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Abstract

Aim: Assess the budget impact of nationwide screening for diminished ovarian reserve (OR), via anti-Müllerian hormone (AMH) levels, to the Portugal National Health System (NHS). Patients & methods: The clinical journey was determined using literature and the family planning decision-making process/response using survey results. A panel of four local clinicians validated all assumptions/inputs. Results: Screening for OR led to an expected savings of € 9.4 million for the NHS, driven by a 24% reduction in medically assisted reproduction (MAR) use. When needed, referral for MAR was earlier and more women used first-line versus second-line techniques. The model estimated a 12% decrease in failure. Conclusion: This model shows AMH screening may allow more informed decisions, leading to a shorter fertility journey, more efficient use of treatments, and substantial cost-savings for the NHS.

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References

Papers of special note have been highlighted as: • of interest
1.
Pordata. Idade média da mãe ao nascimento do primeiro filho. INE - Indicadores Demográficos, Fontes de Dados. www.pordata.pt/portugal/idade+media+da+mae+ao+nascimento+do+primeiro+filho-805 (2020).
2.
Birth rate by country - Thematic Map - Europe. https://www.indexmundi.com/map/?v=25&r=eu&l=en (2020).
3.
Pordata. Saldos populacionais anuais: total, natural e migratório. INE - Estatísticas de Nados-Vivos; INE - Estimativas Anuais da População Residente; INE - Estatísticas de Óbitos, Fontes de Dados. www.pordata.pt/portugal/saldos+populacionais+anuais+saldo+total++saldo+natural+e+saldo+migratorio-657 (2020).
4.
Conselho Nacional De Procriação Medicamente Assistida (CNPMA). Relatório - Atividade Desenvolvida pelos Centros de PMA em 2017. www.cnpma.org.pt/cnpma/Paginas/Relatorios-da-Atividade-em-pma.aspx (2021).
• Report developed from The National Council for Medically Assisted Procreation (CNPMA) detailing various trends and practice results in Portugal. This was used to both develop the model structure and clinical care pathway, as well as populate data elements.
7.
Direção-Geral da Saúde (DGS) Norma nº 003/2011 de 19/01/2011 - Conduta em Infertilidade. www.dgs.pt/directrizes-da-dgs/normas-e-circulares-normativas/norma-n-0032011-de-19012011.aspx (2020).
8.
NICE - National Institute for Health and Care Excellence. Guidance - Fertility problems: assessment and treatment. www.nice.org.uk/guidance/cg156 (2020).
9.
Associação Portuguesa de Fertilidade (APF). Conceber: guia para profissionais e pessoas com problemas de fertilidade. www.apf.pt/sites/default/files/media/2015/conceber_guia_infertilidade.pdf (2020).
10.
World Health Organization (WHO) - IRIS. Family planning: a global handbook for providers. update: evidence-based guidance developed through worldwide collaboration. https://apps.who.int/iris/handle/10665/44028 (2011).
11.
Associação Portuguesa de Fertilidade (APF). Infertilidade. https://apfertilidade.org/infertilidade/ (2020).
12.
Carlsson IB, Scott JE, Visser JA, Ritvos O, Themmen APN, Hovatta O. Anti-Müllerian hormone inhibits initiation of growth of human primordial ovarian follicles in vitro. Hum. Reprod. 21(9), 2223–2227 (2006).
13.
Dewailly D, Andersen CY, Balen A et al. The physiology and clinical utility of anti-Mullerian hormone in women. Hum. Reprod. Update 20(3), 370–385 (2014).
14.
La Marca A, Broekmans FJ, Volpe A, Fauser BC, Macklon NS, Reprodu ESIG. Anti-Mullerian hormone (AMH): what do we still need to know? Hum. Reprod. 24(9), 2264–2275 (2009).
15.
Committee ACOOaGCOGPaP. Female age-related fertility decline. Committee Opinion No. 589. Fertil. Steril. 101(3), 633–634 (2014).
16.
Hansen KR, Knowlton NS, Thyer AC, Charleston JS, Soules MR, Klein NA. A new model of reproductive aging: the decline in ovarian non-growing follicle number from birth to menopause. Hum. Reprod. 23(3), 699–708 (2008).
17.
Heffner LJ. Advanced maternal age–how old is too old? N. Engl. J. Med. 351(19), 1927–1929 (2004).
18.
Mills M, Rindfuss RR, Mcdonald P, Te Velde E. Force ERaST. Why do people postpone parenthood? Reasons and social policy incentives. Hum. Reprod. Update 17(6), 848–860 (2011).
19.
Modi D, Bhartiya D, Puri C. Developmental expression and cellular distribution of Mullerian inhibiting substance in the primate ovary. Reproduction 132(3), 443–453 (2006).
20.
Igarashi H, Takahashi T, Nagase S. Oocyte aging underlies female reproductive aging: biological mechanisms and therapeutic strategies. Reprod. Med. Biol. 14(4), 159–169 (2015).
21.
Instituto Nacional de Estatística (INE). Estimativas anuais da população residente. https://www.ine.pt/xportal/xmain?xpid=INE&xpgid=ine_indicadores&indOcorrCod=0008273&xlang=pt (2019).
22.
Roche Diagnostics Portugal. Internal data, unpublished results. (2020).
• The unpublished results, housed internally at Roche Diagnostics Portugal, of a survey that had been previously conducted on 300 women, aged 25–30 years, randomly selected from an online access panel. This data was used to model the decision-making process of a woman's willingness to undergo the AMH test, along with the potential impact that the results could have on fertility choices and family planning.
23.
Administração Central Do Sistema De Saúde (ACSS). Circular Normativa nº15/2019. www.acss.min-saude.pt/2016/11/24/circulares-normativas/ (2020).
24.
Diário Da República Eletrónico (DRE). Lei n.º 17/2016, de 20 de Junho - Procriação medicamente assistida. https://dre.pt/dre/analise-juridica/lei/17-2016-74738646 (2020).
• National Portuguese legislation/fee schedule used to estimate the line item costs for the various healthcare resources used in the model.
25.
Healthnews. Portugal sem resposta eficaz para casos de infertilidade. https://healthnews.pt/2020/05/19/portugal-sem-resposta-eficaz-para-casos-de-infertilidade/ (2021).
26.
HealthNews. Associação Portuguesa de Fertilidade quer 45 anos como limite para fertilização in vitro. https://healthnews.pt/2020/07/23/associacao-quer-45-anos-como-limite-para-fertilizacao-in-vitro/ (2021).
27.
Diário de Notícias. Centros públicos com dois anos de atraso nos tratamentos de fertilidade. www.dn.pt/sociedade/centros-publicos-com-dois-anos-de-atraso-nos-tratamentos-de-fertilidade-13333723.html (2021).
28.
Rasool S, Shah D. Fertility with early reduction of ovarian reserve: the last straw that breaks the Camel's back. Fertil. Res. Pract. 3(1), 15 (2017).
29.
Reichman DE, Goldschlag D, Rosenwaks Z. Value of antimüllerian hormone as a prognostic indicator of in vitro fertilization outcome. Fertil. Steril. 101(4), 1012–1018.e1011 (2014).
30.
Kedem A, Haas J, Geva LL et al. Ongoing pregnancy rates in women with low and extremely low AMH levels. A multivariate analysis of 769 cycles. PloS One 8(12), e81629 (2013).
31.
La Marca A, Sighinolfi G, Radi D et al. Anti-Mullerian hormone (AMH) as a predictive marker in assisted reproductive technology (ART). Hum. Reprod. Update 16(2), 113–130 (2010).
32.
Lin P-Y, Huang F-J, Kung F-T et al. Evaluation of serum anti-mullerian hormone as a biomarker of early ovarian aging in young women undergoing IVF/ICSI cycle. Int. J. Clin. Exp. Pathol. 7(9), 6245–6253 (2014).
33.
Lukaszuk K, Kunicki M, Liss J, Bednarowska A, Jakiel G. Probability of live birth in women with extremely low anti-Müllerian hormone concentrations. Reprod. Biomed. Online 28(1), 64–69 (2014).
34.
Sefrioui O, Madkour A, Aboulmaouahib S, Kaarouch I, Louanjli N. Women with extreme low AMH values could have in vitro fertilization success. Gynecol. Endocrinol. 35(2), 170–173 (2019).
35.
Weghofer A, Dietrich W, Barad DH, Gleicher N. Live birth chances in women with extremely low-serum anti-Mullerian hormone levels. Hum. Reprod. 26(7), 1905–1909 (2011).
36.
Direção-Geral da Saúde(DGS). Programa Nacional para as Doenças Oncológicas - Relatório. https://comum.rcaap.pt/bitstream/10400.26/15554/1/d190354.pdf (2015).
37.
Serviço Nacional de Saúde (SNS). Relatório Anual - Acesso a Cuidados de Saúde nos Estabelecimentos do SNS e Entidades Convencionadas. www.sns.gov.pt/wp-content/uploads/2020/09/Relatorio_Anual_Acesso_2019.pdf ( 2021).
38.
Mascarenhas MN, Flaxman SR, Boerma T, Vanderpoel S, Stevens GA. National, regional, and global trends in infertility prevalence since 1990: a systematic analysis of 277 health surveys. PLOS Med. 9(12), e1001356 (2012).