Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
Harvard Interfaculty Initiative in Health Policy, Cambridge, MA.
Am J Obstet Gynecol. 2021 Jul;225(1):55.e1-55.e17. doi: 10.1016/j.ajog.2021.01.021. Epub 2021 Feb 2.
A controversial and unresolved question in reproductive medicine is the utility of preimplantation genetic testing for aneuploidy as an adjunct to in vitro fertilization. Infertility is prevalent, but its treatment is notoriously expensive and typically not covered by insurance. Therefore, cost-effectiveness is critical to consider in this context.
This study aimed to analyze the cost-effectiveness of preimplantation genetic testing for aneuploidy for the treatment of infertility in the United States.
As reported to the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System, a national data registry, in vitro fertilization cycles occurring between 2014 and 2016 in the United States were analyzed. A probabilistic decision tree was developed using empirical outputs to simulate the events and outcomes associated with in vitro fertilization with and without preimplantation genetic testing for aneuploidy. The treatment strategies were (1) in vitro fertilization with intended preimplantation genetic testing for aneuploidy and (2) in vitro fertilization with transfers of untested embryos. Patients progressed through the treatment model until they achieved a live birth or 12 months after ovarian stimulation. Clinical costs related to both treatment strategies were extracted from the literature and considered from both the patient and payer perspectives. Outcome metrics included incremental cost (measured in 2018 US dollars), live birth outcomes, incremental cost-effectiveness ratio, and incremental cost per live birth between treatment strategies.
The study population included 114,157 first fresh in vitro fertilization stimulations and 44,508 linked frozen embryo transfer cycles. Of the fresh stimulations, 16.2% intended preimplantation genetic testing for aneuploidy and 83.8% did not. In patients younger than 35 years old, preimplantation genetic testing for aneuploidy was associated with worse clinical outcomes and higher costs. At age 35 years and older, preimplantation genetic testing for aneuploidy led to more cumulative births but was associated with higher costs from both perspectives. From a patient perspective, the incremental cost per live birth favored the no preimplantation genetic testing for aneuploidy strategy from the <35 years age group to the 38 years age group and beginning at age 39 years favored preimplantation genetic testing for aneuploidy. From a payer perspective, the incremental cost per live birth favored preimplantation genetic testing for aneuploidy regardless of patient age.
The cost-effectiveness of preimplantation genetic testing for aneuploidy is dependent on patient age and perspective. From an economic perspective, routine preimplantation genetic testing for aneuploidy should not be universally adopted; however, it may be cost-effective in certain scenarios.
在生殖医学中，一个有争议且尚未解决的问题是，胚胎植入前遗传学检测非整倍体是否可以作为体外受精的辅助手段。不孕不育较为普遍，但治疗费用昂贵，通常不在保险范围内。因此，在这种情况下，成本效益至关重要。
本研究旨在分析美国应用胚胎植入前遗传学检测非整倍体治疗不孕不育的成本效益。
本研究分析了美国生殖技术协会临床结局报告系统（一个全国性的数据登记处）报告的 2014 年至 2016 年期间的体外受精周期。采用经验性输出物建立概率决策树，以模拟与胚胎植入前遗传学检测非整倍体和未检测胚胎移植相关的事件和结局。治疗策略包括：（1）拟行胚胎植入前遗传学检测非整倍体的体外受精，（2）未行胚胎植入前遗传学检测非整倍体的体外受精和胚胎移植。患者接受治疗直至活产或卵巢刺激后 12 个月。从文献中提取与两种治疗策略相关的临床成本，并从患者和支付方两个角度进行考虑。结局指标包括增量成本（以 2018 年美元计）、活产结局、增量成本效益比和两种治疗策略间的增量每活产成本。
研究人群包括 114157 例初次新鲜体外受精刺激和 44508 例相关冷冻胚胎移植周期。在新鲜刺激周期中，16.2%的患者拟行胚胎植入前遗传学检测非整倍体，83.8%的患者未行该检测。在年龄<35 岁的患者中，胚胎植入前遗传学检测非整倍体与较差的临床结局和更高的成本相关。在 35 岁及以上的患者中，胚胎植入前遗传学检测非整倍体导致更多的累积妊娠，但从两个角度来看，成本都更高。从患者角度来看，<35 岁年龄组至 38 岁年龄组，以及 39 岁开始，不进行胚胎植入前遗传学检测非整倍体的策略增量每活产成本更优；从支付方角度来看，无论患者年龄如何，胚胎植入前遗传学检测非整倍体的增量每活产成本都更优。
胚胎植入前遗传学检测非整倍体的成本效益取决于患者年龄和角度。从经济角度来看，胚胎植入前遗传学检测非整倍体不应常规采用；但在某些情况下，其可能具有成本效益。
