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COST CUTTING MEASURES IN IVF PROF. DR. TEKSEN CAMLIBEL 1 COST CUTTING MEASURES IN IVF PROF. DR. TEKSEN CAMLIBEL 1

NEED OF IVF FEWER THAN 20% WHO NEED IVF, USES IT IN 48 COUNTRIES, NEED OF IVF FEWER THAN 20% WHO NEED IVF, USES IT IN 48 COUNTRIES, UTILIZATION IS 289 C. P. M. A ESTIMATED NEED IN 1500 -3000 NUMBER OF CENTERS HIGH COST IF PRICE IS 10% LOWER, UTILIZATION IS 30% HIGHER. COLLINS JA 2002 2

COST CUTTING MEASURES IN IVF NEED OF IVF 3000 IVF/ICSI CYCLES PER MILLION/PER ANNUM COST CUTTING MEASURES IN IVF NEED OF IVF 3000 IVF/ICSI CYCLES PER MILLION/PER ANNUM OPTIMAL NEED 1500 CYCLES PER MILLION/PER ANNUM IN TURKEY OPTIMAL NEED IS 105. 000 ABOUT 40. 000 -50. 000 CYCLES PERFORMED PER YEAR ˜ 200 M $ ECONOMY 3

COST IN TURKEY 850 (SGK) + 700 (PATIENT) + DRUGS (20%) TOTAL 1950 TL/780 COST IN TURKEY 850 (SGK) + 700 (PATIENT) + DRUGS (20%) TOTAL 1950 TL/780 EURO TO 5500 TL + DRUGS (2000 TL) TOTAL 7500 TL/3000 EURO 4

COST OF IVF/GNI WESTERN COUNTRIES > 10 % USA > 25 % 3 RD COST OF IVF/GNI WESTERN COUNTRIES > 10 % USA > 25 % 3 RD WORLD COUNTRIES > 50 % TURKEY > 37 % (3000$/8000$) 5

COST IN THE WORLD COST OR CHARGES PER IVF CYLE COUNTRY COST PER CYCLE COST IN THE WORLD COST OR CHARGES PER IVF CYLE COUNTRY COST PER CYCLE ORIGINAL CURRENCY COLLINS JA 2002 YEAR OF ESTIMATE US 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 , ICSI CYCLES 17% MORE COSTLY IN USA IS 37% MORE COSTLY THAN OTHER COUNTRIES 6

COST COMPONENTS OF IVF/ICSI COST OF FERTILITY DEPARTMENT GYNECOLOGISTS IVF NURSES ANESTHESIA COST OF COST COMPONENTS OF IVF/ICSI COST OF FERTILITY DEPARTMENT GYNECOLOGISTS IVF NURSES ANESTHESIA COST OF MEDICATIONS CC, HMG, r. FSH, HP FSH, HCG, r. HCG, etc LAB COSTS EMBRYOLOGIST (S) TECHINICIAN (S) EQUIPMENT SUPPLIES OPU NEEDLES MEDIUMS CATHETERS FALCON TUBES ETC HOSPITAL CHARGES INITIAL INVESTMENT 7

COST OF IVF BOUWMANS 2008 HORMONAL STIMULATION OPU ET EVALUATION 8 COST OF IVF BOUWMANS 2008 HORMONAL STIMULATION OPU ET EVALUATION 8

STAFF COSTS 10 CASES 100 VISIT 4 VISIT/DAY 1000 TL/CASE 400 EURO/CASE 50 CASES STAFF COSTS 10 CASES 100 VISIT 4 VISIT/DAY 1000 TL/CASE 400 EURO/CASE 50 CASES 500 VISIT 20 VISIT/DAY 200 TL/CASE 80 EURO/CASE EMBRYOLOGIST+TECH. 8000 TL 800/CASE 320 EURO 160/CASE 64 EURO ANESTHESIA 50 TL/20 EURO 100 TL/40 EURO NURSE 1500 TL 150 TL/60 EURO GYNECOLOGIST 10. 000 30 TL/12 EURO 9

COST OF IVF MAX (10 CASE) TL/EURO MIN (50 CASES) TL/EURO r FSH 2280/912 COST OF IVF MAX (10 CASE) TL/EURO MIN (50 CASES) TL/EURO r FSH 2280/912 HMG 460/184 ANTAGONIST 423/170 AGONIST 131/52 r HCG 74/30 HCG 7/3 VAG SUPP. 150/58 PROG. IN OIL 30/12 GYN. 1000/400 GYN. 200/80 EMB. 800/320 EMB. 160/64 ANEST. 75/30 NURSE 150/60 NURSE 30/12 EMB SUPP 900/357 EMB. SUPP. 360/144 TOTAL 5862/2344 TOTAL 1482/592 COST+MED 2925+2927 COST+MED 825+657 10

COST-MINIMIZATION ANALYSIS VARIABLE HIGHLY PURIFIED RECOMBINANT h. MG FSH --------------------------------------------------------NO. OF PATIENTS 396 385 COST-MINIMIZATION ANALYSIS VARIABLE HIGHLY PURIFIED RECOMBINANT h. MG FSH --------------------------------------------------------NO. OF PATIENTS 396 385 TOTAL PER PATIENT COST (95% CI) (£) 2. 423 (2. 356 -2, 495) 2, . 745 (2, 658 -2, 830) TOTAL COST PER ONGOING 10. 781 14. 284 PREGNANCY ((95% CI) (£) (9. 056 -12. 919) (11. 883 -17. 981) --------------------------------------------------------------------------LLOYD 2003 11

HOW TO REDUCE IVF COST PROTOCOL CHANGES SHORT vs LONG 12 HOW TO REDUCE IVF COST PROTOCOL CHANGES SHORT vs LONG 12

COST OF IVF MAX (10 CASE) TL/EURO MIN (50 CASES) TL/EURO r FSH 2280/912 COST OF IVF MAX (10 CASE) TL/EURO MIN (50 CASES) TL/EURO r FSH 2280/912 HMG 460/184 ANTAGONIST 423/170 AGONIST 131/52 r HCG 74/30 HCG 7/3 VAG SUPP. 150/58 PROG. IN OIL 30/12 GYN. 1000/400 GYN. 200/80 EMB. 800/320 EMB. 160/64 ANEST. 75/30 NURSE 150/60 NURSE 30/12 EMB SUPP 900/357 EMB. SUPP. 360/144 TOTAL 5862/2344 TOTAL 1482/592 COST+MED 2925+2927 COST+MED 825+657 13

COST-MINIMIZATION ANALYSIS VARIABLE HIGHLY PURIFIED RECOMBINANT h. MG FSH --------------------------------------------------------NO. OF PATIENTS 396 385 COST-MINIMIZATION ANALYSIS VARIABLE HIGHLY PURIFIED RECOMBINANT h. MG FSH --------------------------------------------------------NO. OF PATIENTS 396 385 TOTAL PER PATIENT COST (95% CI) (£) 2. 423 (2. 356 -2, 495) 2, . 745 (2, 658 -2, 830) TOTAL COST PER ONGOING 10. 781 14. 284 PREGNANCY ((95% CI) (£) (9. 056 -12. 919) (11. 883 -17. 981) --------------------------------------------------------------------------LLOYD 2003 14

HOW TO REDUCE IVF COST PROTOCOL CHANGES SHORT vs LONG MILD STIMULATION 15 HOW TO REDUCE IVF COST PROTOCOL CHANGES SHORT vs LONG MILD STIMULATION 15

HOW TO REDUCE IVF COST MILD STIMULATION TOTAL COST+HMG 64%+ 4 ANT+HCG+PROG. IN OIL HOW TO REDUCE IVF COST MILD STIMULATION TOTAL COST+HMG 64%+ 4 ANT+HCG+PROG. IN OIL 1397 TL/ 558 EURO (FSH START DAY 5) 16

MILD vs STANDARD POLINDER 2007 17 MILD vs STANDARD POLINDER 2007 17

HOW TO REDUCE IVF COST PROTOCOL CHANGES SHORT vs LONG MILD STIMULATION MOD. NATURAL HOW TO REDUCE IVF COST PROTOCOL CHANGES SHORT vs LONG MILD STIMULATION MOD. NATURAL 18

HOW TO REDUCE IVF COST MOD. NATURAL TOTAL COST+HMG 40%+ 4 ANT+HCG+PROG. IN OIL HOW TO REDUCE IVF COST MOD. NATURAL TOTAL COST+HMG 40%+ 4 ANT+HCG+PROG. IN OIL 1287 TL/ 514 EURO HMG 4 DAYS+ANTAGONIST 4 DAYS) 19

HOW TO REDUCE IVF COST PROTOCOL CHANGES SHORT vs LONG MILD STIMULATION MOD. NATURAL HOW TO REDUCE IVF COST PROTOCOL CHANGES SHORT vs LONG MILD STIMULATION MOD. NATURAL 20

HOW TO REDUCE IVF COST NATURAL CYCLE TOTAL COST+HCG+PROG. IN OIL 862 TL/345 EURO HOW TO REDUCE IVF COST NATURAL CYCLE TOTAL COST+HCG+PROG. IN OIL 862 TL/345 EURO 21

NATURAL CYCLE vs STANDARD NARGUND 2001 Estimated costs for a hypothetical cohort of 100 NATURAL CYCLE vs STANDARD NARGUND 2001 Estimated costs for a hypothetical cohort of 100 couples Natural cycle IVF Cumulative pregnancy after four consecutive cycles (%) Stimulated cycle IVFa 46 44– 65 396. 92 1717. 35 Cost per couple (£) 1315 5599– 4879 Cost per pregnancy (£) 2864 12 721– 7633 Cost per cycle (£) a. Ranges represent results for severe to mild tubal factor. 22

HOW TO REDUCE IVF COST PROTOCOL CHANGES SHORT vs LONG MILD STIMULATION MOD. NATURAL HOW TO REDUCE IVF COST PROTOCOL CHANGES SHORT vs LONG MILD STIMULATION MOD. NATURAL MINI-IVF 23

HOW TO REDUCE IVF COST MINI IVF COST+CLOMID+HCG+PROG. IN OIL TOTAL COST 882 TL/355 HOW TO REDUCE IVF COST MINI IVF COST+CLOMID+HCG+PROG. IN OIL TOTAL COST 882 TL/355 EURO 24

HOW TO REDUCE IVF COST PROTOCOL CHANGES SHORT vs LONG MILD STIMULATION MOD. NATURAL HOW TO REDUCE IVF COST PROTOCOL CHANGES SHORT vs LONG MILD STIMULATION MOD. NATURAL MINI-IVF IVM 25

HOW TO REDUCE IVF COST IVM COST+HCG+PROG. IN OIL TOTAL COST 862 TL/345 EURO HOW TO REDUCE IVF COST IVM COST+HCG+PROG. IN OIL TOTAL COST 862 TL/345 EURO 26

HOW TO REDUCE IVF COST PROTOCOL CHANGES SHORT vs LONG MILD STIMULATION MOD. NATURAL HOW TO REDUCE IVF COST PROTOCOL CHANGES SHORT vs LONG MILD STIMULATION MOD. NATURAL MINI-IVF IVM FROZEN CYCLE DRUGS r. FSH – HMG r. HCG – HCG VAG. SUPP vs PROG. IN OIL SUPPLIES MEDICAL STAFF 27

EMBRYOLOGY SUPPLIES 10 CASES 50 CASES MIN TL/EURO MAX TL/EURO OPU NEEDLE 38/15 130/520 EMBRYOLOGY SUPPLIES 10 CASES 50 CASES MIN TL/EURO MAX TL/EURO 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 MIN MAX * SOME MEDIUMS (HYALURONIDASE; VITRIFICATION VE EMBRYO THAW MEDIUMLAR) MAY BE PREPARED HOME MADE. 28

HOW ABOUT HARDWARE COSTS 5 YEAR COST RENT MICROMANIPULATOR INCUBATORS (2) LAMINAR FLOW USG HOW ABOUT HARDWARE COSTS 5 YEAR COST RENT MICROMANIPULATOR INCUBATORS (2) LAMINAR FLOW USG ANDROLOGY FREEZING HGPA FILTER SURGICAL TABLE SURGICAL LAMP PATIENT BEDS (3) DECORATION 7000 TL 420. 000 TL/168. 000 EURO 30. 000 EURO 25. 000 EURO 20. 000 EURO 5000 EURO 30. 000 EURO TOTAL 351. 000 EURO FOR 10 CASES/MONTH: 1462 TL/585 EURO FOR 50 CASES/MONTH: 292 TL/117 EURO 29

TOTAL COST OF IVF 10 CASES (MAX) TL/EURO 50 CASES (MIN) TL/EURO HARDWARE COST TOTAL COST OF IVF 10 CASES (MAX) TL/EURO 50 CASES (MIN) TL/EURO HARDWARE COST 1462/585 292/117 FIX COSTS 2925/1170 825/1170 2927/1170 ---------7324/2935 657/1170 --------1774/709 MED 30

CONCLUSIONS • • • IVF IS A COSTLY BUSSINES RENTS ARE HIGH! STAFF SALARIES CONCLUSIONS • • • IVF IS A COSTLY BUSSINES RENTS ARE HIGH! STAFF SALARIES DRUGS SHOULD BE CHOSEN TO KEEP EXPENSES DOWN. PROTOCOLS CAN BE CHANGED TO KEEP MEDICATION COST DOWN FROZEN CYCLE BE ENCOURAGED. OTHER THAN INCUBATORS, 2 ND HAND EQUIPMENT MAYBE CONSIDERED. PRIVATE ELECTRIC CONTRACTS TELEPHONE CONTRACTS EMBRYOLOGYST CAN MAKE OR BREAK THE PROFITS. COST IS REVERIBLY ASSOCIATED WITH CASE/MONTH 31

THANK YOU! 32 THANK YOU! 32