UTILITY OF THREE-DIMENSIONAL ULTRASOUND (3D-US) IN WOMEN WITH ARCUATE UTERI SCHEDULED FOR INVITRO-FERTILIZATION (IVF): A SCENARIO ECONOMIC ANALYSIS

Abstract

Subtle septae have been reported in women with hysterosalpingography (HSG) diagnosis of arcuate uterus who had prior failed IVF. The optimal diagnostic tool and definition for arcuate uterus diagnosis, that behaves benignly from implantation perspective, is an area of debate. This study is a scenario economic analysis to determine whether implementation of 3D-US after HSG to screen for subtle septae in women with arcuate uterus anomaly prior to IVF treatment could be cost-effective. A decision-analytic-model A decision-analytic-model was developed to compare 2 screening strategies utilized in daily practice. Modeled women were 100 infertile women, indicated for IVF with HSG diagnosis of arcuate uterus. The first strategy (3D strategy) offers 3D-US screening of subtle septum in IVF women with arcuate uterus diagnosis based on initial HSG. The second strategy (NO-3D strategy) is the reference standard that adopts proceeding to IVF without 3D-US screening in similar cohort; widely practiced in low resource settings. ASRM-2016 defining criteria for uterine septum were followed to categorize modeled women. Model endpoints were cumulative costs and live birth (LB) after 3 successive IVF cycles. The incremental cost-effectiveness ratio (ICER) was calculated. Baseline input probability data were obtained utilizing the best available evidence concerning the effect of uterine septum incision before IVF therapy and the prevalence of missed septum in a population of arcuate uterus. Medicare 2019 National Fee Estimates were considered for costs assumptions. Costs were reported in US dollars. USA population based LB for year 2017 was also used. For modeling and analysis, we used TreeAge Pro Healthcare 2020 software. Sensitivity analysis was conducted. Base-case analysis revealed that 3D-US screening strategy prior to IVF was more cost effective than NO-3D strategy. After 3 IVF cycles, 3D-US screening resulted in cumulative LB of 73.2% with $ 2,203,250 total costs compared to 58.9 % cumulative LB and $ 2,255,000 total costs in NO-3D strategy. 3D-US implementation would cause initial costs of $142,250 for diagnosis of missed septae and their accompanying metroplasty procedure; however, this would yield cost saving of $ 3620 per live birth gained after 3 IVF cycles. Even in the worst-case-scenario of sensitivity analysis, when low probability of missed septate was evaluated, 3D strategy was still cost effective with extra-costs and more benefits (ICER: $1160 per LB) utilizing $50,000/QALY willingness-to-pay threshold. The higher the probability of missed septum detection in arcuate IVF population and the higher the increase in LB after septum resection, the more would be the cost effectiveness of 3D-startegy. Sensitivity analyses were robust. Adoption of 3D-US prior to IVF, to reevaluate arcuate uteri initially diagnosed by HSG, could minimize the financial burden due to failed cycle caused by missed septum. This strategy may be helpful, since randomized controlled trials in IVF women with uterine septum face recruitment challenges.