1

COST CUTTING COST CUTTING MEASURES IN IVFMEASURES IN IVF

PROF. DR. TEKSEN PROF. DR. TEKSEN CAMLIBELCAMLIBEL

2

NEED OF IVFNEED OF IVF

FEWER THAN 20% WHO NEED IVF, USES ITFEWER THAN 20% WHO NEED IVF, USES IT

IN 48 COUNTRIES, UTILIZATION IS 289 C.P.M.A IN 48 COUNTRIES, UTILIZATION IS 289 C.P.M.A ESTIMATED NEED IN ESTIMATED NEED IN

1500-30001500-3000

NUMBER OF CENTERSNUMBER OF CENTERS

HIGH COSTHIGH COST

IF PRICE IS 10% LOWER, UTILIZATION IS IF PRICE IS 10% LOWER, UTILIZATION IS 30% 30% HIGHER.HIGHER.

COLLINS JA 2002COLLINS JA 2002

3

COST CUTTING MEASURES IN COST CUTTING MEASURES IN IVFIVF

NEED OF IVFNEED OF IVF

3000 IVF/ICSI CYCLES PER MILLION/PER ANNUM3000 IVF/ICSI CYCLES PER MILLION/PER ANNUM

OPTIMAL NEED 1500 CYCLES PER MILLION/PER OPTIMAL NEED 1500 CYCLES PER MILLION/PER ANNUMANNUM

IN TURKEY OPTIMAL NEED IS 105.000IN TURKEY OPTIMAL NEED IS 105.000

ABOUT 40.000-50.000 CYCLES PERFORMED PER YEARABOUT 40.000-50.000 CYCLES PERFORMED PER YEAR

˜ 200 M $ ECONOMY˜ 200 M $ ECONOMY

4

COST IN TURKEYCOST IN TURKEY

850 (SGK) + 700 (PATIENT) + 850 (SGK) + 700 (PATIENT) + DRUGS (20%)DRUGS (20%)

TOTAL 1950 TL/780 EUROTOTAL 1950 TL/780 EURO

TOTO

5500 TL + DRUGS (2000 TL)5500 TL + DRUGS (2000 TL)

TOTAL 7500 TL/3000 EUROTOTAL 7500 TL/3000 EURO

5

COST OF IVFCOST OF IVF

COST OF IVF/GNICOST OF IVF/GNI

WESTERN COUNTRIESWESTERN COUNTRIES > 10 % > 10 %

USAUSA > 25 % > 25 %

3RD WORLD COUNTRIES3RD WORLD COUNTRIES > 50 % > 50 %

TURKEYTURKEY > 37 % > 37 % (3000$/8000$)(3000$/8000$)

6

COST IN THE WORLDCOST IN THE WORLD COST OR CHARGES PER IVF CYLE COST OR CHARGES PER IVF CYLE

COLLINS JA 2002 COLLINS JA 2002

ICSI CYCLES 17% MORE COSTLY IN USAICSI CYCLES 17% MORE COSTLY IN USA

USA IS 37% MORE COSTLY THAN OTHER COUNTRIESUSA IS 37% MORE COSTLY THAN OTHER COUNTRIES

COUNTRYCOST PER

CYCLEORIGINAL

CURRENCYYEAR OF

ESTIMATEUS 2002 COST

($) REFERENCE

CANADA 5700 CAD 1995 4532 FLUKER et al (1996)

NETHERLANDS 3350 GUILDERS 1995 2042 GOVERDE et al (2000)

DENMARK 1900 STERLING 1994 3753 GRANBERG et al (1998)

FINLAND 1300 , . 2568 ,

ICELAND 2000 . . 3950 ,

NORWAY 1800 . . 3555 ,

SWEDEN 2100 . . 4148 ,

ITALY 5.85 LIRA (a) 1997 4326 MANTOVANI et al. (1999)

UK 1717 STERLING 1998 2955 PHILLIPS et al. (2000)

CHINA 1500 USD 1995 1908 SCHENKER AND SHUSHAN (1996)

HONG KONG 5000 . , 6361 * ,

INDIA 2000 . , 2545 ,

INDONESIA 3000 . , 3817 ,

IRAN 1000 . , 1272 * ,

ISRAEL 3000 . , 3817 ,

JAPAN 2500 . , 3181 ,

JORDAN 1500 . , 1908 ,

KOREA 1100 . , 1400 ,

LEBANON 4000 . , 5089 ,

MALAYSIA 4500 . , 5725 ,

PAKISTAN 1000 . , 1272 ,

SAUDI ARABIA 4000 . , 5089 ,

SINGAPORE 4500 . , 5725 ,

TAIWAN 3000 .   3817 ,

THAILAND 2500 . , 3181 ,

7

COST COMPONENTS OF IVF/ICSICOST COMPONENTS OF IVF/ICSI

COST OF FERTILITY DEPARTMENTCOST OF FERTILITY DEPARTMENTGYNECOLOGISTSGYNECOLOGISTSIVF NURSESIVF NURSES

ANESTHESIAANESTHESIACOST OF MEDICATIONSCOST OF MEDICATIONS

CC, HMG, rFSH, HP FSH, HCG, rHCG, CC, HMG, rFSH, HP FSH, HCG, rHCG, etcetc

LAB COSTSLAB COSTSEMBRYOLOGIST (S)EMBRYOLOGIST (S)TECHINICIAN (S)TECHINICIAN (S)EQUIPMENTEQUIPMENTSUPPLIESSUPPLIES

OPU NEEDLESOPU NEEDLES MEDIUMSMEDIUMS

CATHETERSCATHETERSFALCON TUBES ETCFALCON TUBES ETC

HOSPITAL CHARGESHOSPITAL CHARGESINITIAL INVESTMENTINITIAL INVESTMENT

8

COST OF IVFCOST OF IVF BOUWMANS 2008BOUWMANS 2008

PRICE OPTIONS OF THE TREATMENT STAGES OF IN VITRO FERTILIZATION /

INTRACYTOPLASMIC SPERM INJECTION

0

10

20

30

40

50

60

70

1

TREATMENT STAGE

CO

ST

S

IVF

ICSI

HORMONAL STIMULATION OPU ET EVALUATION

9

STAFF COSTSSTAFF COSTS 10 CASES10 CASES 50 CASES 50 CASES

GYNECOLOGISTGYNECOLOGIST 100 VISIT100 VISIT 500 VISIT 500 VISIT10.000 10.000 4 VISIT/DAY 20 VISIT/DAY 4 VISIT/DAY 20 VISIT/DAY

1000 TL/CASE1000 TL/CASE 200 200 TL/CASETL/CASE

400 EURO/CASE 80 EURO/CASE400 EURO/CASE 80 EURO/CASE

EMBRYOLOGIST+TECH. EMBRYOLOGIST+TECH. 800/CASE800/CASE 160/CASE 160/CASE8000 TL8000 TL 320 EURO 320 EURO 64 EURO 64 EURO

ANESTHESIAANESTHESIA 50 TL/20 EURO 50 TL/20 EURO 100 TL/40 EURO100 TL/40 EURO

NURSENURSE 150 TL/60 EURO 30 TL/12 EURO 150 TL/60 EURO 30 TL/12 EURO1500 TL1500 TL

10

COST OF IVFCOST OF IVFMAX (10 CASE)MAX (10 CASE) MIN (50 CASES)MIN (50 CASES)TL/EUROTL/EURO TL/EUROTL/EURO

r FSHr FSH 2280/9122280/912 HMG HMG460/184460/184

ANTAGONISTANTAGONIST 423/170423/170 AGONISTAGONIST 131/52131/52

r HCGr HCG 74/3074/30 HCGHCG 7/37/3

VAG SUPP.VAG SUPP. 150/58150/58 PROG. IN OILPROG. IN OIL 30/1230/12

GYN.GYN. 1000/4001000/400 GYN.GYN. 200/80200/80

EMB.EMB. 800/320800/320 EMB. EMB. 160/64160/64

ANEST.ANEST. 75/3075/30 ANEST.ANEST. 75/3075/30

NURSENURSE 150/60150/60 NURSENURSE 30/1230/12

EMB SUPPEMB SUPP 900/357900/357 EMB. SUPP.EMB. SUPP. 360/144360/144

TOTALTOTAL 5862/23445862/2344 TOTALTOTAL1482/5921482/592

COST+MEDCOST+MED 2925+2927 COST+MED 2925+2927 COST+MED 825+657825+657

11

COST-MINIMIZATION COST-MINIMIZATION ANALYSISANALYSIS

VARIABLEVARIABLE HIGHLY PURIFIED HIGHLY PURIFIED RECOMBINANTRECOMBINANT

hMGhMG FSH FSH

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

NO. OF PATIENTSNO. OF PATIENTS 396 396 385385

TOTAL PER PATIENT COSTTOTAL PER PATIENT COST 2.4232.423 2,.7452,.745

(95% CI) ((95% CI) (££) ) (2.356-2,495)(2.356-2,495) (2,658-2,830)(2,658-2,830)

TOTAL COST PER ONGOING TOTAL COST PER ONGOING 10.781 10.781 14.28414.284

PREGNANCY ((95% CI) (PREGNANCY ((95% CI) (££) ) (9.056-12.919)(9.056-12.919) (11.883-17.981)(11.883-17.981)

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

LLOYD 2003LLOYD 2003

12

HOW TO REDUCE IVF HOW TO REDUCE IVF COSTCOST

PROTOCOL CHANGESPROTOCOL CHANGES

SHORT vs LONGSHORT vs LONG

13

COST OF IVFCOST OF IVFMAX (10 CASE)MAX (10 CASE) MIN (50 CASES)MIN (50 CASES)TL/EUROTL/EURO TL/EUROTL/EURO

r FSHr FSH 2280/9122280/912 HMG HMG460/184460/184

ANTAGONISTANTAGONIST 423/170423/170 AGONISTAGONIST 131/52131/52

r HCGr HCG 74/3074/30 HCGHCG 7/37/3

VAG SUPP.VAG SUPP. 150/58150/58 PROG. IN OILPROG. IN OIL 30/1230/12

GYN.GYN. 1000/4001000/400 GYN.GYN. 200/80200/80

EMB.EMB. 800/320800/320 EMB. EMB. 160/64160/64

ANEST.ANEST. 75/3075/30 ANEST.ANEST. 75/3075/30

NURSENURSE 150/60150/60 NURSENURSE 30/1230/12

EMB SUPPEMB SUPP 900/357900/357 EMB. SUPP.EMB. SUPP. 360/144360/144

TOTALTOTAL 5862/23445862/2344 TOTALTOTAL1482/5921482/592

COST+MEDCOST+MED 2925+2927 COST+MED 2925+2927 COST+MED 825+657825+657

14

COST-MINIMIZATION COST-MINIMIZATION ANALYSISANALYSIS

VARIABLEVARIABLE HIGHLY PURIFIED HIGHLY PURIFIED RECOMBINANTRECOMBINANT

hMGhMG FSH FSH

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

NO. OF PATIENTSNO. OF PATIENTS 396 396 385385

TOTAL PER PATIENT COSTTOTAL PER PATIENT COST 2.4232.423 2,.7452,.745

(95% CI) ((95% CI) (££) ) (2.356-2,495)(2.356-2,495) (2,658-2,830)(2,658-2,830)

TOTAL COST PER ONGOING TOTAL COST PER ONGOING 10.781 10.781 14.28414.284

PREGNANCY ((95% CI) (PREGNANCY ((95% CI) (££) ) (9.056-12.919)(9.056-12.919) (11.883-17.981)(11.883-17.981)

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

LLOYD 2003LLOYD 2003

15

HOW TO REDUCE IVF HOW TO REDUCE IVF COSTCOST

PROTOCOL CHANGESPROTOCOL CHANGES

SHORT vs LONGSHORT vs LONG

MILD STIMULATIONMILD STIMULATION

16

HOW TO REDUCE IVF HOW TO REDUCE IVF COSTCOST

MILD STIMULATIONMILD STIMULATION

TOTAL COSTTOTAL COST

COST+HMG 64%+ 4 ANT+HCG+PROG. IN OILCOST+HMG 64%+ 4 ANT+HCG+PROG. IN OIL 1397 1397 TL/ 558 EUROTL/ 558 EURO

(FSH START DAY 5)(FSH START DAY 5)

17

MILD vs STANDARDMILD vs STANDARD POLINDER POLINDER

20072007

18

HOW TO REDUCE IVF HOW TO REDUCE IVF COSTCOST

PROTOCOL CHANGESPROTOCOL CHANGES

SHORT vs LONGSHORT vs LONG

MILD STIMULATIONMILD STIMULATION

MOD. NATURALMOD. NATURAL

19

HOW TO REDUCE IVF HOW TO REDUCE IVF COSTCOST

MOD. NATURALMOD. NATURAL

TOTAL COSTTOTAL COST

COST+HMG 40%+ 4 ANT+HCG+PROG. IN OIL COST+HMG 40%+ 4 ANT+HCG+PROG. IN OIL 1287 TL/ 1287 TL/ 514 EURO514 EURO

HMG 4 DAYS+ANTAGONIST 4 DAYS)HMG 4 DAYS+ANTAGONIST 4 DAYS)

20

HOW TO REDUCE IVF HOW TO REDUCE IVF COSTCOST

PROTOCOL CHANGESPROTOCOL CHANGES

SHORT vs LONGSHORT vs LONG

MILD STIMULATIONMILD STIMULATION

MOD. NATURALMOD. NATURAL

NATURALNATURAL

21

HOW TO REDUCE IVF HOW TO REDUCE IVF COSTCOSTNATURAL CYCLENATURAL CYCLE

TOTAL COSTTOTAL COST

COST+HCG+PROG.IN OILCOST+HCG+PROG.IN OIL 862 TL/345 862 TL/345 EUROEURO

22

NATURAL CYCLE vs NATURAL CYCLE vs STANDARDSTANDARD

NARGUND NARGUND 20012001

Estimated costs for a hypothetical cohort of 100 couples

  Natural cycle IVF Stimulated cycle IVFa

Cumulative pregnancy after four consecutive cycles (%) 46 44–65

Cost per cycle (£) 396.92 1717.35

Cost per couple (£) 1315 5599–4879

Cost per pregnancy (£) 2864 12 721–7633

aRanges represent results for severe to mild tubal factor.

23

HOW TO REDUCE IVF HOW TO REDUCE IVF COSTCOST

PROTOCOL CHANGESPROTOCOL CHANGES

SHORT vs LONGSHORT vs LONG

MILD STIMULATIONMILD STIMULATION

MOD. NATURALMOD. NATURAL

NATURALNATURAL

MINI-IVFMINI-IVF

24

HOW TO REDUCE IVF HOW TO REDUCE IVF COSTCOST MINI IVFMINI IVF

TOTAL COSTTOTAL COST

COST+CLOMID+HCG+PROG. IN OILCOST+CLOMID+HCG+PROG. IN OIL 882 882 TL/355 EUROTL/355 EURO

25

HOW TO REDUCE IVF HOW TO REDUCE IVF COSTCOST

PROTOCOL CHANGESPROTOCOL CHANGES

SHORT vs LONGSHORT vs LONG

MILD STIMULATIONMILD STIMULATION

MOD. NATURALMOD. NATURAL

NATURALNATURAL

MINI-IVFMINI-IVF

IVMIVM

26

HOW TO REDUCE IVF HOW TO REDUCE IVF COSTCOST IVMIVM

TOTAL COSTTOTAL COST

COST+HCG+PROG.IN OIL COST+HCG+PROG.IN OIL 862 862 TL/345 EUROTL/345 EURO

27

HOW TO REDUCE IVF HOW TO REDUCE IVF COSTCOSTPROTOCOL CHANGESPROTOCOL CHANGES

SHORT vs LONGSHORT vs LONGMILD STIMULATIONMILD STIMULATIONMOD. NATURALMOD. NATURALNATURALNATURALMINI-IVFMINI-IVFIVMIVMFROZEN CYCLEFROZEN CYCLE

DRUGSDRUGSrFSH – HMGrFSH – HMGrHCG – HCGrHCG – HCGVAG. SUPP vs PROG. IN OILVAG. SUPP vs PROG. IN OIL

SUPPLIESSUPPLIESMEDICAL STAFFMEDICAL STAFF

28

EMBRYOLOGY SUPPLIESEMBRYOLOGY SUPPLIES

  MINTL/EURO

MAX TL/EURO

10 CASES 50 CASES

MIN MAX MIN MAX

OPU NEEDLE 38/15 130/520        

ET CATHETER 38/15 70/28        

ICSI PIPETTE 40/16 60/24        

HOLDING PIPETTE 15/6 50/20        

DENUDATION PIPETTE 30/12 40/16        

PLASTIC DISPOSABLE 25/10 ±40/16        

MEDIUMS 100/40 ±300/120        

TOTAL 286/114 ± 690-900/276-360 286/114 900/360 286/114 592/236

* SOME MEDIUMS (HYALURONIDASE; VITRIFICATION VE EMBRYO THAW MEDIUMLAR) MAY BE PREPARED HOME MADE.

29

HOW ABOUT HARDWARE HOW ABOUT HARDWARE COSTSCOSTS

5 YEAR COST5 YEAR COSTRENTRENT 7000 TL 7000 TL 420.000 TL/168.000 420.000 TL/168.000

EUROEUROMICROMANIPULATOR MICROMANIPULATOR 30.000 EURO 30.000 EUROINCUBATORS (2)INCUBATORS (2) 20.000 EURO 20.000 EURO LAMINAR FLOWLAMINAR FLOW 25.000 EURO 25.000 EUROUSGUSG 20.000 EURO 20.000 EUROANDROLOGYANDROLOGY 20.000 EURO 20.000 EUROFREEZINGFREEZING 5000 EURO 5000 EURO HGPA FILTERHGPA FILTER 20.000 EURO 20.000 EUROSURGICAL TABLESURGICAL TABLE 5.000 EURO 5.000 EURO SURGICAL LAMPSURGICAL LAMP 5000 EURO 5000 EUROPATIENT BEDS (3) 3000 PATIENT BEDS (3) 3000

EUROEURODECORATIONDECORATION 30.000 EURO 30.000 EURO

TOTALTOTAL 351.000 EURO351.000 EUROFOR 10 CASES/MONTH: 1462 TL/585 EUROFOR 10 CASES/MONTH: 1462 TL/585 EUROFOR 50 CASES/MONTH: 292 TL/117 EUROFOR 50 CASES/MONTH: 292 TL/117 EURO

30

TOTAL COST OF IVFTOTAL COST OF IVF

10 CASES (MAX) 50 CASES 10 CASES (MAX) 50 CASES (MIN)(MIN)

TL/EUROTL/EURO TL/EURO TL/EURO

HARDWARE COSTHARDWARE COST 1462/585 292/117 1462/585 292/117

FIX COSTSFIX COSTS 2925/1170 825/1170 2925/1170 825/1170

MEDMED 2927/1170 2927/1170 657/1170 657/1170 ------------------ ---------------------------------- ----------------

7324/2935 7324/2935 1774/7091774/709

31

CONCLUSIONSCONCLUSIONS• IVF IS A COSTLY BUSSINESIVF IS A COSTLY BUSSINES• RENTS ARE HIGH!RENTS ARE HIGH!• STAFF SALARIESSTAFF SALARIES• DRUGS SHOULD BE CHOSEN TO KEEP DRUGS SHOULD BE CHOSEN TO KEEP

EXPENSES DOWN.EXPENSES DOWN.• PROTOCOLS CAN BE CHANGED TO KEEP PROTOCOLS CAN BE CHANGED TO KEEP

MEDICATION COST DOWNMEDICATION COST DOWN• FROZEN CYCLE BE ENCOURAGED.FROZEN CYCLE BE ENCOURAGED.• OTHER THAN INCUBATORS, 2ND HAND OTHER THAN INCUBATORS, 2ND HAND

EQUIPMENT MAYBE CONSIDERED.EQUIPMENT MAYBE CONSIDERED.• PRIVATE ELECTRIC CONTRACTSPRIVATE ELECTRIC CONTRACTS• TELEPHONE CONTRACTSTELEPHONE CONTRACTS• EMBRYOLOGYST CAN MAKE OR BREAK THE EMBRYOLOGYST CAN MAKE OR BREAK THE

PROFITS.PROFITS.• COST IS REVERIBLY ASSOCIATED WITH COST IS REVERIBLY ASSOCIATED WITH

CASE/MONTHCASE/MONTH

32

THANK YOU!THANK YOU!