Posts

25
Nov

The high cost of increasing age and FSH in IVF treatment

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This article is provided for patients who are trying to conceive and have concerns regarding the potential cost- effectiveness of IVF. It is written for patients who have an understanding of the basic concepts being discussed. For explanation of the significance of FSH values, please see articles on this website on IVF and prognosis, and low response. At CNY Fertility Centers, access to care is a concern addressed by offering low cost IVF options in Syracuse, New York, Rochester NY and Albany NY.

The age of a woman who is trying to get pregnant with IVF and her ovarian reserve as reflected in day 3 FSH values are good predictors of IVF outcomes. Henne and colleagues at Walter Reed Hospital and the NIH evaluated 1238 first IVF cycles of women between age 26 and 42 years and an FSH level of <13 miu/ml.  A cost analysis was applied and focused on these patients who by normal standard were good prognosis. Patients need to understand that statistics for overall success even with a specific age group may not apply if the FSH is higher than 12 as results would be even worse. At a cost of $10,803 per cycle costs soared to over $100,000 per baby born as FSH and age of the patient increased over age 38-39.
This is not surprising as Voorhis had estimated cost per baby of $89,981 for patients over 38. Trad calculated the cost to be about $75,000. Neumann, who used very low success rates estimated that in low prognosis patients, costs per baby could be as high as $800,000.

For comparison and for patients concerned about the high cost of donor egg treatment the delivery rates of the alternative must be considered. At a cost of $25,000 per cycle, and delivery rate of 51%, the cost per baby is $49,000. These costs will be dropping rapidly as egg banking becomes widely available. As a woman’s predicted delivery rate falls below 10%, the donor egg option becomes favored treatment economically. CNY Fertility Center offers multiple options to make IVF and donor eggs more affordable including a refund program for IVF and donor egg IVF, 0% financing, six cycle discount program, and Fall IVF specials.

References:
Henne, MB et al The combined effect of age and basal FSH on the cost of live birth at assisted reproductive technology Fertil Steril 2008; 89:104-10.
Neumann, PJ Johanesson M The willingness to pay for in vitro fertilization: a pilot study using contingent valuation. Med Care 1994; 32: 686-99.
Trad, FS et al In vitro fertilization: a cost effective alternative for infertile couples? J Assist Reprod Genet 1995; 12 418-21.
Van Voorhis BJ et al. Cost effectiveness of infertility treatments. Fertil Steril 1997; 67:830-6

12
Nov

IVF and Antral Follicle Count

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This information is provided for patients interested in their prognosis for infertility treatment. CNY Fertility Center in Syracuse NY, Albany, NY and Rochester, NY provide consultations, and treatments for couples trying to conceive.
The number of follicles, each containing one egg, which are available in the ovarian pool relates to the chance of success of In Vitro Fertilization (IVF). These numbers decline with age, and in some women decline abnormally fast. For couples who are trying to conceive and their care givers, methods of predicting the potential outcome of IVF can be important in making medical decisions.

One important tool for measuring the ovarian pool is a direct measure of the follicles as they emerge in a given month. The number of small follicles in the ovary during a menstrual period are observed using ultrasound. At this point there are no large follicles, and the pool of follicles which will emerge that month are beginning to grow. As the fluid accumulates, even a few milliliters (a teaspoonful is 5 ml) of fluid in the antral follicle can produce a measurable echo on the highly sensitive ultrasound machines used for transvaginal evaluation of the ovaries. Follicles between 2 and 5 mm can be visualized and counted. The antral follicle count (AFC) must be done when the follicles have not begun to grow. Thus it is scheduled day 2, 3 or 4 of the cycle prior to considering IUI or IVF therapy. Since there is not a huge variation from month to month, this test can give a good idea of the prognosis for the future.
antral follicle
Antral Follicle from www.DKImages.com
antral follicle ultrasound
Ultrasound image of antral follicles from www.healthline.com
Because not all of the follicles can be visualized , after stimulation by clomiphene or injectable gonadotropins, the number of follicles which eventually develop may be higher that the number of antral follicles in that particular cycle.

In a review of studies, Verkagen has concluded that the AFC is as good as any of the biochemical tests to determine ovarian reserve. In IVF treatment, if the AFC is less than 4, there is a much lower rate of successful pregnancies. Since this cut off is so low, this limits the value of the test. How high can it go? Egg donors or young infertility patients might have an antral follicle count of 17 or more. The typical mid-30 year old infertility patient will have 5-10 antral follicles. Sometimes in women with low ovarian reserve it is tempting to try to find a cycle with more antral follicles in order to get a slightly better result. However, there is low variability of the AFC from month to month (Jayaprakasan 2008) so waiting for another month is not likely to change much.

More indirect biomarkers of ovarian reserve include serum FSH, day 3 estradiol levels, inhibin B and anti-Mullarian hormone. These tests of ovarian reserve are covered in the section on IVF prognosis on this web site. In practice all available information is used for prognosis. Thus, the AFC is used in conjunction with the indirect tests of ovarian reserve.
For additional information and opportunities to get involved in infertility chat rooms, visit CNY Fertility Center’s patient discussion forums for medical questions or support.

Selected References
Verkagen et al Fertil Steril 2008
Jayaprakasan, K et al. Establishing the intercycle variability of ultrasonographic predictors of ovarian reserve. Fertil Steril 2008;90:2126-2151.
Edited by JBM on 9-26-09

IVF and antral follicle count.

This information is provided for patients interested in their prognosis for infertility treatment. CNY Fertility Center in Syracuse NY, Albany, NY and Rochester, NY provide consultations, and treatments for couples trying to conceive. For a glossary of terms please refer to www.fertilitylifelines.com

The number of follicles, each containing one egg, which are available in the ovarian pool relates to the chance of success of in vitro fertilization (IVF). These numbers decline with age, and in some women decline abnormally fast. For couples who are trying to conceive and their care givers, methods of predicting the potential outcome of IVF can be important in making medical decisions.

One important tool for measuring the ovarian pool is a direct measure of the follicles as they emerge in a given month. The number of small follicles in the ovary during a menstrual period are observed using ultrasound. At this point there are no large follicles, and the pool of follicles which will emerge that month are beginning to grow. As the fluid accumulates, even a few milliliters (a teaspoonful is 5 ml) of fluid in the antral follicle can produce a measurable echo on the highly sensitive ultrasound machines used for transvaginal evaluation of the ovaries. Follicles between 2 and 5 mm can be visualized and counted. The antral follicle count (AFC) must be done when the follicles have not begun to grow. Thus it is scheduled day 2, 3 or 4 of the cycle prior to considering IUI or IVF therapy. Since there is not a huge variation from month to month, this test can give a good idea of the prognosis for the future.

secondaryFollicle-thumb.jpg

Antral Follicle from www.DKImages.com

antral healthline .com

Ultrasound image of antral follicles from www.healthline.com

Because not all of the follicles can be visualized , after stimulation by clomiphene or injectable gonadotropins, the number of follicles which eventually develop may be higher that the number of antral follicles in that particular cycle.

In a review of studies, Verkagen has concluded that the AFC is as good as any of the biochemical tests to determine ovarian reserve. In IVF treatment, if the AFC is less than 4, there is a much lower rate of successful pregnancies. Since this cut off is so low, this limits the value of the test. How high can it go? Egg donors or young infertility patients might have an antral follicle count of 17 or more. The typical mid-30 year old infertility patient will have 5-10 antral follicles. Sometimes in women with low ovarian reserve it is tempting to try to find a cycle with more antral follicles in order to get a slightly better result. However there is low variability of the AFC from month to month (Jayaprakasan 2008) so waiting for another month is not likely to change much.

More indirect biomarkers of ovarian reserve include serum FSH, day 3 estradiol levels, inhibin B and anti-Mullarian hormone. These tests of ovarian reserve are covered in the section on IVF prognosis on this web site. In practice all available information is used for prognosis. Thus, the AFC is used in conjunction with the indirect tests of ovarian reserve.

For additional information and opportunities to get involved in infertility chat rooms, visit CNY Fertility Center’s patient discussion forums for medical questions or support.

Selected References

Verkagen et al Fertil Steril 2008

Jayaprakasan, K et al. Establishing the intercycle variability of ultrasonographic predictors of ovarian reserve. Fertil Steril 2008;90:2126-2151.

Edited by JBM on 9-26-09