Prof Ben Willem Moll - University of Adelaide
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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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Transcript of Prof Ben Willem Moll - University of Adelaide
Aspire 2014
Should ART treatment always be supported by public resources?
Ben Willem Mol
Adelaide, Australia
RANZCOG CREI 2015
Aspire 2014
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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
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