Cost-effectiveness of primary offer of IVF vs. primary offer of IUI followed by IVF (for IUI failures) in couples with unexplained or mild male factor subfertility

Mathematical modelling was used to estimate comparative clinical and cost effectiveness of either primary offer of one full IVF cycle (including frozen cycles when applicable) or "IUI + IVF" (defined as primary IUI followed by IVF for IUI failures) to a hypothetical cohort of subfertile couples who are eligible for both treatment strategies. Data used in calculations were derived from the published peer-reviewed literature as well as activity data of local infertility units.Cost-effectiveness ratios for IVF, "unstimulated-IUI (U-IUI) + IVF", and "stimulated IUI (S-IUI) + IVF" were ￡12,600, ￡13,100 and ￡15,100 per live birth-producing pregnancy respectively. For a hypothetical cohort of 100 couples with unexplained or mild male factor subfertility, compared with primary offer of IVF, 6 cycles of "U-IUI + IVF" or of "S-IUI + IVF" would cost an additional ￡174,200 and ￡438,000, representing an opportunity cost of 54 and 136 additional IVF cycles and 14 to 35 live birth-producing pregnancies respectively.For couples with unexplained and mild male factor subfertility, primary offer of a full IVF cycle is less costly and more cost-effective than providing IUI (of any modality) followed by IVF.In any health care system, cost-effective commissioning of health care in order to maximise population health outcomes with the minimum possible resource use, is an important consideration. The UK National Institute for Clinical Excellence (NICE) [1] recommends offer of up to six cycles of Unstimulated Intrauterine Insemination (U-IUI) for couples with unexplained or mild male factor subfertility. Supplementary cost calculation guidance suggested overall savings to the NHS from a "switch" of activity from Stimulated IUI (S-IUI) to U-IUI, which was also recommended [2]. These calculations however were based on 'head-to-head' comparisons between S-IUI and U-IUI and completely ignored the cost implications of the fact that many couples who fail IUI will subsequently require in-vitro fer