Given the annual publicly funded utilization of infertility treatment in Hungary, the prevalence of female infertility was estimated to be 5.1%. The annual health insurance expenditure on certain disorders demanded 7.2 billion HUF (21.8 million EUR), which represented a 5.8% market share of the total health insurance expenditure in 2019 in Hungary.
A total of 92,709 female patients diagnosed with infertility received public healthcare services. However, it is important to highlight that there might be an extensive difference between the number of patients affected by infertility and the number of patients who receive therapy. As international studies show, only 58% of infertility patients undergo infertility treatment. [36–39] In Hungary, there are no publicly available databases on private health service utilization, but it is important to note that the use of gynecological services is one of the highest among the utilization of private medical care. [40]
Studies have reported an overall prevalence of infertility of 24.6% among women aged 20–40 years in a certain province of China [41], while in the UK, infertility is diagnosed in approximately 12.5% of women aged 16–74 years. [42] In Hungary, similar to Western European countries, more than 10% of couples of reproductive age face infertility problems. [43] International findings show that the number of patients affected by infertility is increasing year by year. [44]
In terms of the analyzed disorders, “female infertility, unspecified” (ICD N97.9) was the most common in the study population, which correlates with the results of other international studies. [45, 46] The experience of clinical practice confirms that these Hungarian claims data do not cover all gynecological diagnoses and report lower claims for the prevalence of infertility involving a specific female organ (N97.4, N97.3, N97.2, N97.1, N97.0) compared to previous studies on a similar topic. [47] This may be due to coding bias or a lower number of targeted medical imaging and laboratory tests (e.g., transvaginal ultrasound), which provide detailed information on the pelvic organs and could contribute significantly to an accurate diagnosis.
Patients are often faced with the fact that the cause of infertility remains unknown. [48] Infertility increases steadily with age and is twice as likely to occur above the age of 35 years in those cases where the cause is still unknown. [49] Our study partially confirms this finding, as women aged 30–39 years are the most affected by this diagnosis in our sample, with a more than 2.5 times higher number of registered cases in this age group than in the 20–29 age group.
Pathology-induced utilization was most prevalent in outpatient care (n = 33,151; 37.8%). The following types of services were registered in outpatient care: gynecological examination, consultation, genetic counseling, and reproductive procedures. Almost a quarter of the patient population received drug treatment (n = 21,624; 23.3%), which was below the ratio in other nations. [50] Higher utilization rates were recorded for pharmaceutical utilization compared to the patient flow in inpatient care: 12.2 times for “female infertility associated with anovulation” (ICD N97.0) and 3.1 times for “female infertility of uterine origin” (ICD N97.2), while for “female infertility, unspecified” (ICD N97.9) and “infertility of other origins” (ICD N97.8) had 2.1 times higher utilization rates for pharmaceutical subsidies.
Among our sample, only 16.7% of patients treated for infertility had a laboratory test performed. From this viewpoint, the Hungarian treatment pattern is underused, as other publications report a significantly higher rate of laboratory diagnostics. [46]
The use of general practitioner consultations and treatments was rather low in our sample, with only 12.6% of the patients visiting their doctors (n = 11,702). General practitioners, who are the most familiar with patients' medical history, have an important role in the timely initiation of patient investigations and referral to specialist clinics, as they have a key gatekeeper function in the provision of medical care [51, 52]. Furthermore, in contrast to international studies, no significant correlation could be captured between the number of cases and the mean age of patients for general practitioner care, but as with laboratory diagnostics, the number of cases per patient is higher in older patients than in younger patients. [53]
The mean expenditure related to inpatient care and pharmaceutical utilization per patient is correlated with the costs of similar treatment in Western European countries. A similar expenditure in terms of the average per capita cost of pharmaceutical care (1,182 USD/patient, 1,055 EUR /patient) was reported by Katz. [54]
A significant part of the treatment cost was linked to inpatient care and the utilization of pharmaceuticals worldwide [35]. Hungary follows a similar pattern, with inpatient care and medicaments accounting for a significant share of expenditure on infertility. The market share of the annual expenditure related to inpatient care and pharmaceuticals was 94.6%, which accounted for 21 million EUR on an annual basis.
ART interventions, which represent the cost-demanding treatment of infertility, currently play a key role in the treatment of the disorder. [55] A survey among OECD countries shows that the cost of IVF procedures varies considerably between countries, which is closely linked to the specificities of their healthcare systems. In Hungary, the cost of IVF procedures is significantly lower than that in the United States (HUN is approximately 3,800 USD/cycle, while in the US, it is approximately 13,000 USD/cycle). The cost of ART treatments in Hungary is 70% cheaper than in the US and 10–15% lower than in Western Europe [56]. The average cost of inpatient care reimbursement for an IVF cycle in Hungary is 1,638 EUR/cycle, which is below the expenditure levels for interventions in the US and the UK as well. [57]
In many Western societies, there is a growing pattern of postponing childbearing, with the proportion of women planning to have children after the age of 35 rising steadily. The trend also has a significant economic impact, with the increase in maternal age leading to a significant increase in healthcare expenditure. [58] In the early 2000s, more than 60% of the patients treated in infertility centers were women under 30 years of age, while today, the highest utilization of infertility treatment is among women aged between 30–49 years. [59, 60]
Reproductive techniques are constantly evolving worldwide, while access to high-quality care is clearly improving. These components might even have the potential to create a false sense of security among members of the population in postponing the timing of childbearing. [61] Nevertheless, it is also important to emphasize that age is one of the most significant determinants, which might play a remarkable role in affecting the probability of both natural conception and successful pregnancy through reproductive procedures. [62, 63]. The prevalence of infertility and the use of associated gynecological interventions and the number of cases per patient correlate with patient age. [54]
Our results and international publications also highlight that the prevalence of infertility is multiplying above the age of 30 years. [64] In European countries, the prevalence of female infertility ranges from 6.6–16.7%. The prevalence of infertility in India is 8.9% among women of reproductive age and 13.1% in China. [65, 66] Our study shows that Hungary is one of the countries with a prevalence of infertility in the lower third among European countries (5.1%).
The number of couples affected by infertility is increasing worldwide, making reproductive healthcare a necessity in an increasing number of countries. Reproductive healthcare can also be part of primary care, initially targeting the young population with a preventive approach. Prevention has particular importance in this regard to ensure patients’ awareness of regular screening and eliminate external factors that impair reproductive capacity before childbearing. [67, 68, 69]
The study has several limitations. Firstly, our research database did not include information on cases provided by private healthcare facilities. These data are not available publicly in Hungary. Given the lack of data, it was not possible to analyze the utilization and expenditures related to private healthcare, which may be of considerable interest to the international audience. If we had data from the utilization in private healthcare, we would have assumed that the number of cases would have increased significantly.
Secondly, the study database did not contain information about the out-of-pocket expenditures of patients who received publicly funded infertility treatment. Thirdly, the data did not contain information about sick leave related to infertility, which has direct and indirect costs for both the patient and the society level.