The value of treatment for infertility: A systematic literature review of willingness-to-pay thresholds and approaches for determining the cost effectiveness of fertility therapies

Willingness to pay (WTP) for an infertility treatment is the maximum amount of money a patient is willing to pay per treatment, or to achieve a live birth or pregnancy. Such thresholds are important to determine the cost effectiveness of a treatment. A systematic review was conducted to identify and explore the studies that attempt to ascertain WTP for infertility and compare them with the cost-effectiveness studies that claimed to use WTP thresholds. For comparison, all the costs were converted and inflated to 2021 euros. The results demonstrated that there were no standard outcomes or WTP thresholds for an outcome/treatment, and the methodologies used vary. Cost-effectiveness studies either used the incremental cost-effectiveness ratio to imply a WTP threshold, or used thresholds that were previously accepted for a quality-adjusted life year outcome converted, inappropriately, to an infertility outcome. There is a need for further research by health economists to develop a consensus for the meaningful assessment of WTP for ART.     

The cost of care of the less-than-1000-gram infant

One of the most difficult ethical issues in neonatal intensive care concerns the treatment of extremely low birth weight infants (ELBW). Because of their extreme prematurity, aggressive medical intervention is needed to sustain life. Advances in perinatal medicine have made it possible for these extremely immature infants to survive. More importantly, although the mortality and long-term morbidity are high, particularly for infants less than 700 gm, many of the survivors are expected to become productive members of society and produce measurable economic benefit. The limits set for aggressive management of the VLBW infant have gradually been lowered in virtue of the successful survival at each birth weight. It appears that, with each reduction in the birth weight at which maximal efforts should be used, enough babies have survived to encourage us to continue. As we drive to bring the limit of viability to lower gestations and lower birth weights, we are finding some biologic limitations to extrauterine survival that present technology and knowledge cannot overcome. Unquestionably, there is a need for more comprehensive statistics to allow us to define the lower limit of survival. Because of the poor survival rate among infants weighing less than 700 gm, and because of the high cost of their care and statistically poor quality of life among many of the surviving infants, it has been suggested that perhaps a less aggressive approach should be adopted for those extremely immature infants. However, some recent data indicate that aggressive treatment is effective in saving lives, even at the lower spectrum of birth weight, and many of the survivors are normal or have mild handicaps. The importance of economic considerations to solve the ethical dilemma posed by the intensive care of ELBW infants is being questioned. Concerns that reflect moral absolutes cannot be adequately answered in terms of mere dollars and cents. Although the cost of neonatal intensive care is high on a per diem or per case basis, it appears to be reasonable in relation to the health benefits it provides. For infants in the weight class less than 750 gm, probably none would have survived in the absence of neonatal intensive care. We believe that a policy of benign neglect for the ELBW infant is not justified in the present era of perinatal medicine. Given these considerations, we think that aggressive treatment is reasonable, at least initially at birth.(ABSTRACT TRUNCATED AT 400 WORDS)     

Cost-effectiveness of magnetic resonance-guided focused ultrasound surgery for treatment of uterine fibroids

Objective  To estimate the cost-effectiveness of a treatment strategy for symptomatic uterine fibroids, which starts with Magnetic Resonance-guided Focused Ultrasound Surgery (MRgFUS) as compared with current practice comprising uterine artery embolisation, myomectomy and hysterectomy.
Design  Cost-utility analysis based on a Markov model.
Setting  National Health Service (NHS) Trusts in England and Wales.
Population  Women for whom surgical treatment for uterine fibroids is being considered.
Methods  The parameters of the Markov model of the treatment of uterine fibroids are drawn from a series of clinical studies of MRgFUS, and from the clinical effectiveness literature. Health-related quality of life is measured using the 6D. Costs are estimated from the perspective of the NHS. The impact of uncertainty is examined using deterministic and probabilistic sensitivity analysis.
Main outcome measures  Incremental cost-effectiveness measured by cost per quality-adjusted life-year (QALY) gained.
Results  The base-case results imply a cost saving and a small QALY gain per woman as a result of an MRgFUS treatment strategy. The cost per QALY gained is sensitive to cost of MRgFUS relative to other treatments, the age of the woman and the nonperfused volume relative to the total fibroids volume.
Conclusions  A treatment strategy for symptomatic uterine fibroids starting with MRgFUS is likely to be cost-effective.     

Quality of life in Turkish infertile couples and related factors

Infertility is a major life crisis affecting couples’ psychosocial and physical health. We aimed to assess the quality of life in Turkish infertile couples. This cross-sectional survey was carried out in 127 infertile couples admitted to a University Hospital. The quality of life was measured using the fertility quality of life tool (FertiQoL) scale. Women had lower overall quality of life than men. Women and men who were married for fewer than 10 years had a significantly lower emotional score. Women who had a history of infertility treatment, men who have lived in the town or village men with primary infertility and men who have had primary education or lower, had lower scores for mind/body subscale. Social scores were found lower in women under the age of 30, women with middle or low income, men who were married for fewer than 10 years, men who did not have children for 5 years or more and men with primary infertility. The tolerability and environment scores were significantly higher in women who had been married more than once. We conclude that health care providers should be aware of the factors affecting the quality of life (QoL) and give counselling to improve couples’ quality of life at infertility clinics.     

The cost of urogynaecological treatments: which are more cost-effective?

AIMS: To determine the cost-effectiveness of four urogynaecological treatments. MATERIALS: Two prospective trials were performed in which 205 women with urinary incontinence underwent urogynaecological treatments. The cost incurred and the improvement in quality of life (QOL) as a result of treatment was calculated as cost/quality-adjusted life year (QALY) and then ranked in order of cost-effectiveness. RESULTS: The Nurse Continence Advisor (NCA) group (N = 73) and the Urogynaecologist (UG) group (N = 72) both had significant improvements in leaks per week and incontinence score. QOL improvement was also similar (1.5% vs 1.2%). The economic data found a similar improvement in pad usage costs ($A2.90 vs $A3.52). The clinician costs were significantly lower for the NCA group ($A60.00 vs $A105.00) (P < 0.0001). The cost per QALY was significantly lower for the NCA group ($A28,009 vs $A35,312) (P = 0.03). Both groups had significant improvements in pad testing and leaks per week. The cure/improvement rates were also similar at three months (100% vs 89%). There was no significant difference in the improvement in QOL between the laparoscopic colposuspension (LC) and open colposuspension (OC) groups (2.09% vs 1.54%). The economic data found a similar improvement in pad usage costs ($A11.74 vs $A16.17). The theatre costs were significantly higher for the LC group ($A403.45 vs $A266.94) (P < 0.0001), however the overall costs were significantly lower ($A4,668 vs $A6,124) (P < 0.0001). The cost/QALY was lower for the LC group ($A63,980 vs $A134,069), however this did not reach significance. CONCLUSIONS: Overall, on comparison of the cost/QALY's, conservative treatment of urinary incontinence by a NCA was the most cost-effective.     

Cost-effective treatment for the couple with infertility

Although the evaluation of cost-effective approaches to infertility treatment remains in its infancy, several important principles have emerged from the initial studies in this field. Currently, in treating couples with infertility without tubal disease or severe male-factor infertility, the most cost-effective approach is to start with IUI or superovulation-IUI treatments before resorting to IVF procedures. The woman's age and number of sperm present for insemination are significant factors influencing cost-effectiveness. The influence of certain diagnoses on the cost-effectiveness of infertility treatments requires further study. Even when accounting for the costs associated with multiple gestations and premature deliveries, the cost of IVF decreases within the range of other cost-effective medical procedures and decreases to less than the willingness to pay for these procedures. Indeed, for patients with severe tubal disease, IVF has been found to be more cost-effective than surgical repair. The cost-effectiveness of IVF will likely improve as success rates show continued improvements over the course of time. In addition, usefulness of embryo selection and practices to reduce the likelihood of high-order multiple pregnancies, without reductions in pregnancy rates, will significantly impact cost-effectiveness. The exclusion of infertility treatments from insurance plans is unfortunate and accentuates the importance of physicians understanding the economics of infertility treatment with costs that are often passed directly to the patient. The erroneous economic policies and judgments that have led to inequities in access to infertility health care should not be tolerated.     

Children born after assisted reproductive technology

Since the birth of Louise Brown in July 1978 and the birth of the first intracytoplasmic sperm injection (ICSI) child in January 1992 many couples with longstanding female-factor or male-factor infertility can be helped to overcome their infertility resulting in a delivery and birth of a child. The final and ultimate goal of all infertility treatments has been to give the large population of infertile couples a chance to fulfil their childwish and experience the happiness of having a healthy child. Major advances have been made in the different treatment protocols for infertility during the last 25 years. It is, however, surprising that only a limited number of studies have been carried out assessing the health of the children born after ART. In this review we shall comment on the limitations of follow-up studies on ART children and we shall review existing data on the outcome of in vitro fertilization (IVF) and ICSI pregnancies. The most important outcome data consist of information on minor and major congenital malformations obtained prenatally or after birth, as well as on the further development of the children.     

British Fertility Society the University of Sheffield 15–17 April 1998

Abstract

Infertility is experienced as a deeply personal and private condition, which has been investigated across disciplines, from psycho-social to bio-behavioural (van den Akker, 2012). This is undoubtedly, in part, because the interactions between the biological–behavioural axis and psychological–social axis have been linked to aetiological and treatment factors and to the consequences of infertility. Recent data from the Human Fertilization and Embryology Authority (HFEA, 2012) show that medically assisted reproduction (MAR) for infertility is continuing to increase, with 46,000 women in the UK seeking treatment in 2010 alone. Infertility is therefore considered to be a public health concern. However, prevention and ethical treatment require individual and collective responsibility. The currently identified public health concerns are compounded by evidence that genetic factors are linked to infertility, with new generations of children conceived through IVF/ICSI potentially affected by inherited damaged DNA (Bonde et al., 2008) that would otherwise not have found its way into the gene pool of new generations. Since treatment takes place at one point in time, and consideration of the moral rights and wrongs of the consequences of some treatments takes place at another, usually much later on within the social contexts in which they coexist with others, there is a discontinuity between the initial treatment and the future consequences of these treatments. In this paper I propose a simple prevention outcome consequences (POC) model for future comprehensive research priorities with substantial policy and practice implications. The time has come to face the new challenges with all eyes wide open.     

Cost-effective treatment of the infertile couple

Objective: To review the published literature on the cost-effective approach to infertility treatment.

Design: The literature on the economics and cost-effectiveness of infertility treatments was reviewed. Studies related to this topic were identified through MEDLINE.

Result(s): Few cost-effectiveness studies about infertility treatment have been published. In the absence of tubal blockage and severe male factor, use of IUI and hMG-IUI is more cost-effective than IVF. In vitro fertilization is at least as cost-effective as tubal surgery. Although IVF costs are high, they fall well within the range of other accepted medical treatments and are below the general public’s willingness to pay for these treatments.

Conclusion(s): Cost-effectiveness analysis is an important means of improving quality of care while controlling costs. Further work regarding cost-effectiveness of treatments among different diagnostic groups is needed.     

Factors influencing the quality of life of infertile women in United Arab Emirates.

OBJECTIVES: To measure the quality of life in a representative sample of infertile women and evaluate their sociocultural attitude to this condition. METHODS: Two hundred sixty-nine infertile women attending the Assisted Reproduction clinic, Tawam Hospital were consecutively selected. They were interviewed about the effect of infertility on their quality of life using a structured, measurement-specific and pre-tested questionnaire. RESULTS: Parameters mostly affected were mood-related mainly in women above 30 years, with primary and female factor infertility and those in polygamous marriages. Quality of life did not affect sexual performance and was not affected by duration of infertility or cost of treatment. CONCLUSION: The results highlight the importance of bearing children and the stresses exerted on infertile women in Eastern societies. Thorough counseling and continuing support of infertile women is therefore indicated to improve their quality of life.     

Childlessness in Andhra Pradesh, India: Treatment-seeking and consequences

Andhra Pradesh has a high incidence of childlessness, compared to the rest of India. This paper is based on a study that explored the psychosocial consequences of childlessness in Ranga Reddy district, Andhra Pradesh, India in 1998, and describes the extent and kinds of infertility treatment sought. Currently married women aged 20 years or more who had been married for at least three years with no live birth were included; the rate ofchildlessness was five per cent On average, they started allopathic treatment and visits to holy places after three years of not having a baby. A large majority sought allopathic treatment first, and only tried other sorts of treatment prayer, rituals and traditional treatments when this did not work or cost too much. About ten per cent had adopted children and others would consider it in future. For a minority of women, there was a risk of divorce and husbands marrying a second wife to have children. Two-thirds of the women experienced violence from their husbands; 13 per cent thought this was partly due to their childlessness. There is a clear need for infertility investigation and treatment to be included in the reproductive health programme in India, and for health workers to be trained to provide information, care and referrals.     

Cost-effectiveness analysis of different embryo transfer strategies in England

Objective  The objective of this study was to assess the cost-effectiveness of different embryo transfer strategies for a single cycle when two embryos are available, and taking the NHS cost perspective.
Design  Cost-effectiveness model.
Setting  Five in vitro fertilisation (IVF) centres in England between 2003/04 and 2004/05.
Population  Women with two embryos available for transfer in three age groups (<30, 30–35 and 36–39 years).
Methods  A decision analytic model was constructed using observational data collected from a sample of fertility centres in England. Costs and adverse outcomes are estimated up to 5 years after the birth. Incremental cost per live birth was calculated for different embryo transfer strategies and for three separate age groups: less than 30, 30–35 and 36–39 years.
Main outcome measures  Premature birth, neonatal intensive care unit admissions and days, cerebral palsy and incremental cost-effectiveness ratios.
Results  Single fresh embryo transfer (SET) plus frozen single embryo transfer (fzSET) is the more costly in terms of IVF costs, but the lower rates of multiple births mean that in terms of total costs, it is less costly than double embryo transfer (DET). Adverse events increase when moving from SET to SET+fzSET to DET. The probability of SET+fzSET being cost-effective decreases with age. When SET is included in the analysis, SET+fzSET no longer becomes a cost-effective option at any threshold value for all age groups studied.
Conclusions  The analyses show that the choice of embryo transfer strategy is a function of four factors: the age of the mother, the relevance of the SET option, the value placed on a live birth and the relative importance placed on adverse outcomes. For each patient group, the choice of strategy is a trade-off between the value placed on a live birth and cost.     

Preferences for fertility in women with pelvic inflammatory disease

OBJECTIVE: To identify the value that women with pelvic inflammatory disease (PID) assign to the health impact of future infertility. DESIGN: Cross-sectional observations on patient preferences. SETTING: Participants in an existing multicenter clinical trial of PID treatment options. PATIENT(S): Five hundred thirty-two women with signs and symptoms of PID who were identified from emergency departments and sexually transmitted disease clinics. INTERVENTION(S): Women were asked to rate whether life with future infertility was more or less meaningful than life with each of seven chronic health conditions: sinus congestion, insomnia, chronic headache, asthma, incontinence, dialysis, and paralysis. MAIN OUTCOME MEASURE(S): Preferences regarding future infertility. RESULT(S): Most respondents rated future infertility as being worse than sinus congestion and asthma but better than the health impact of incontinence, dialysis, and paralysis. There was a wide range of opinion, with 18% viewing future infertility as minor (better than all conditions) and 5% viewing it as extremely important (worse than all conditions). Future infertility ratings were influenced by race, parity, difficulty in conceiving, and views on the importance of future pregnancy. CONCLUSION(S): The majority of women with PID rate future infertility as a significant issue. Optimizing access to infertility treatment may affect the quality of life for such women.     

Economic evaluation of Medically Assisted Reproduction: An educational overview of methods and applications for healthcare professionals

Economic evaluations of the value-for-money of Medically Assisted Reproduction (MAR) interventions are increasingly important due to growing pressure on healthcare budgets. Although such evaluations are commonplace in the published literature, the number/methodological complexity of different evaluations available, and the challenges specific to MAR interventions, can complicate the interpretation of such analyses for fertility treatments. This article aims to serve as an educational resource and provide context on the design/interpretation of economic analyses for MAR interventions. Several areas are relevant for first-line providers and decision makers: scope of analysis, comparator used, perspective/time horizon considered, outcomes used to measure success, and how results from cost-effectiveness studies can be summarised and used in clinical practice. We aim to help clinicians better understand the strengths/weaknesses of economic analyses, to enable the best use of the evidence in practice, so resources available for MAR interventions can provide maximum value to patients and society.     

Cost-effectiveness of freeze-all policy – A retrospective study based upon the outcome of cumulative live births

ObjectWe have previously reported that cumulative live birth rates (CLBRs) are higher in the freeze-all group compared with controls (64.3% vs. 45.8%, p = 0.001). Here, we aim to determine if the freeze-all policy is more cost-effective than fresh embryo transfer followed by frozen-thawed embryo transfer (FET).Materials and methodsThe analysis consisted of 704 ART (Assisted reproductive technology) cycles, which included in IVF (In vitro fertilisation) and ICSI (Intra Cytoplasmic Sperm Injection) cycles performed in Taichung Veterans General Hospital, Taiwan between January 2012 and June 2014. The freeze-all group involved 84 patients and the fresh Group 625 patients. Patients were followed up until all embryos obtained from a single controlled ovarian hyper-stimulation cycle were used up, or a live birth had been achieved. The total cost related to treatment of each patient was recorded. The incremental cost-effectiveness ratio (ICER) was based on the incremental cost per couple and the incremental live birth rate of the freeze-all strategy compared with the fresh ET strategy. Probabilistic sensitivity analysis (PSA) and a cost-effectiveness acceptability curve (CEAC) were performed.ResultsThe total treatment cost per patient was significantly higher for the freeze-all group than in the fresh group (USD 3419.93 ± 638.13 vs. $2920.59 ± 711.08 p < 0.001). However, the total treatment cost per live birth in the freeze-all group was US $5319.89, vs. US $6382.42 in the fresh group. CEAC show that the freeze-all policy was a cost-effective treatment at a threshold of US $2703.57 for one additional live birth. Considering the Willingness-to-pay threshold per live birth, the probability was 60.1% at the threshold of US $2896.5, with the freeze-all group being more cost-effective than the fresh-ET group; or 90.1% at the threshold of $4183.8.ConclusionThe freeze-all policy is a cost-effective treatment, as long as the additional cost of US $2703.57 per additional live birth is financially acceptable for the subjects.     

Tubal surgery vs in vitro fertilization for the treatment of infertility due to distal tubal occlusion

Background: The optimal treatment of infertility due to tubal occlusion has not been established. Many practitioners feel that the success of tubal repair exceeds that of in vitro fertilization (IVF); however, previous studies of pregnancy after tubal surgery have been limited by bias in patient selection, follow-up, or surgical expertise. The purpose of the present study was to determine the outcome after repair of distal tubal occlusion performed by experienced surgeons in an unselected patient population with consistent follow-up.Design: Chart review with telephone contact of patients lost to follow-up.Methods: The records of all tubal surgery performed between 1989 and 1996 at the University of Alabama Hospital and The Kirklin Clinic outpatient surgery facility were reviewed. All women with infertility due to distal tubal occlusion, with or without pelvic adhesions, who had no other significant infertility factors were included for study. Details of the infertility history, operative procedure, and postoperative course were recorded. Patients lost to follow-up within 1 year after surgery were contacted by telephone for information regarding subsequent testing and treatment and pregnancy outcome.Results: Eighty-three women aged 19–39 years met the entry criteria for this study. Follow-up of at least 1 year was obtained in all but 11 patients. Tubal surgery was accomplished by laparotomy in 19 women; 64 women underwent tubal repair by laparoscopy. Within 1 year of surgery, 9 hysterosalpingograms, 51 clomiphene cycles, and 20 gonadotropin cycles were performed on the study group. Pregnancy was achieved within 1 year in 13 women; of these, there were 6 live births (9.6% birth rate per surgery), 2 spontaneous abortions, and 3 ectopic pregnancies. There were no live births among women who underwent tubal repair by laparotomy. None of the postoperative gonadotropin cycles resulted in pregnancy. Seven women underwent IVF within 1 year after surgery because of extensive tubal damage noted at surgery. Based on current charges for the infertility treatments performed, the cost of a live birth with tubal surgery exceeded $120,000, versus less than $50,000 per live birth with IVF using results obtained nationally or at UAB.Conclusions: The cost-effectiveness of reconstructive surgery in unselected patients with distal tubal occlusion is less than that of IVF. Empiric use of gonadotropins for ovarian stimulation does not improve pregnancy rates after tubal surgery. In our series, laparoscopic tubal repair seemed to give results superior to that of laparotomy.     

Affordable ART for developing countries: a cost benefit comparison of low dose stimulation versus high dose GnRH antagonist protocol

OBJECTIVE: Low dose stimulation (LS) is emerging as an alternative regime in assisted reproductive technology (ART). This study aimed to compare the cost-effectiveness of LS to the high dose GnRH antagonist (Atg) regime. METHODS: An observational prospective study conducted at an academic infertility unit from January to June 2007. Outcome measures included the numbers of follicles, oocytes and embryos, morphological quality of oocytes and embryos, clinical pregnancy (PR) and complication rate. RESULT: Ninety five first attempt ICSI cycles consisting of 54 LS and 41 Atg were analyzed. Subjects in both groups had comparable sociodemographics and reproductive characteristics. LS generated significantly fewer follicles, total oocytes, mature oocytes (all p < 0.0005) and immature oocytes (p = 0.009) than Atg but the number of excellent quality oocytes was similar. Significantly fewer embryos were available in LS although the proportion of usable embryos was higher, 83.2% vs. 67.0% for Atg. Mean embryos per transfer was 2.0 +/- 1.1 vs. 2.6 +/- 1.0 (p = 0.02) for a clinical PR per transfer of 43.2% vs. 50.0% for LS and Atg respectively. LS regime had a shorter gonadotrophin administration period with resultant COH cost one third of the Atg protocol (both, p < 0.0005). The cost per live birth per started cycle worked out to be USD 13,200 and 24,900 for LS and Atg respectively. Furthermore, LS had fewer incidences of OHSS compared to the Atg regime, 3.7% vs. 12.2%. CONCLUSION: LS cost benefits included lower amounts of gonadotrophin used and fewer injections. It is a viable alternative regime in producing comparable clinical PR at lower cost and less complication in ART.     

Cost-Effectiveness of Continuous Support From a Layperson During a Woman’s First Two Births

ObjectiveTo evaluate the cost-effectiveness and health outcomes related to continuous support from a layperson during a woman’s first two births in a theoretical population.DesignCost-effectiveness analysis.ParticipantsA theoretical cohort of 1.2 million women based on an approximation of annual low-risk, nulliparous, term, singleton births in the United States with the assumption that these women have second births. This reflects the average number of births per woman in the United States.MethodsWe designed a cost-effectiveness model to compare outcomes in women with continuous support from relatives, friends, or community members with minimal to no training (excluding trained doulas) during labor and birth compared with outcomes for women with no continuous support. Outcomes included mode of birth, uterine rupture, hysterectomy, maternal death, cost, and quality-adjusted life years (QALYs). We derived probabilities from the literature and set a cost-effectiveness threshold at $100,000/QALY.ResultsIn this theoretical model, continuous support by a layperson during the first birth resulted in fewer cesarean births, decreased costs, and increased QALYs for the first and subsequent births. Women with support from laypersons had 71,090 fewer cesarean births, 35 fewer uterine ruptures, 9 fewer hysterectomies, and 16 fewer maternal deaths, which saved $364 million with 2,673 increased QALYs. Sensitivity analyses showed that continuous support in the first birth was cost-effective even when varying the estimate of lost wages of the support person up to $708.ConclusionContinuous labor support from a layperson leads to fewer cesarean births, improved outcomes, decreased costs, and increased QALYs. This highlights the need to increase women’s access to continuous layperson support during labor and birth uninhibited by financial and institutional barriers.     

Hidden costs of infertility treatment in employee health benefits plans

OBJECTIVES: Many employers exclude infertility treatment from coverage under their health benefits plans. However, infertility treatment is often provided under other diagnoses or in association with therapy rendered for other disease processes. This study attempted to estimate those hidden costs and to determine what the impact would be of providing coverage for infertility treatment. STUDY DESIGN: A 1-year retrospective analysis was carried out to isolate the hidden costs of infertility treatment from specific medical claims data gathered from a large representative employer with no infertility benefit provided. Data were analyzed in the context of the claims experience of a health plan covering approximately 28,000 employees. Infertility treatment was excluded under this plan. Medical claims for specific procedures and diagnoses in 1996 were analyzed by using Current Procedural Terminology codes in conjunction with International Classification of Diseases, Ninth Revision codes to estimate the hidden costs of infertility treatment. Forty-one Current Procedural Terminology codes and 68 International Classification of Diseases, Ninth Revision codes were used for the analysis. Clinical practice experience was used to set boundaries (conservative and moderate estimate) regarding the likelihood of a given treatment being associated with infertility. This was compared with 100% covered charges to generate claims per employee per month. Procedures covered operative, diagnostic, and laboratory services. These figures were used to compute a range of cost for infertility treatment per member per month. RESULTS: Forty-one Current Procedural Terminology codes were identified that indicated possible infertility treatment. These covered the areas of laparoscopic and hysteroscopic surgery, lysis of adhesions, neosalpingostomy, cyst drainage, oocyte retrieval or embryo transfer, echography, and various hormonal analyses. Sixty-eight International Classification of Diseases, Ninth Revision codes indicated the possibility of infertility treatment. These included endocrine disorders, various uterine pathologic conditions, pelvic pain, endometriosis, pregnancy loss, irregular menses, and various ovulatory dysfunctions. The retrospective analysis found that 35 Current Procedural Terminology codes were involved in claims highly indicative of infertility services, such as 56353, hysteroscopic division of uterine septum, and 58345, transcervical fallopian tube catheterization. According to the 35 Current Procedural Terminology codes, $603,807.95 would have been paid if 100% of the charges had been covered; this would have resulted in a claim per employee per month of $1.12 by conservative estimate to $0.60 by moderate estimate. Computed cost figures per member per month showed the hidden costs of infertility to range between $0.27 and $0.50. CONCLUSION: On the basis of various cost studies, rate filings, and employee data, the cost of providing coverage for infertility treatment has previously been shown to vary between $0.20 and $2.00 per member per month. Through appropriate cost sharing, managed care, and algorithms, infertility coverage can be offered at a cost of $0.40 to $0.50 per member per month. This analysis indicates that at least some employers already pay this much even when infertility is specifically excluded under the plan.