the three other diagnostic categories (i.e. Male infertility, Hormonal and Immunological/Cervical).
  
  
  
  We applied estimates of chances with IVF, excluding frozen embryos, for which we had no data. Therefore, we do not know the effect of frozen embryo transfers on the CE.
  
  
  
  The duration of infertility at which IVF becomes cost-effective depends, firstly, on the level of society's willingness to pay for one extra live birth, and secondly, given a certain level of willingness to pay, on the woman's age and the diagnostic category. In current guidelines, the chances of a natural conception should always be taken into account before deciding whether to start IVF treatment and at which time.
  
  
  
  Supported by Netherlands Organisation for Health Research and Development (ZonMW, grant 945-12-013). ZonMW had no role in designing the study, data collection, analysis and interpretation of data or writing of the report. Competing interests: none.
authors.affiliation: Department of Biostatistics and Research Support, Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands.|Department of Public Health, Erasmus MC, University Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands.
authors.forename: M J C
authors.initials: MJC
authors.lastname: Eijkemans
authors.affiliation: Department of Obstetrics and Gynaecology, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
authors.forename: F A M
authors.initials: FAM
authors.lastname: Kersten
authors.affiliation: Department of Obstetrics and Gynaecology, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
authors.forename: A M E
authors.initials: AME
authors.lastname: Lintsen
authors.affiliation: Department of Public Health, Erasmus MC, University Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands.|National Dutch Poisons Information Center, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands.
authors.forename: C C
authors.initials: CC
authors.lastname: Hunault
authors.affiliation: Institute for Medical Technology Assessment, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, The Netherlands.
authors.forename: C A M
authors.initials: CAM
authors.lastname: Bouwmans
authors.affiliation: Institute for Medical Technology Assessment, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, The Netherlands.
authors.forename: L Hakkaart-van
authors.initials: LH
authors.lastname: Roijen
authors.affiliation: Department of Public Health, Erasmus MC, University Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands.
authors.forename: J D F
authors.initials: JDF
authors.lastname: Habbema
authors.affiliation: Department of Obstetrics and Gynaecology, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
authors.forename: D D M
authors.initials: DDM
authors.lastname: Braat
mesh_terms: D000328:Adult; D001723:Birth Rate; D003362:Cost-Benefit Analysis; D005260:Female; D005307:Fertilization in Vitro / Q000191:economics* / Q000379:methods; D006801:Humans; D007246:Infertility / Q000191:economics* / Q000628:therapy; D050498:Live Birth; D008297:Male; D008423:Maternal Age; D008962:Models, Theoretical; D009426:Netherlands; D011247:Pregnancy; D018873:Pregnancy Rate; D011379:Prognosis; D013997:Time Factors
keywords: IVF/ICSI; cost-effectiveness; expectant management; natural pregnancy; prediction models