Session: PD18: Infertility: Epidemiology & Evaluation II
PD18-10: A Markov model for fertility treatment: subfertile couples with a varicocele save time and money by pursuing male-first evaluation prior to treatment
Introduction: Clinical practice presents a variety of obstacles to prompt male evaluation in a subfertile couple. Varicocele repair improves sperm parameters in most patients and has been suggested to improve pregnancy rates in both natural conception and assisted reproductive technologies (ART). The course of an infertile couple’s work-up, however, is often non-linear and hard to predict. We constructed a discrete-time Markov model to simulate various evaluation and treatment strategies and thereby estimate success rates and costs for a couple with a clinically significant varicocele. Methods: A discrete-time Markov chain was constructed to represent the various treatment and evaluation states for a couple with a clinically significant varicocele. Transition probabilities, treatment success rates, and discontinuation rates were estimated from the literature. Treatment strategies included Current Practice (CP), Male-First Evaluation (MF), IUI-First (IUI), and IVF-First (IVF). A sensitivity analysis predicted total cost and time-to-pregnancy for 50%,75%, and 99% of couples at different treatment-cost levels and different expected success rates following varicocelectomy. Results: At 1% increased pregnancy rate following varicocele diagnosis and treatment, 75% of couples pursuing CP treatment were pregnant at 20.1 months at a cost of $35,550, compared to those pursuing MF (21.2 months, $38,892), IUI (16.8 months, $41,324.51), or IVF (12.3 months, $49,537.29). At 5% improved success rate, there was an inflection – 75% of couples were pregnant via MF at 19.2 months at a cost of $33,976.81, compared to CP (19.9 months, $34,172.18), IUI (16.6 months, $39,757.48), or IVF (12.2 months, $48,589.41). Conclusions: For couples that harbor a clinically significant varicocele, strict adherence to MF treatment with even a modest benefit (5% increase in pregnancy rate), varicocele ligation leads to significant cost- and time-savings over CP. Moreover, transitioning directly to ART too soon achieves limited gains in time (2-5 months), at 40-80% increased costs when compared to MF. Adherence to an MF approach, in addition to these benefits, offers couples valuable opportunities to screen for other pathologies and ensure male health. SOURCE OF Funding: NA
