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Should ART treatment always be supported by public resources?

Ben Willem Mol

Adelaide, Australia

RANZCOG CREI 2015

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• “In Australia couples start IVF after 6-12 months of trying”

• “In Australia, 50% of the Medicare reimbursement for IVF goes to the 25% couples with the highest income”

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John Rock: “What a boon for the barren woman

with closed tubes”1937 New England Journal Medicine

Introduction of the concept of IVF

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The first successful fertilisation of a human egg in vitroFebruary 1969

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IVF ectopic pregnancy: 1976

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Louise Joy Brown - July 25th 1978

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25th July 1978

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The signal to noise ratio of clinical research

• Signal = cure with treatment• Noise = spontaneous recovery

signal

noise

P Glasziou et al.: BMJ 2007;334:349

Hans Evers

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What about IVF?

Hans Evers

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Steptoe, Edwards; Lancet, 1978, Aug 12;2(8085):366.RANZCOG CREI 2015

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Steptoe, Edwards; Lancet, 1978, Aug 12;2(8085):366.

Hans Evers

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IVF for absent tubes

• Signal = cure with treatment 14% / cycle IVF• Noise = spontaneous recovery 0% / lifetime

signal

noiseHans Evers

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IVF for unexplained subfertility

Signal = pregnant with treatment 32% (EIM, 2010)

Noise = spontaneous pregnancy 29% (Collins & Taylor, 1992)

noisesignal

Hans Evers

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Brandes et al. 2010

All patients

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Brandes et al. 2010

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Growth of IVF

IVF cycles in Australia/New Zealand

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Are we doing any harm?

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Responsibilities of doctors

Effectiveness of ART

Safety of ART for the childSafety of ART for the mother

Use of scarce resources

Effectiveness

Safe

ty

Effectiveness

Safe

ty

Offer treatment

Considertreatment

Considertreatment

Do not offertreatment

Categories of ART

Clear indication for ART (tubal blockage, very poor semen quality, anovulation)

ART while prognosis for natural conception is still good (> 30%)

ART while chances of success are futile (women > 4..)

Categories of ART

Effective-ness

Safety Cost-effectiveness

IVF with proven indication

IVF while prognosis is still good

Futile IVF

Categories of ART

Effective-ness

Safety Cost-effectiveness

IVF with proven indicationIVF while prognosisis still goodFutile IVF

Categories of ART

Effective-ness

Safety Cost-effectiveness

IVF with proven indicationIVF while prognosisis still goodFutile IVF

Categories of ART

Effective-ness

Safety Cost-effectiveness

IVF with proven indication

? ++IVF while prognosisis still goodFutile IVF

Scenario based modelling estimates at 18 months (< 30 years)

Scenario based modelling estimates at 18 months (< 30 years)

Categories of ART

Effective-ness

Safety Cost-effectiveness

IVF with proven indication

? ++IVF while prognosis is still good

≅ ? -Futile IVF

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IUI – COH versus no treatment

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RR: 1,0 (CI: 0,86-1,2)

IUI – COH versus no treatment

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INeS trial

Categories of ART

Effective-ness

Safety Cost-effectiveness

IVF with proven indication

? ++IVF while prognosis is still good

≅ ? -Futile IVF ≅ ? -

Conclusions

Reimbursement should be limited to couples with a clear indication for ART (>3 years, tubal blockage, very poor semen quality, anovulation)

Conclusion

There is no argument against ART while prognosis for natural conception is still good (> 30%)ART while chances of success are futile (women > 4..)

As long asThe couple pays it out-of-pocketThe couple is well informed

Aspire 2014RANZCOG CREI 2015

Aspire 2014RANZCOG CREI 2015