Cost Analysis Of Estrogen Priming Vs Microdose Leuprolide Flare Protocols For Women With Diminished Ovarian Reserve Undergoing Ivf.

Previous studies comparing E2 priming and leuprolide flare IVF protocols report that E2 priming protocols result in longer cycles and higher total gonadotropin dose with similar oocyte yield, fertilization, and pregnancy rates; though, one report suggests a trend toward higher quality embryos in E2 priming cycles. We aimed to compare cost effectiveness between these two cycle types in women with DOR and hypothesized that a leuprolide flare protocol would be more cost effective. Retrospective cost effectiveness analysis. We reviewed all IVF cycles in women diagnosed with DOR with E2 priming protocol or microdose leuprolide flare protocol in an academic fertility clinic by retrospective chart review from January 2016 through February 2020. We included only the first cycle of either type and excluded any cycles cancelled before retrieval. Variables assessed included patient age at retrieval, markers of ovarian reserve, total dose of gonadotropins, cycle length, number of mature oocytes (M2) retrieved, and number of 2 pronuclear embryos (2PN). We calculated total cost based on charge data from number of monitoring visits, estimated medication cost, and relevant procedure codes. The effectiveness was calculated as total M2 per cycle and total 2PN per cycle. We performed a separate cost effectiveness analysis for each measure, M2 and 2PN. Descriptive statistics, cost effectiveness, and t-test analysis were conducted using SAS 9.4. P values <0.05 were considered statistically significant. We evaluated a total of 182 cycles (149 E2 priming, 33 leuprolide flare). Mean age was 36.8 years in the E2 priming group, and 37.97 years in the leuprolide flare group. There was an average of 6.95 monitoring visits in the E2 priming groups and 6.18 visits in the leuprolide flare group. The cycle length was shorter (p value=0.013) and the total dose of gonadotropins was lower (p value=0.0026) in the leuprolide flare group (11.0 days, 4536.3 IU) vs E2 priming (12.3 days, 5301.7 IU). The mean number M2 per cycle was higher in the E2 priming group (7.06) vs leuprolide flare (5.0) (p value=0.035). The mean number of 2PN per cycle was also higher in the E2 priming group (5.46) vs leuprolide flare (3.48) (p value=0.002). The total cost per cycle was $24,156 in the E2 priming groups and $22,112 in the leuprolide flare group. The cost per both M2 and 2PN was lower in the E2 priming group ($3,209 and $4,424, respectively) than the leuprolide flare group ($4,134 and $6,345, respectively). Despite a longer cycle, higher total gonadotropin dose, and higher overall cost per cycle, patients treated with E2 priming protocol in our cohort had a greater mean number of M2 and 2PN, resulting in significantly lower cost per M2 and 2PN. Based on these data, E2 priming appears to be more cost effective than leuprolide flare in women with DOR. Cost effectiveness of medical care is becoming increasingly important in health systems, and application of this type of analysis in the field of reproductive medicine can help increase treatment success, improve allocation of resources, and ultimately increase access to infertility care.