Fertility Treatment Cost Background Understanding Infertility Infertility is generally defined as the inability to conceive after 1 year of properly timed unprotected intercourse. Fertility problems affect up to 1 in 8 Canadian couples. 1,2 The most common causes of infertility are ovulatory dysfunction, tubal disease, sperm defect, and endometriosis. 2 Up to 50% of infertility is caused by male factors. 3 Infertility is an emotionally painful experience. 4,5 Infertile couples often suffer marital problems and one or both partners may experience depression, anxiety, stress, loss of self-esteem, health problems, sleep problems, sexual dysfunction, impaired quality of life, and reduced job performance when they have difficulty conceiving. 3,4,5,6,7,8,9 Evidence suggests that the psychological effects of infertility are as severe as that of cancer, HIV, or heart disease. 8,10 In 1994, the Canadian Royal Commission on New Reproductive Technologies clearly accepted that sub-fertility is both a medical condition and a social problem. 11 In 2006, the UN General Assembly recognized the universal right to reproductive health. 12 Couples suffering the emotional devastation of an inability to conceive want access to the same health care rights as those suffering other health conditions such as diabetes, mental illness or cancer. 13 For couples that delay childbearing, their ability to conceive is significantly impaired. 2 Often, couples put off starting a family to focus on their career only to find out later that it may be too late to conceive. Ironically, private insurance plans in Canada collectively reimburse about $290,000,000 annually for birth control but less than one-tenth of that (about $25,000,000) is reimbursed for fertility treatments. According to the U.S. National Infertility Association (RESOLVE), a survey conducted by the William M. Mercer consulting firm in 2006 found that 91% of employers offering infertility treatment have not experienced a measurable increase in their medical costs as a result of providing this coverage. 14 Importantly, the result did not vary between employers that included in vitro fertilization (IVF) costs versus those that excluded the higher cost care. The reasons cited for including fertility treatment as a benefit on plans included employee demand, and the desire to provide access to quality care, to be recognized as a family friendly employer, and to attract and retain valued employees. In addition, some employers reported the unintended benefit of producing better morale and positive public relations following their decisions to include fertility treatment as a reimbursed health benefit. The 2007 sanofi-aventis healthcare survey indicated that 91% of employees rank a good benefits package as an important factor in determining whether they thought they had a good job and ranked high relative to other factors including: being treated well and fairly, supportive co-workers, trusting co-workers, and competent management. 15 Thus, adding fertility medications would contribute to employee job satisfaction. On the flip side, 44% of employees who believe that their health benefit plan does not meet their needs stated that 1/7
they are more likely to consider leaving their job compared with only 31% of employees who are satisfied with their benefit plan. A literature review and interviews with medical, scientific and psychological experts conducted by the British Royal College of Obstetricians and Gynaecologists has found that infertility directly costs employers in absenteeism, poor productivity and wasted resources. 16 By providing coverage for infertility treatment, it is expected that some employer costs could be reduced by avoiding some of the depression and anxiety caused by infertility that is known to affect workplace productivity, increase sick leave, and increase other healthcare and disability costs. 17,18 Patient Treatment Pathway Following a diagnosis of infertility, about 21% of couples will seek further treatment with hormones. 19 The most common treatments for couples undergoing infertility hormone treatment are shown in Table 1. Table 1. Typical Pathway of Progression Through Infertility Care Percent Attempting * Approximate Drug Cost per Cycle** No. of Cycle Attempts Drug Cost per Client Published Pregnancy Rates Clomiphene citrate with or without follicle stimulating hormone 18% $100 6 $100 - $600 30% 20 Gonadotrophins for ovulation induction 6.5% $2,000 3 $6,000 30% 21 High dose gonadotrophins for Advanced Reproductive Technologies (ART) 0.6% $4,000 3 $12,000 60% 22 *The percent of couples progressing through the fertility treatment pathway during a 12-month period. 19 **Treatment cost is the list cost of the most commonly used medications for each step of the pathway and includes medication for follicle maturation, luteal support, etc. Cost of drugs dispensed by physicians may vary. Current Public and Private Reimbursement of Infertility Treatment in Canada Provincial health care systems in Canada now recognize that infertility is a medical condition. On average, provincial governments paid $770 per infertile couple annually in 1999 to investigate the cause of couples inability to conceive. 23,24 In contrast, public reimbursement for the treatment of infertility is available to a small minority of couples outside of Quebec that require it (e.g., the Ontario government pays for infertility treatment only if it is caused by bilaterally blocked fallopian tubes). 25 2/7
A survey of private insurers in Canada revealed that 65% of insurance plans provide some coverage of fertility medications. 26 Annual and lifetime maximums mean that the levels of coverage allow very few couples to complete all the steps that may be required to achieve a successful outcome. The proportion of plans that have some coverage for each of the three main pathways of treatment are as follows: ~65% allow some coverage of cycles with oral hormones. ~30% have higher maximums that provide some coverage for injectable hormones for ovulation induction. ~6% have maximums sufficient to provide some reimbursement of high dose injectable hormones for IVF. Insurance plans in Canada have not been updated according to standards of care and, as a result, the majority of plans are underserving the needs of the insured. The current levels of reimbursement for fertility medications mean that the majority of Canadian couples (> 80%) with insurance cannot access the full treatment they need to achieve a successful pregnancy. According to data from Brogan Inc., private insurers in Canada spend about $25 million annually on the total portfolio of fertility medications. Required Reimbursement of Infertility Treatment To maximize the potential for successful outcomes, reimbursement should be provided for all infertile couples for a lifetime maximum of 6 cycles of clomiphene citrate, 3 cycles of ovulation induction, and 3 cycles of ART. Extension of treatment beyond this number of cycles is not required because a successful pregnancy is relatively rarely achieved with extended treatment cycles. The per patient cost to provide this reimbursement would vary from a minimum of about $100 (for one cycle of oral treatment) to a maximum of $18,000 (for 6 cycles of oral treatment + 3 cycles of low dose gonadotropins + 3 cycles of ART) per lifetime. The total cost to provide reimbursement of infertility medications in Canada is estimated to be about $193 million annually (~$10 per life covered per year), of which about $25 million is paid currently. The expected cost of infertility treatment is significantly less than the current annual cost for private insurance reimbursement of other medications as follows: statins - $600M or $32 per life covered per year oral contraceptives - $290M or $15 per life covered per year proton pump inhibitors - $360M or $19 per life covered per year. 3/7
Appendix A: MEDICATIONS USED IN THE TREATMENT OF INFERTILITY Medication Drug Identification Number (DIN) Wholesaler Price ORAL HORMONE THERAPY Ovulation induction 7 days therapy with an oral follicle stimulating hormone Clomid 50 mg 02091879 $5.44 Serophene 50 mg 00893722 $5.02 Follicle maturation and release one injection Ovidrel (r-hcg) 02262088 $76.03 hcg 10,000 iu 02247459 $66.53 Luteal Support Estrogen Prometrium 100 mg 02166704 $1.02 OVULATION INDUCTION Ovulation induction 15 days therapy with an injectable follicle stimulating hormone Gonal F (follitropin inj) 02248157 $997.92 Puregon (follitropin inj) 02243948 $272.27 Repronex (FSH/LH inj) 02247790 $58.03 Bravelle (urofollitropin inj) 02268140 $311.52 Follicle maturation and release one injection Ovidrel (r-hcg) 02262088 $76.03 HCG 10,000 iu 02247459 $66.53 Luteal Support 14 days Prometrium 200 mg 2-3 times daily 02166704 $1.02 Progesterone suppositories twice daily compounded $0.85/day Crinone once daily 02241013 228.10 4/7
Medication Drug Identification Number (DIN) Wholesaler Price IN VITRO FERTILIZATION Ovulation induction 15 days therapy with double dose injectable follicle stimulating hormone Gonal F 02248157 $997.92 Puregon 02243948 $272.75 Repronex 02247790 $58.04 Bravelle 02268140 $311.52 Follicle maturation one injection Luveris 02269066 $71.28 Repronex 02247790 $58.03 20% of patients require inhibition of premature LH surge 4 daily doses Orgalutran 02245641 $100.01 Cetrotide 02247766 $359.04 80% of patients require GnRH Analogue daily for ~14 days Lupron $348.25 Suprefact 02225166 $51.56 Follicle maturation with hcg - one dose Profasi 01925679 $54.41 Pregnyl 02182904 $47.48 Preparation of uterine lining 14 days Prometrium 200 mg 2-3 times daily 02166704 $1.02 Progesterone suppositories twice daily compounded $0.85/day Crinone once daily 02241013 $228.10 Source: Pharmex Direct Inc., 2333 Wyecroft Road, Unit 8, Oakville, ON L6L 6L4 (http://www.pharmexdirect.com/contact/) Prices include a wholesaler mark-up but do not include pharmacy fees or dispensing fees. 5/7
References 1 Health Canada. Introduction to Assisted Human Reproduction (AHR). http://www.hcsc.gc.ca/hl-vs/reprod/hc-sc/index-eng.php. (Accessed January 8, 2009) 2 Case AM. Infertility evaluation and management. Strategies for family physicians. Can Fam Physician 2003;49:1465-72. 3 Brugh VM, Lipshultz LI. Male factor infertility: evaluation and management. Med Clin North Am 2004;88:367-85. 4 Greil AL. Infertility and psychological distress: a critical review of the literature. Soc Sci Med 1997 Dec;45(11):1679-704. 5 Redshaw M, Hockley C, Davidson LL. A qualitative study of the experience of treatment for infertility among women who successfully became pregnant. Hum Reprod 2006; Epub ahead of print. 6 Baor L, Blickstein I. The journey from infertility to parenting multiples: a dream come true? Int J Fertil Womens Med. 2005 May-Jun;50(3):129-34. 7 Ozkan M, Baysal B. Emotional distress of infertile women in Turkey. Clin Exp Obstet Gynecol 2006;33:44-46. 8 A T Fidler and J Bernstein. Infertility: from a personal to a public health problem. Public Health Rep. 1999 Nov Dec; 114(6): 494 511. 9 National collaborating center for women s and children s health (2004). Fertility assessment and treatment for people with fertility problems: Clinical guideline. London: RCOG Press. http://www.rcog.org.uk/resources/public/pdf/fertility_full.pdf (Accessed January 12, 2009) 10 Domar AD, Zuttermeister PC, Friedman R. The psychological impact on fertility: a comparison with patients with other medical conditions. J Psychosom Obstet Gynaecol 1993;45-52. 11 Hughes, EG. Paying for Fertility Treatment in Canada:The Pain and the Politics. http://www.iaac.ca/en/library/legislation/paying-for-fertility-treatment-in-canada--the-painand-the-politics- (Accessed January 8, 2009) 12 World Health Organization. http://www.who.int/reproductivehealth/publications/infertility.html. (Accessed January 9, 2009) 13 Insure.com. Paying the price for infertility. http://www.insure.com/articles/healthinsurance/infertility-price.html (Accessed January 8, 2009). 14 RESOLVE. National Infertility Association. http://www.resolve.org/site/pageserver?pagename=ta_ic_empletter (Accessed January 8, 2009). 15 The sanofi-aventis Healthcare Survey 2007. Sanofi-aventis Canada Inc. http://www.sanofiaventis.ca/live/ca/en/layout.jsp?cnt=fa429e80-7df6-4f0a-a151-629860de4837 (Accessed January 15, 2009) 6/7
16 Kon A. Infertility: the real costs, ISSUE, CHILD for National Fertility Week, 1993. 17 Lecrubier Y. Depressive illness and disability. Eur Neuropsychopharmacol. 2000 Dec;10 Suppl 4:S439-43. 18 Bender A, Farvolden P. Depression and the workplace: a progress report. Curr Psychiatry Rep 2008;10:73-9. 19 Stephen EH, Chandra A. Use of Infertility Services in the United States: 1995. Family Planning Perspectives, 2000, 32(3):132 137. 20 EMD Serono, Inc. Serophene Product Monograph. 21 Custers IM, Steures P, Hompes P, Flierman P, van Kasteren Y, van Dop PA, et al. Intrauterine insemination: how many cycles should we perform? Hum Reprod 2008;23:Epub 2008 Feb 8. 22 Olivius K, Friden B, Lundin K, Bergh C. Cumulative probability of live birth after three in vitro fertilization/intracytoplasmic sperm injection cycles. Fertil Steril 2002;77:505-510. 23 Leader A. New reproductive technologies: Why are we limiting choice for infertile couples? Can Med Assoc J 1999;161:1411-1412. 24 Collins JA, Feeny D, Gunby J. The cost of infertility diagnosis and treatment in Canada in 1995. Hum Reprod 1997;12:951-958. 25 Ontario Health Technology Advisory Committee. In Vitro Fertilization. Report Summary. October 2006. http://www.health.gov.on.ca/english/providers/program/ohtac/tech/reviews/sum_ivf_101906. html (Accessed January 12, 2009) 26 Health Systems Innovations Inc. Report on Private Insurance for Fertility Medications 2005. 7/7