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Abstract
Significant improvements in the treatment of infertility have been achieved through advances in assisted reproductive technologies (ART). However, achieving acceptable success rates in women of advanced maternal age using their own oocytes remains an intractable challenge, primarily due to increasing rates of aneuploidy in embryos created from women towards the end of their reproductive lives.
Preimplantation genetic diagnosis for aneuploidy (PGD-A) which screens all 24-chromosomes, is increasingly used in clinical practice to select euploid embryos for transfer. However, there is a dearth of evidence regarding its effectiveness beyond a single ART cycle.
This thesis is constructed around four interrelated studies, providing new evidence on the clinical and cost-effectiveness of PGD-A in women of advanced maternal age over repeated ART cycles.
Study One provides a systematic review of relevant literature published up to 2017. Study Two is a retrospective cohort analysis of 2,093 ART-naive women aged 37-years or older who commenced either PGD-A or conventional morphological assessment for the selection of embryos for transfer. Although the per-cycle live-birth rate was higher in the PGD-A group, the cumulative live-birth rates (CLBR) for up to three ‘complete ART cycles’ (fresh plus frozen embryo transfers) were not statistically different. However, the PGD-A group had a lower rate of pregnancy loss, required less time and fewer ART cycles to achieve a live-birth. Study Three extended the analysis by performing a patient-level cost-effectiveness analysis, concluding that PGD-A is likely to be considered cost-effective from a healthcare perspective, with an incremental cost-effective ratio per live-birth of 28,103 Australian dollars. The final study used a Markov model to evaluate the cost-effectiveness of standard ART treatment compared to PGD-A, ‘social egg freezing’, and donor ART. Notwithstanding the limitations of modelling studies, the analysis suggests that PGD-A is the most cost-effectiveness strategy from a healthcare perspective.
In conclusion, this doctoral research program found that in women of advanced maternal age undergoing ART treatment, PGD-A resulted in a similar CLBR compared to standard ART treatment but had a lower rate of pregnancy loss, required shorter time to achieve a live-birth and fewer cycles needed-to-treat. PGD-A is also likely to be considered cost-effective in this patient group undergoing ART treatment from a public-funding perspective.