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The health economics of infertility treatment

Lilford, Richard, CBE, DSc (Hons), PhD, FRCOG, FRCP, FFPH

Global Reproductive Health: December 2018 - Volume 3 - Issue 4 - p e23
doi: 10.1097/GRH.0000000000000023
Brief Reports

The health economics of infertility raises a number of issues that are not generally considered in the standard canon for health economic assessment of health technology assessments. Six issues stand out, which are briefly considered in turn.

Warwick Medical School, University of Warwick, Coventry, UK

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Published online 26 November 2018

Corresponding author. Address: Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK. Tel. +44(0)24 765 75884. E-mail address: r.j.lilford@warwick.ac.uk (R. Lilford).

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms. http://creativecommons.org/licenses/by-nc-sa/4.0/

Received August 14, 2018

Accepted October 18, 2018

The health economics of infertility raises a number of issues that are not generally considered in the standard canon for health economic assessment of health technology assessments (HTA)1. Six issues stand out:

  • The benefits of infertility treatment are more difficult to capture on a single quality of life (QoL) scale than in the case for standard HTA.
  • The standard practice of discounting benefits can be questioned.
  • The beneficiaries are more diverse—the father and grandparents in particular benefit directly from the child.
  • The issue of whether the lifelong utility of the potential child should be included is controversial.
  • Still more controversial is the potential child’s economic payback to society.
  • The issue of moral hazard may arise.

I shall briefly consider these in turn.

  • Benefit—generic QoL scales do not seem up to the job. First, it is very difficult to capture the benefits over a lifetime. The “area under the curve” is the important relevant quantity and this is not well captured in cross-sectional studies. Second, QoL deteriorates when a subfertile couple have a baby, as it does for fertile people. I discovered this many years ago in a collaborative study with the Health Economics department at the University of York (unpublished). This finding reinforces the importance of a lifetime perspective. Third, it is doubtful that maximization of the dimensions captured in a generic QoL scale are the things that people wish to maximize when they decide to have children—there is a deeper purpose in play. So, a utility function based on a direct trade-off would be preferable to a standard generic QoL scale, such as the SF-12 or EQ-5D. This way, the respondent can take a lifetime perspective and factor in all the valued benefits and disbenefits of treatment. Torrance used a standard gamble on a large study of US citizens and measured a disutility of 0.07 (utility 0.93)2. That is to say, the average respondent would run up to a 7% risk of death to enable them to have a first child. Such a hypothetical standard gamble method may underestimate the utility loss for those who actually experience infertility3. A perhaps better method to capture the benefit over a lifetime would be willingness-to-pay studies and here, in addition to studies at the population level (say using discrete choice methods), studies of revealed preferences are possible. This is because much IVF takes place in an entirely private market. This enables the “market clearing” price for infertility services to be observed (ideally in relation to disposable income). The high proportions of disposable incomes infertile people allocate to infertility treatment, sometimes amounting to catastrophic losses4, provides some evidence that Torrance’s study underestimates the trade-offs people will make in order to have children.
  • Choice of discount rate—the fact that benefits of having a child continue to accrue, and may increase, over time, suggests that discounting is an extremely bad idea in the case of infertility. That said, it is important to factor disbenefits of treatment and downstream costs into the analysis. Disbenefits include the cost and discomfort of treatment and knock-on costs, for example, resulting from an increased risk of prematurity. Conversely, there may be hidden benefits beyond the joys of parenthood—for example, in reduced Intimate Partner Violence5.
  • Diverse beneficiaries—in “normal” health economics, benefits are hypothecated on the affected person, even though loved ones also stand to benefit. Loved ones benefit through the improved health of the affected person. Ignoring third party benefits can be condoned on the “level playing field” principle—in a comparison across diseases of middle-age, beneficiaries of various alternative treatments are in a roughly similar position—they have similar numbers of loved ones on average. On this basis, the decision tree can be “pruned.” It could be argued that this argument breaks down when comparisons are made across generational lines. In the particular case of infertility, mothers and fathers get direct benefits, as do grandparents and others, not only through the “affected” person, but directly from the child that results from the treatment. For instance, the father is just as much a beneficiary as the mother. Grandparents are not far behind. On the other hand, factoring these beneficiaries into the equation strongly increases the estimate of payback from infertility services. Factoring the benefits that accrue to all these “third parties” would weight services for children in general, and infertility services in particular. This is a topic requiring more philosophical analysis and, perhaps, empirical investigation.
  • What about the child who would otherwise not have existed—the question of the utility of the hypothetical lives is vexed. Certainty, no-one counts the utility loss from contraception, even when no later “replacement child” is envisaged. On the other hand, the utility of neonatal survival is included in standard economic practice. My preference is not to include this utility, but I am hard-pressed to defend this on a bottom-up, philosophical basis. Richard Hare, the famous Oxford philosopher, did attempt such an analysis and his conclusions support my instinct. Certainly, including the lifetime utility of the child massively improves the cost-benefit ratio of infertility services6–8.
  • Tax return—if the tax return from the child is included, then a treatment such as IVF becomes a “no-brainer” as it “dominates”—it saves money and yields benefit down to a very low success rate (<6% of so)9. Health economic analysis would weight allocation decisions heavily toward children and young people if their future productivity or even tax contributions were included. Perhaps economists worry that this would result in “discrimination” against older people. But such an argument is illogical as it goes from conclusion to justification.
  • Moral hazard—Jim Thornton has argued that publically funded infertility treatment is open to abuse since people who otherwise would have procreated at an earlier age will now wait until they are older, on the grounds that they can resort to IVF if necessary. While this must be a theoretical possibility, I will let the reader decide whether the risk is material.

What would happen if we:

  • Accepted a utility function of 0.9 (close to that of Torrance).
  • Ignored other beneficiaries, including the child?

I present such an analysis in Table 1. Even under these conservative constraints, IVF is cost-effective in most countries, and could be cost-effective in low-income and middle-income countries if some new idea, such as incubation within the vagina, were used.

Table 1

Table 1

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Sources of funding

R.L. is supported by the National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) West Midlands; and the NIHR Global Health Research Unit on Improving Health in Slums. Views expressed in this work do not necessarily reflect those of the funders.

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Conflict of interest disclosures

The author declares that there is no financial conflict of interest with regard to the content of this report.

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Acknowledgments

The author thanks Sheryl van der Poel for sending some of the references quoted in this article, and Jim Thornton for the point regarding delayed childbearing. This article is an adaptation of a piece the author has previously published in an online blog (goo.gl/kpaAeX).

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References

1. Drummond MF. Methods for the Economic Evaluation of Health Care Programmes. Oxford: Oxford University Press; 2005.
2. Torrance GW. Measurement of health state utilities for economic appraisal. J Health Econ 1986;5:1–30.
3. Arnold D, Girling A, Stevens A, et al. Comparison of direct and indirect methods of estimating health state utilities for resource allocation: review and empirical analysis. BMJ 2009;339:b2688.
4. Wu AK, Odisho AY, Washington SL III, et al. Out-of-pocket fertility patient expense: data from a multicenter prospective infertility cohort. J Urology 2014;191:427–32.
5. Stellar C, Garcia-Moreno C, Temmerman M, et al. A systematic review and narrative report of the relationship between infertility, subfertility, and intimate partner violence. Int J Gynecol Obstet 2016;133:3–8.
6. Connolly MP, Pollard MS, Hoorens S, et al. Long-term economic benefits attributed to IVF-conceived children: a lifetime tax calculation. Am J Manag Care 2008;14:598–604.
7. Svensson A, Connolly M, Gallo F, et al. Long-term fiscal implications of subsidizing in-vitro fertilization in Sweden: a lifetime tax perspective. Scand J Pub Health 2008;36:841–9.
8. Fragoulakis V, Maniadakis N. Estimating the long-term effects of in vitro fertilization in Greece: an analysis based on a lifetime-investment model. Clinicoecon Outcomes Res 2013;5:247–55.
9. Baird DT, Collins J, Egozcue J, et al. Fertility and ageing. Hum Reprod Update 2005;11:261–76.
Keywords:

Health economics; Infertility; Quality of life; Utilities

Copyright © 2018 The Authors. Published by Wolters Kluwer on behalf of the International Federation of Fertility Societies. All rights reserved.