Prof Ben Willem Moll - University of Adelaide
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Aspire 2014
Should ART treatment always be supported by public resources?
Ben Willem Mol
Adelaide, Australia
RANZCOG CREI 2015
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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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Aspire 2014
John Rock: “What a boon for the barren woman
with closed tubes”1937 New England Journal Medicine
Introduction of the concept of IVF
RANZCOG CREI 2015
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Aspire 2014
The first successful fertilisation of a human egg in vitroFebruary 1969
RANZCOG CREI 2015
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Aspire 2014
IVF ectopic pregnancy: 1976
RANZCOG CREI 2015
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Aspire 2014
Louise Joy Brown - July 25th 1978
RANZCOG CREI 2015
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Aspire 2014
25th July 1978
RANZCOG CREI 2015
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Aspire 2014
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
RANZCOG CREI 2015
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What about IVF?
Hans Evers
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Aspire 2014
Steptoe, Edwards; Lancet, 1978, Aug 12;2(8085):366.RANZCOG CREI 2015
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Aspire 2014
Steptoe, Edwards; Lancet, 1978, Aug 12;2(8085):366.
Hans Evers
RANZCOG CREI 2015
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Aspire 2014
IVF for absent tubes
• Signal = cure with treatment 14% / cycle IVF• Noise = spontaneous recovery 0% / lifetime
signal
noiseHans Evers
RANZCOG CREI 2015
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Aspire 2014
IVF for unexplained subfertility
Signal = pregnant with treatment 32% (EIM, 2010)
Noise = spontaneous pregnancy 29% (Collins & Taylor, 1992)
noisesignal
Hans Evers
RANZCOG CREI 2015
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Aspire 2014
Brandes et al. 2010
All patients
RANZCOG CREI 2015
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Aspire 2014
Brandes et al. 2010
RANZCOG CREI 2015
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Growth of IVF
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IVF cycles in Australia/New Zealand
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Aspire 2014
Are we doing any harm?
RANZCOG CREI 2015
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Aspire 2014RANZCOG CREI 2015
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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
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Effectiveness
Safe
ty
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Effectiveness
Safe
ty
Offer treatment
Considertreatment
Considertreatment
Do not offertreatment
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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..)
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Categories of ART
Effective-ness
Safety Cost-effectiveness
IVF with proven indication
IVF while prognosis is still good
Futile IVF
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Categories of ART
Effective-ness
Safety Cost-effectiveness
IVF with proven indicationIVF while prognosisis still goodFutile IVF
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Categories of ART
Effective-ness
Safety Cost-effectiveness
IVF with proven indicationIVF while prognosisis still goodFutile IVF
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Categories of ART
Effective-ness
Safety Cost-effectiveness
IVF with proven indication
? ++IVF while prognosisis still goodFutile IVF
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Scenario based modelling estimates at 18 months (< 30 years)
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Scenario based modelling estimates at 18 months (< 30 years)
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Categories of ART
Effective-ness
Safety Cost-effectiveness
IVF with proven indication
? ++IVF while prognosis is still good
≅ ? -Futile IVF
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Aspire 2014
IUI – COH versus no treatment
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Aspire 2014
RR: 1,0 (CI: 0,86-1,2)
IUI – COH versus no treatment
RANZCOG CREI 2015
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Aspire 2014RANZCOG CREI 2015
INeS trial
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Categories of ART
Effective-ness
Safety Cost-effectiveness
IVF with proven indication
? ++IVF while prognosis is still good
≅ ? -Futile IVF ≅ ? -
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Conclusions
Reimbursement should be limited to couples with a clear indication for ART (>3 years, tubal blockage, very poor semen quality, anovulation)
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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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Aspire 2014RANZCOG CREI 2015
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Aspire 2014RANZCOG CREI 2015