A decision analysis of treatments for nonobstructive azoospermia associated with varicocele.

摘要

OBJECTIVE: To examine the economic impact of initial treatments for varicocele-associated nonobstructive azoospermia, specifically varicocelectomy versus microsurgical testicular sperm extraction (TESE) with IVF/intracytoplasmic sperm injection (ICSI). DESIGN: Decision analytic model based on 1) outcomes data from Society for Assisted Reproductive Technology (SART) database and peer-reviewed literature and 2) costing data from Medicare Resource-Based Relative Value Scale and sampling of high volume US IVF centers. SETTING: Academic medical center. PATIENT(S): Simulation with a decision analytic model. INTERVENTION(S): Variation of successful spontaneous live delivery after varicocelectomy versus rate of successful live delivery after IVF/ICSI. MAIN OUTCOME MEASURE(S): Cost-effectiveness. RESULT(S): Microsurgical TESE was more cost effective than varicocelectomy. In 1999, initial treatment with microsurgical TESE was more cost effective (Dollars 65,515) than varicocelectomy (Dollars 76,878). Relative cost-effectiveness was unchanged in 2005: Dollars 69,731 versus Dollars 79,576. The cost-effectiveness of both treatments improved in relation to projections by inflation. Sensitivity analyses suggest that the relative cost-effectiveness of TESE versus varicocelectomy can only be changed with either substantial improvement in spontaneous live delivery rates after varicocelectomy or with deterioration in IVF success rates. CONCLUSION(S): Microsurgical TESE appears to be more cost effective than varicocelectomy for treatment of varicocele-associated nonobstructive azoospermia when indirect costs are considered. The cost-effectiveness of both treatments has improved with time. These results may be tailored with institution-specific data to allow more individualized results.