Objective
Regret after tubal ligation continues to be a problem. After tubal ligation, couples have the option of tubal surgery or in vitro fertilization (IVF).
Study Design
Using decision analysis techniques, we compared cost-effectiveness of tubal reanastomosis by tubal type vs tubal surgery or in vitro fertilization (IVF) for 3 separate age groups of women: <35 years of age, 35 to 40 years of age and >40 years of age. Tubal techniques was divided into type A, those with more favorable prognosis because of the likelihood of having a more significant length tube at time of reanastomosis and type B, those with a worse prognosis of success. We incorporated delivery costs to address the impact of high order multiples in IVF. Data were extracted by studies available in the literature. All costs were adjusted to 2012 US dollars. One-way and 2-way sensitivity analyses were performed.
Results
The laparoscopic reanastomosis of type A dominated the other groups, because it was more effective and less costly then type B and IVF. However, when women were >40 years old with a history of type B, IVF was favored when its costs were at the lower limit.
Conclusion
The most cost-effective choice for a woman desiring pregnancy after tubal ligation is laparoscopic reanastomosis after a prior clip or ring tubal ligation for women ≤40 years old. It is also the most cost-effective for the oldest cohort, assuming IVF costs are greater than $4500.
Currently, 700,000 women have tubal ligation performed every year. The use of long-acting contraception (LARC) has been a major focus within the US. LARC has the distinct advantage of allowing a patient to have highly effective contraception that can be changed in the future. Counseling is essential; a long-acting reversible contraception option may be a better choice compared with bilateral tubal ligation in women who are not concrete in their decision and especially in younger women in whom the risk of regret is higher. Yet, irreversible contraception such as tubal ligation is still performed to a significant degree.
Although women are counseled that tubal ligation is a permanent form of contraception, 2-30% of women subsequently regret their decision. After tubal ligation, if a woman is interested in future childbearing she can proceed with surgical tubal reanastomosis or in vitro fertilization (IVF). The type of tubal ligation performed can influence the success rates of surgical anastomosis. This is due to the likelihood of having a more substantial remnant tubal length for reanastomosis. For instance, the success rates of tubal reanastomosis as measured by subsequent live birth after a clip or ring placement is estimated at 56.6-100% compared with 40-74.3% success with history of Pomeroy, Parkland, electrocautery, and other modalities. Age is also known to be an important prognostic factor with women less than 40 years of age having higher success rates of live birth compared with older women. Thus, when deciding which modality to recommend, practioners have to consider multiple factors. The recommendation for surgery vs IVF has traditionally been based on multiple factors including: age of the women, type of tubal ligation procedure, ovarian reserve, surgical candidacy, other infertility diagnosis, insurance coverage, number of children desired, and others.
Recently, an American Society of Reproductive Medicine (ASRM) Committee Opinion concluded that although IVF has a higher per cycle pregnancy rate, tubal anastomosis, with significantly higher cumulative pregnancy rates, is more cost-effective for all woman including those greater than 40 years of age. Interestingly, a retrospective article comparing IVF to tubal anastomosis used in the ASRM recommendation assessed cost-effectiveness in the absence of delivery costs. Therefore, tubal anastomosis was more cost effective than IVF even without considering costs associated with multiple births.
The most cost-effective strategy for women with a history of tubal ligation interested in future childbearing remains somewhat uncertain. There are currently neither longitudinal comparative studies nor randomized trials addressing this, and either would be difficult to accomplish. We sought to compare cost-effectiveness between tubal reanastomosis and IVF incorporating the impact of age, type of tubal procedure, and delivery costs to address the impact of multiples with IVF.
Materials and Methods
This study compared the cost-effectiveness of laparoscopic tubal reanastomosis using 2 different types of tubal ligation compared with each other, as well as, IVF. The types of tubal ligation techniques were divided into type A—the more favorable prognosis group (ie, clip or ring tubal ligation) because of the likelihood of having a more significant length of tube remaining at the time of reanastomosis and type B—the less favorable prognosis group encompassing all other types of tubal ligation (ie, postpartum tubal ligation, electrocautery, Parkland, or unknown type). Both types of tubal ligation reanastomosis were compared with each other and to IVF. Laparoscopic tubal reanastomosis was chosen over open technique in attempts to minimize costs associated with the procedures. The likelihood of patients having a tubal ligation with type A vs B was estimated to be 46.1% and 53.90%, respectively.
Probability estimates for a successful reanastomosis and IVF were extracted from published data and were formulated into a decision tree comparing types of tubal ligation—type A or B—vs IVF ( Table 1 ). The average pregnancy following surgery was 12-24 months, the range within the literature was 2-88 months. Society for Assisted Reproductive Technology (SART) rates were used to estimate live birth rates from assisted reproductive technologies (ART) based on age and risk of multiples was based. Only fresh IVF outcomes were considered. Each scenario that used ART was allowed to run a total of four rounds to simulate the number of times insurance would cover attempted pregnancy with IVF in states with state mandated-insurance. Although insurance companies may cover a different number of cycles depending on their policy and the respective state, we chose to allow our model to run four times to simulate a middle range number of cycles covered in states with mandated insurance. Three separate trees were created to compare patients of the following ages: less than 35 years of age, 35 to 40 years of age, and greater than 40 years of age. The decision tree model was constructed using TreeAge version 3.5 (Tree Age Software, Williamstown, MA).
| Clinical situation | Age range | Base case (range) | References |
|---|---|---|---|
| Successful tubal reanastomosis with A | NA | 75% (56.6–100%) | |
| Successful tubal reanastomosis with B | NA | 67.5% (40–74.3%) | |
| Successful live birth with tubal reanastomosis A and B | NA | 72.5% (18–85%) | |
| Live birth rate (singleton) after tubal reanastomosis [assume same for tubal A and B] | ≤35 | 79.89% (50–100%) | |
| Live birth rate (twins) after tubal reanastomosis [assume same for tubal A and B] | ≤35 | 1.09% (0–2%) | |
| Live birth rate (triples or more) after tubal reanastomosis [assume same for tubal A and B] | ≤35 | 0.014% (0–0.3%) | |
| IVF live birth rate singleton | ≤35 | 27.3% (13–40%) | |
| IVF live birth rate twins | ≤35 | 12.9% (6–24%) | |
| IVF live birth rate triplets or more | ≤35 | 1.3% (0–3%) | |
| Live birth rate (singleton) after tubal reanastomosis [assume same for tubal A and B] | 35–40 | 66.08% (50–100%) | |
| Live birth rate (twins) after tubal reanastomosis [assume same for tubal A and B] | 35–40 | 0.9% (0–2%) | |
| Live birth rate (triplets) after tubal reanastomosis [assume same for tubal A and B] | 35–40 | 0.011% (0–0.3%) | |
| IVF live birth rate singleton | 35–40 | 19.5% (10–30%) | |
| IVF live birth rate twins | 35–40 | 9.2% (6–24%) | |
| IVF live birth rate triplets or more | 35–40 | 1% (0–3%) | |
| Live birth rate (singleton) after tubal reanastomosis [assume same for tubal A and B] | >40 | 49.32% (50–100%) | |
| Live birth rate (twins) after tubal reanastomosis [assume same for tubal A and B] | >40 | 0.68% (0–2%) | |
| Live birth rate (triples or more) after tubal reanastomosis [assume same for tubal A and B] | >40 | 0.0085% (0–0.3%) | |
| IVF live birth rate singleton | >40 | 10.1% (5–15%) | |
| IVF live birth rate twins | >40 | 4.7% (6–24%) | |
| IVF live birth rate triplets or more | >40 | 0.49% (0–3%) |
Costs for tubal reanastomosis and IVF were extrapolated from published data and were adjusted to 2012 US dollars using the medical care component of the Consumer Price Index ( Table 2 ). Studies that described costs were preferred and chosen when available. When only charges were available, they were converted to costs using 0.6 cost-to-charge ratios. Costs were also converted from foreign currency to US dollars with the average exchange rates for that given calendar year. The study also incorporated delivery costs of singleton; twin and multiple births to address the impact of high order multiples with ART. Only direct costs were considered.
| Service | Base case (range) | Charge or cost | Reference |
|---|---|---|---|
| LSC tubal reanastamosis | $8006.67 ($1097.87–8006.67) | Cost | |
| Delivery cost singleton | $15,238.63 | Charge | |
| Delivery cost twins | $58,736.43 | Charge | |
| Delivery cost triplets | $169,900.22 | Charge | |
| IVF cycle | $10,043.32 ($7,363.67–16,015.99/cycle) | Charge and cost |
The effectiveness measure in the analysis was live birth, and the primary cost-effective outcome was the marginal cost (USD) per live birth for each strategy. The primary outcome of the decision analysis is cost per live birth. Ectopic pregnancies are increased in patients with a history of tubal reversal and in patients that have undergone ART. Ectopic pregnancy is estimated at 2% in the general population and in one study comparing ectopic pregnancy in tubal reanastomosis vs in ART was 6.7% vs 5.6%, respectively. Thus, ectopic gestation is at increased risk for patients in both groups.
The most effective and least costly is noted as the dominant strategy in the model. Difference in cost and effectiveness were used to calculate the marginal costs and marginal effectiveness respectively for each model. One-way sensitivity analysis was used to test the model’s probability changes and costs, with base cases and ranges derived from published data. When ranges were not available from literature, the range was set at ± 50% of the case base value. Two-way sensitivity analyses were also conducted.
The study was considered exempt by the institutional review board at University of Illinois Medical Center At Chicago.
Results
Decision trees were formulated for each age group using cost-based estimates. Base-case estimated costs were cheapest for Type A reanastomosis per live birth at every age. It was estimated at $19,300/live birth a for 35 years old, $23,000/live birth at 35-40 years old, and $26,200/ live birth for woman greater than 40 years of age. Marginal costs for type B reanastomosis and IVF ranged from $1000–8000. Type A reanastomosis was also more effective per live birth for each age group compared with the other 2 strategies, and thus the dominating or preferred strategy. This was true for all 3 ages using base-case estimates ( Table 3 ).
| Strategy | Age range | Cost | Effectiveness | Marginal cost | Marginal effectiveness | Marginal cost/Effectiveness |
|---|---|---|---|---|---|---|
| Tubal reanastomosis A | ≤35 | 19.3K | 0.977 | |||
| Tubal reanastomosis B | ≤35 | 20.7K | 0.953 | 1.4K | −0.024 | Dominated |
| IVF | ≤35 | 26.2K | 0.754 | 6.9K | −0.223 | Dominated (30.9K) |
| Tubal reanastomosis A | 35–40 | 23K | 0.937 | |||
| Tubal reanastomosis B | 35–40 | 25K | 0.919 | 2K | −0.018 | Dominated |
| IVF | 35–40 | 31K | 0.756 | 8K | −0.181 | Dominated (44K) |
| Tubal reanastomosis A | >40 | 26.2K | 0.768 | |||
| Tubal reanastomosis B | >40 | 27.2K | 0.743 | 1K | −0.026 | Dominated |
| IVF | >40 | 28.9K | 0.485 | 2.7K | −0.283 | Dominated (9.54K) |
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