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  • (2023) Keller, Elena
    Infertility affects 1 in 6 couples and >180 million people worldwide. It represents an increasingly important public health problem, amplified by the continuing global trend to later childbearing. Fertility treatment including in vitro fertilization (IVF) is not suited to traditional health technology assessment (HTA) methods, because its value is derived by its ability to create life, rather than extend, improve, or save existing lives. Consequently, there is a lack of guidance, and satisfactory HTA methods to determine whether fertility treatment provides good value for money. Moreover, the ever-increasing demand for elective egg freezing (EEF) to preserve female fertility poses additional challenges for economic assessments. This thesis describes 5 studies that move the research agenda forward for guiding the economic evaluation of fertility treatment. Study 1, a systematic review, identified and quantified 5 methodological categories for value-of-statistical-life elicitation. Based on these categories, Study 2 investigated methods for eliciting the value of a statistical baby (VSB) and concluded that discrete choice experiments (DCEs) are the most appropriate method in a fertility treatment context. Study 3 applied DCE outputs to derive a VSB estimate, which was used to assess value for money of publicly funded IVF in a cost-benefit analysis, finding that at least 5 IVF cycles likely provide good value for women <42 years. Study 4 elicited patient preferences for fertility treatment based on a DCE and Study 5 performed an incentive-compatible lab experiment to assess the impact of patient and treatment characteristics on the demand for IVF and EEF. Both experiments indicate that the demand for fertility treatment is price-inelastic and unresponsive to income level, which might explain why women continue fertility treatment once they have commenced despite their financial capacity. This research makes several methodological contributions and provides an evidence base to assess the public investment in fertility treatment. Overall, patients and society were found to value fertility treatment highly. New knowledge generated includes: (1) identifying the number of cost-beneficial IVF cycles by female age; (2) quantifying price and income elasticities for IVF and EEF; (3) bridging the gap between the proliferation of DCEs and policy by applying DCE outputs to HTA; and (4) demonstrating that government funding decisions can be explored in a lab experiment.