Is assisted reproduction the optimal treatment for varicocele-associated male infertility? A cost-effectiveness analysis

Objectives. To evaluate the cost-effectiveness of assisted reproduction using in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) as a primary treatment for varicocele-associated infertility. Methods. Analysis of cost per delivery using published and contemporary results for treatment with ICSI in the United States for male factor infertility was compared with cost per delivery after surgical varicocelectomy. Only results from controlled trials of varicocelectomy were used for evaluation of pregnancy and delivery rates. Cost estimates were based on prevailing nationwide charges for services in 1994. Results. The cost per delivery with ICSI was found to be $89,091 (95% confidence interval $78,720 to $99,462), whereas the cost per delivery after varicocelectomy was only $26,268 (95% confidence interval $19,138 to $44,656). Assuming the highest possible Published success rate for ICSI resulted in a cost estimate as low as $62,263. The average published U.S. delivery rate after one attempt of ICSI was only 28%, whereas a 30% delivery rate was obtained after varicocelectomy. Conclusions. Specific treatment of varicocele-associated male factor infertility with surgical varicocelectomy is more cost-effective than primary treatment with assisted reproduction. Continued evaluation and treatment of the man with infertility is warranted. Despite the apparent success of ICSI for the most severe cases of male factor infertility, application of assisted reproduction for all cases of male factor infertility also does not necessarily provide as high a delivery rate as specific treatment of the cause of male factor infertility. Copyright 1997 by Elsevier Science Inc.