Does sperm retrieval increase cost without benefit for men with non-obstructive azoospermia? A cost-effectiveness analysis of sperm retrieval vs. donor sperm

Abstract

OBJECTIVE: Infertile couples with non-obstructive azoospermia are faced with the decision to pursue sperm retrieval techniques with ICSI or donor sperm with artificial insemination to achieve pregnancy. We determined the cost-effectiveness of these two decisions in the setting of no female factor infertility.DESIGN: We used clinical decision analysis techniques to model direct medical costs per live birth and per quality adjusted life year (QALY) in men with non-obstructive azoospermia.MATERIALS AND METHODS: A decision analysis model was developed to represent treatment options and outcomes. Outcome probabilities and costs were derived from published and institutional sources. Sensitivity analyses were performed to determine variables of maximal importance. Sperm retrieval was assumed to be preferred 4:1 over donor sperm for the base case analysis. This assumption is based upon the observation that the majority of couples with non-obstructive azoospermia choose sperm retrieval as their first treatment option.RESULTS: Donor sperm was associated with a lower cost per live birth ($7,200/live birth) and an additional 3 children per 100 couples compared to sperm retrieval. Sperm retrieval increased QALYs, due to the preference for genetic offspring, at a cost of $8,230 per QALY gained. Individual preferences played a strong role in determining outcome as costs per QALY increased to $78,000 with a 50% preference for genetic offspring (retrieval chosen 50% more often than donor sperm by couples) and decreased to $3,300 per QALY for a 10-fold increase in preference for genetic offspring (retrieval chosen 10 times more often than donor sperm). These costs per QALY for infertility treatment are comparable to those of medical therapy for moderate hypertension ($6,250/QALY) and neonatal intensive care for premature infants ($5,500/QALY). Infertility care becomes a cost-effective treatment (<$20,000/QALY) when patients prefer sperm retrieval 2-fold more than donor sperm. The cost of IUI, IVF, ICSI, and sperm retrieval played a significant role in determining cost per QALY.CONCLUSIONS: Donor sperm is less expensive and results in more live children with each attempt. However, individual preferences for genetic offspring play a strong role in determining treatment choice. Cost effective infertility treatment will be maximized by understanding patient preferences for genetic offspring and minimizing costs of interventions. OBJECTIVE: Infertile couples with non-obstructive azoospermia are faced with the decision to pursue sperm retrieval techniques with ICSI or donor sperm with artificial insemination to achieve pregnancy. We determined the cost-effectiveness of these two decisions in the setting of no female factor infertility. DESIGN: We used clinical decision analysis techniques to model direct medical costs per live birth and per quality adjusted life year (QALY) in men with non-obstructive azoospermia. MATERIALS AND METHODS: A decision analysis model was developed to represent treatment options and outcomes. Outcome probabilities and costs were derived from published and institutional sources. Sensitivity analyses were performed to determine variables of maximal importance. Sperm retrieval was assumed to be preferred 4:1 over donor sperm for the base case analysis. This assumption is based upon the observation that the majority of couples with non-obstructive azoospermia choose sperm retrieval as their first treatment option. RESULTS: Donor sperm was associated with a lower cost per live birth ($7,200/live birth) and an additional 3 children per 100 couples compared to sperm retrieval. Sperm retrieval increased QALYs, due to the preference for genetic offspring, at a cost of $8,230 per QALY gained. Individual preferences played a strong role in determining outcome as costs per QALY increased to $78,000 with a 50% preference for genetic offspring (retrieval chosen 50% more often than donor sperm by couples) and decreased to $3,300 per QALY for a 10-fold increase in preference for genetic offspring (retrieval chosen 10 times more often than donor sperm). These costs per QALY for infertility treatment are comparable to those of medical therapy for moderate hypertension ($6,250/QALY) and neonatal intensive care for premature infants ($5,500/QALY). Infertility care becomes a cost-effective treatment (<$20,000/QALY) when patients prefer sperm retrieval 2-fold more than donor sperm. The cost of IUI, IVF, ICSI, and sperm retrieval played a significant role in determining cost per QALY. CONCLUSIONS: Donor sperm is less expensive and results in more live children with each attempt. However, individual preferences for genetic offspring play a strong role in determining treatment choice. Cost effective infertility treatment will be maximized by understanding patient preferences for genetic offspring and minimizing costs of interventions.