Health system level microcosting of infertility management in India: a retrospective cross-sectional study

Abstract

Objectives

This study estimates the cost of managing infertility, including intrauterine insemination (IUI) from health system perspective in India.

Design

This was a retrospective cross-sectional microcosting study using mixed approach. Unit costs were estimated at the cost-centre level based on average resource utilisation and aggregated by facility type and cause of infertility. The cost data was collected for the year 2022–2023 and adjusted for inflation in 2025.

Setting

The study was conducted at five healthcare facilities providing infertility services, of which three were public and two were private hospitals situated in different parts of country.

Participants

The cost data was collected from different departments of hospitals. To determine the service utilisation, 100 infertility patients were enrolled at each hospital. Patients undergoing infertility treatment (including IUI) for five selected causes of infertility and willing to participate in the study were included.

Primary and secondary outcome measures

The cost of providing infertility treatment for 1 year was the primary outcome measure. The share of different cost-components in the total cost was the secondary outcome measure.

Results

The one-year health system cost of infertility management ranged from INR 5515 (USD 63) to INR 15 139 (USD 173). Median costs were generally higher in public hospitals compared to private hospitals. Outpatient consultations contributed about two-thirds of total costs. The mean cost of one IUI cycle ranged from INR 8272 (USD 94) to INR 8887 (USD 101).

Conclusions

This first-of-its-kind study provides robust evidence on the health system cost of infertility management in India. The findings highlight significant cost variations by infertility cause and facility type, underscoring the need for inclusion of infertility services, particularly IUI, within public health financing packages. These results offer a foundation for future cost-effectiveness analyses and policy decisions related to infertility treatment in India.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• The cost data is collated from both public and private hospitals located across different regions of the country improving the generalisability of cost estimates and their applicability for informing package rates under publicly financed health insurance schemes.

• This detailed microcosting exercise using mixed method approach and standardised prevalidated data collection tools is, to our knowledge, the first of its kind being reported from India.

• In the absence of standard treatment guidelines, costing was based on observed clinical practices and informed by expert opinion, which may introduce interfacility variation.

• The cost estimates are from health system perspective and do not include out of pocket expenditure (OOPE) incurred by couples for some medicines/investigations.

• The estimated costs do not represent the full treatment pathway for individual patients but reflect costs within the observation window which may be driven by their treatment stage and care pathway. Thus, it is difficult to identify clinical characteristics as cost drivers.

Introduction

WHO defines infertility as a disease of the male or female reproductive system defined by the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse.¹ As per National Family Health Survey-5 (NFHS-5) data, the prevalence of infertility in India is 18.7 per 1000 women among those married for at least 5 years and currently in union.²

Any management of infertility patient starts with identifying the cause of infertility followed by treatment of the cause. A number of different factors may cause infertility, in either the male or female reproductive systems. Female factor for infertility contributes to about 46% of all causes of infertility.³ Some of the major causes of female factor infertility are tubal disorders such as blocked fallopian tubes; uterine disorders which could be inflammatory in nature, congenital in nature (such as septate uterus) or benign in nature (such as fibroids); disorders of the ovaries, such as polycystic ovarian syndrome (PCOS), endometriosis and other follicular disorders and disorders of the endocrine system causing imbalances of reproductive hormones. Male factors contribute to about one-third of all cases of infertility either due to poor semen quantity or quality. In one third of cases, it is difficult to explain the causes of infertility. About 10% of infertile couples have both male and female contributory factors.³ Except for the patients with unexplained cause of infertility, treatment of infertility constitutes the treatment of cause of infertility spanning across medical and surgical interventions, ovulation induction and management of coexisting conditions. The next stage of treatment consists of assisted reproductive technology (ART) services. These include intrauterine insemination (IUI) and in vitro fertilisation (IVF) depending on the patient suitability.

Although infertility is one of the important reproductive health problems increasingly faced by couples in India it still does not feature on the public health agenda in India. Thus, these services are rarely covered through public health financing. While some diagnostic and treatment services are provided under the general gynaecology services at public hospitals, availability, access and quality of interventions to address infertility remain a challenge in most public health facilities. Moreover, a lack of trained personnel and the necessary equipment and infrastructure, and the currently high costs of medicines are major barriers even for countries that are actively addressing the needs of people with infertility. ART rules notified under ART (Regulation) Act, 2021 regulates ART clinics and ART practices in India.⁴ Nevertheless, the prices of these services remain unregulated. There is a lack of scientific data to suggest the cost of providing these services in India. This results in huge out-of-pocket expenditure and financial burden on infertile couples. As per a systemic review of financial costs of ART for patients in low- and middle-income countries, medical costs of one ART cycle are significantly higher (166.4%) than patients’ average annual income in India.⁵

As per our knowledge, there is no study in India estimating the health system cost of infertility management in India. This study tries to fill this gap. Such costing data can guide policymakers in evidence-based resource allocation decisions. This paper reports the health system cost of infertility management including IUI. The findings of health system cost of IVF are reported separately. These findings can be further used for economic evaluations of infertility treatments.

Methodology

Study setting

A microcosting study using mixed approach with health system perspective was conducted at five healthcare facilities providing infertility services. The five facilities were selected using a convenience sampling approach, ensuring representation from both public and private sectors across different regions of India. The three public hospitals included Sree Avittom Thirunal (SAT) Hospital in Kerala, Maulana Azad Medical College (MAMC) in Delhi and Post-Graduate Institute of Medical Education and Research (PGIMER) in Chandigarh. The two private hospitals included Jawaharlal Nehru Medical College (JNMC) in Wardha and Sri Ramchandra Institute of Higher Education and Research (SRIHER) in Chennai.

To determine the service utilisation, 100 infertility patients were enrolled at each hospital. Patients undergoing infertility treatment (including IUI) for five selected causes of infertility and willing to participate in the study were included. The five selected causes of infertility included PCOS, endometriosis, tubal factors, uterine factors and male infertility. patients with idiopathic infertility and multiple factors of infertility were excluded from the study as it is difficult to segregate the expenditure for different factors from patients’ perspective. The services used by them along with their frequencies in 1 year were captured through patient interviews and verified from bills/documents available with the patients.

Data collection

Data collection tool was adapted from the pretested prevalidated tool of a national level costing study, that is, Costing of Health Services in India (CHSI).⁶ The cost-centres for infertility services were identified by expert consultation and literature review. The data was collected through personal interviews, administrative records and direct observation from relevant cost-centres. For top-down costing, hospital records were mainly used and for bottom-up costing, personal interviews and direct observations were used to collect the data. Economic costs of resources were considered for data collection. The cost data of 1 year time period was collected starting from 1 April 2022 to 31 March 2023. The data was collected by trained staff and analysed using MS Excel.

Major cost-centres of infertility services included outpatient department (OPD), laboratory, sonography room and wards. The adjoining small cost-centres were grouped under these major centres for analysis. The OPD included the cost-centres of registration room, consultation room, reception area, waiting area, examination room, store room, record room, washrooms and OPD corridors. The cost-centres of semen collection room and semen processing were grouped under the larger category of laboratory. The cost of surgical procedures was taken from the National Health System Cost Database for India.⁷ Across all hospitals, the OPD, sonography units and inpatient wards were integrated within the Department of Gynaecology infrastructure. Two public hospitals operated dedicated weekly clinic hours specifically for infertility services, whereas in the remaining hospitals, patients seeking infertility care were managed within the general gynaecology OPD. While laboratory services were provided through the hospital’s shared laboratory infrastructure, dedicated rooms for semen collection and processing were available exclusively for infertility patients.

Ethical and administrative approvals

Patient information sheets were prepared and translated in local languages. For patient level data, informed consent was taken from the couples after explaining the information sheet. Necessary administrative approvals were taken as per institutional requirements before collecting the hospital level data.

Data analysis

All costs were calculated in Indian National Rupees (INR or Rs.) at 2025 prices. The costs are also converted in US Dollars (USD or $) using the current (August 2025) exchange rate of 87.7 INR per USD. Cost of resources were divided into fixed and variable costs. Fixed costs included the costs that were incurred irrespective of the volume of service users. While variable costs changed with the volume of service delivery in the year. Classification of costs in these two categories is given in table 1. Cost of all the components for any cost-centre was apportioned for infertility patients using different apportioning factors as mentioned in table 1.

Table 1. Apportioning factors for cost-components.

Cost-component	Cost category (fixed/variable)	Apportioning factor
Infrastructure (building/rental cost)	Fixed	Area of the cost-centre
Overheads like electricity, water, phone, internet charges	Variable	Area of the cost-centre
Furniture and fixtures	Fixed	Number of patients
Non-medical equipments	Fixed	Number of patients
Consumables, stationery	Variable	Number of patients
Medical equipments	Fixed	Number of patients
HR	Fixed+variable	Time allocated, number of patients
Medicines	Variable	Mean frequency, procurement price (if available) or IndiaMart price
Lab tests	Variable	Mean frequency, unit costs (from CHSI)

Detailed methodology used for costing of different cost-components and cost-centres is described below.

CHSI, Costing of Health Services in India; HR, human resources.

Human resources (HR)

The cost of human resources (HR) had both fixed and variable cost-components. The HR permanently employed at the institute were considered under fixed cost category while ad hoc HR that were called on a per-service basis were considered as variable. The cost of HR was allocated using mixed approach (top down+bottom up). At cost-centres where HR had fixed hours of service delivery, HR costing was done using top-down approach. For cost-centres where the hours spent on the service delivery were not fixed, HR costing was done using bottom-up approach. The cost of HR paid on a per-case basis was added to relevant cost-centres.

Fixed costs

Infrastructure

The annual rental cost for the area of different cost-centres was used as a proxy for rental cost. Annual expenditure on different overheads like property tax, maintenance cost, phone/electricity/water charges was captured from the hospital records. These expenditures were allocated to different cost-centres using area as the apportioning factor. This apportioned cost was then allocated to service users to derive the unit costs, for example, infrastructure cost per OPD visit.

Furniture and fixtures

The number of furniture and fixture items in each identified cost-centre was captured through observation. Their cost was captured from the administration department. The total cost of furniture and fixtures for each cost-centre was converted to Equivalent Annual Cost using 3% discount rate and 10 years of expected use.

Equipment: medical and non-medical

The total price of the equipment and its expected life were collected from hospital records. Based on this data Equivalent Annual Costs of the Equipment were derived using 3% discount rate. The uses of the equipment were identified to derive the total number of users. Using this denominator, Equivalent Annual Cost per unit of use was derived.

Variable costs

Consumables and stationery

The annual expenditure on consumables and stationery was collected from administrative records. From the total cost of these items for a cost-centre, cost per unit of service use was derived.

Deriving unit cost of 1 year management of infertility

All the apportioned cost-components were summed up to derive the cost of one unit of service delivery at the identified cost-centres, that is, OPD, ultrasonography (USG) room, laboratory and ward. The number of visits made by the couple both for OPD consultation and USG during 1 year was derived from the sample of 100 patients at each hospital. The derived frequency was validated by clinicians at these hospitals. Cost data for inpatient care was considered as 2 bed days. The costs of common lab tests were taken from the CHSI data.⁸

𝑇𝑜𝑡𝑎𝑙 𝑐𝑜𝑠𝑡 𝑜𝑓 𝑚𝑎𝑛𝑎𝑔𝑖𝑛𝑔 𝑠𝑖𝑛𝑔𝑙𝑒 𝑓𝑎𝑐𝑡𝑜𝑟 𝑖𝑛𝑓𝑒𝑟𝑡𝑖𝑙𝑖𝑡𝑦 𝑑𝑢𝑒 𝑡𝑜 𝑋 𝑓𝑜𝑟 1 𝑦𝑒𝑎𝑟 = 𝑓𝑟𝑒𝑞𝑢𝑒𝑛𝑐𝑦 𝑜𝑓 𝑑𝑖𝑎𝑔𝑛𝑜𝑠𝑡𝑖𝑐 𝑡𝑒𝑠𝑡 𝐴, 𝐵, 𝐶 … ∗ 𝑢𝑛𝑖𝑡 𝑐𝑜𝑠𝑡 𝑜𝑓 𝑑𝑖𝑎𝑔𝑛𝑜𝑠𝑡𝑖𝑐 𝑡𝑒𝑠𝑡𝑠 𝐴, 𝐵, 𝐶 … + 𝑓𝑟𝑒𝑞𝑢𝑒𝑛𝑐𝑦 𝑜𝑓 𝑎𝑛𝑦 𝑜𝑡ℎ𝑒𝑟 𝑑𝑖𝑎𝑔𝑛𝑜𝑠𝑡𝑖𝑐 𝑖𝑛𝑡𝑒𝑟𝑣𝑒𝑛𝑡𝑖𝑜𝑛 ∗ 𝑢𝑛𝑖𝑡 − 𝑐𝑜𝑠𝑡 𝑜𝑓 𝑎𝑛𝑦 𝑜𝑡ℎ𝑒𝑟 𝑑𝑖𝑎𝑔𝑛𝑜𝑠𝑡𝑖𝑐 𝑖𝑛𝑡𝑒𝑟𝑣𝑒𝑛𝑡𝑖𝑜𝑛 + 𝑓𝑟𝑒𝑞𝑢𝑒𝑛𝑐𝑦 𝑜𝑓 𝑂𝑃𝐷 𝑣𝑖𝑠𝑖𝑡 ∗ 𝑢𝑛𝑖𝑡 𝑐𝑜𝑠𝑡 𝑜𝑓 𝑂𝑃𝐷 𝑣𝑖𝑠𝑖𝑡 + (𝑝𝑒𝑟 𝑏𝑒𝑑 𝑑𝑎𝑦 𝑐𝑜𝑠𝑡 ∗ 𝑙𝑒𝑛𝑔𝑡ℎ 𝑜𝑓 𝑠𝑡𝑎𝑦)(𝑖𝑓 𝑎𝑝𝑝𝑙𝑖𝑐𝑎𝑏𝑙𝑒) + 𝑐𝑜𝑠𝑡 𝑜𝑓 𝑠𝑢𝑟𝑔𝑒𝑟𝑦 𝑜𝑟 𝑠𝑢𝑟𝑔𝑒𝑟𝑖𝑒𝑠 (𝑖𝑓 𝑎𝑝𝑝𝑙𝑖𝑐𝑎𝑏𝑙𝑒)

The management of infertility, as is currently practised, was captured in the 500 participants of the study. From this data, the frequency of different diagnostic and treatment interventions for management of five factors of infertility for 1 year was derived. Based on this, cost functions were derived for health system costing of infertility services. The data was analysed to derive the mean frequency of service use that was used to derive facility-level cost. Median and IQR (Q1, Q3) were derived from these facility-level costs. The results are aggregated at the level of type of health facility (public/private) and the cause of infertility. The median cost of managing specific fertility factors was stratified between public and private hospitals.

The usual hormone medicines prescribed as a part of infertility management were not available in any public system. Thus, most of the medicines were purchased by patients from the market by spending out of their pockets. The health system cost of infertility management excludes the cost of medicines.

Results

Among all study sites, the average infertility consultation in the year was 16 359 (±6995). A total of 500 participants were enrolled. Among the study participants, 73% had primary infertility and 27% had secondary infertility. On average, patients had been undergoing infertility treatment for 4 (±3) years and had consulted 3 (±2) hospitals for the same. The share of female factor and male factor infertility among them was 80% and 20% respectively. Among those with female factor infertility, 38% had PCOS followed by 22% having tubal factor. Azoospermia accounted for 51% of the male factor infertility.

During the study period, out of total participants enrolled, the causes of infertility (from five specified causes) at five hospitals were as depicted in table 2. Majority (38%) were PCOS cases.

Table 2. Causes of infertility among the participants (infertility).

Factor of infertility	PGIMER	MAMC	SAT	JNMC	SRIHER	Total number (n=500)	%
Endometriosis	10	4	22	9	8	53	10.6
Tubal block	21	46	4	32	6	109	21.8
Uterine factor	12	8	7	9	14	50	10
PCOS	41	41	44	25	39	190	38
Male infertility	16	1	23	25	33	98	19.6

JNMC, Jawaharlal Nehru Medical College; MAMC, Maulana Azad Medical College; PCOS, polycystic ovarian syndrome; PGIMER, Post-Graduate Institute of Medical Education and Research; SAT, Sree Avittom Thirunal; SRIHER, Sri Ramchandra Institute of Higher Education and Research.

The cost of management of infertility for 1 year ranged between Rs. 1711 ($ 20) and Rs. 17 595 ($ 201) with median cost at Rs. 7513 (IQR: 4015–10 625) ($ 86 (IQR: 46–121)). Table 3 presents the cost estimates across the five study hospitals as well as stratified by hospital type.

Table 3. Health system cost of management of infertility stratified by hospital type.

	PGIMER Mean (range)	MAMC Mean (range)	SAT Mean (range)	JNMC Mean (range)	SRIHER Mean (range)	Public hospitals Median (IQR: 25%, 75%) (n=300)	Private hospitals Median (IQR: 25%, 75%) (n=200)	All sites Median (IQR: 25%, 75%) (n=500)
Endometriosis (n=53)	Rs. 3426 (3319)	Rs. 11 841 (6136)	Rs. 8089 (8278)	Rs. 7513 (5244)	Rs. 9245 (3812)	Rs. 8085 (5755, 9961)  $92 (65, 113)	Rs. 8376 (7943, 8810)  $95 (90, 100)	Rs. 8089 (7513, 9245) $92 (86, 106)
Tubal block (n=109)	Rs. 3008 (3160)	Rs. 13 941 (8147)	Rs. 7168 (6474)	Rs. 5078 (5011)	Rs. 9309 (4071)	Rs. 7166 (5086, 10 550)  $82 (58, 120)	Rs. 7191 (6134, 8248)  $82 (70, 94)	Rs. 7168 (5078, 9309) $82 (58, 106)
Uterine factor (n=50)	Rs. 3078 (3024)	Rs. 15 145 (6715)	Rs. 17 595 (22836)	Rs. 3398 (4460)	Rs. 9513 (4967)	Rs. 15 139 (9108,16363)  $172 (104, 186)	Rs. 6453 (4925, 7981)  $74 (56, 91)	Rs. 9513 (3398, 15145) $109 (39, 173)
PCOS (n=190)	Rs. 1711 (2418)	Rs. 13 588 (10403)	Rs. 12 952 (10577)	Rs. 5060 (5467)	Rs. 8511 (4839)	Rs. 12 947 (7329, 13 265)  $148 (84, 151)	Rs. 6782 (5920, 7646)  $77 (67, 87)	Rs. 8511 (5060, 12952) $97 (58, 148)
Male infertility (n=98)	Rs. 3945 (7545)	Rs. 10 625 (10 625)	Rs. 7493 (5705)	Rs. 4015 (5380)	Rs. 7020 (3708)	Rs. 7490 (5717, 9056)  $85 (65, 103)	Rs. 5515 (4764, 6266)  $63 (54, 71)	Rs. 7020 (4015, 7493) $80 (46, 86)

JNMC, Jawaharlal Nehru Medical College; MAMC, Maulana Azad Medical College; PCOS, polycystic ovarian syndrome; PGIMER, Post-Graduate Institute of Medical Education and Research; SAT, Sree Avittom Thirunal; SRIHER, Sri Ramchandra Institute of Higher Education and Research.

As evident from the results, the cost of infertility treatment for 1 year is higher in public hospitals for most factors of infertility. The wide range of cost is due to variations in the management of patients based on the cause of infertility. Among the overall median cost, OPD consultations constituted 67% (±2%) and diagnostics constituted 33% (±2%) of the total. Figure 1 presents the average frequency of utilisation of key services for infertility management across different causes. The ‘procedures’ constitute any minor or major surgical procedures for the treatment of infertility. Category of ‘lab tests’ include all blood/urine/semen tests while ‘other diagnostics’ comprise sonography, sonohysterography, MRI and other such diagnostics. Outpatient consultations constituted the highest frequency of service use, followed by laboratory investigations and other diagnostic procedures. The utilisation of surgical procedures was comparatively low across all infertility conditions. The cost of surgery along with cost of in-patient days (bed-days) is mentioned separately. These costs will be incurred only for the patients undergoing these surgical procedures.

Figure 1. Frequency of service utilisation in 1 year. The mean number of utilisations of different services was stratified by factor of infertility. Consultations and lab tests constitute the majority of services used by infertility patients. Since very few patients in the sample underwent procedures in the study period, its mean frequency is 0. PCOS, polycystic ovarian syndrome.

Among the study participants, 16% of all tubal block patients underwent tuboplasty as part of infertility management. For them, the additional cost of surgery along with bed- days comes at median (IQR) Rs. 12 828 ($146). For uterine factor, 12% of patients underwent myomectomy, which will amount to an additional median (IQR) cost of Rs. 17 616 ($201). Around 12% of patients with PCOS underwent laparoscopic ovarian drilling, which will lead to additional cost of median (IQR) Rs. 14 018 ($160).

Figure 2 presents the share of different cost-components contributing to the total cost of infertility management across the five study hospitals. HR constituted the largest share across all facilities (~63%–83%), followed by infrastructure (~4%–26%) and medical equipment (~1%–15%). Public hospitals were characterised by a higher share of infrastructure and HR costs, whereas private hospitals had a relatively greater contribution from medical equipment and consumables.

Figure 2. Share of cost components as per type of facility. Share of different cost components in the total cost of infertility treatment is stratified by study hospitals and type of hospital. Across all hospitals, human resources constituted the largest share of total cost. HR, human resources.

Table 4 presents the Spearman rank correlations and simple linear regression results for different services as a predictor of total treatment cost. All four service groups demonstrated highly significant associations with total cost (all p<0.001). Consultations exhibited the strongest relationship (ρ=0.792; R²=0.535), explaining 53.5% of the variance in total expenditure. Diagnostics ranked second (R²=0.353), followed by procedures (R²=0.320) and laboratory tests (R²=0.233). An additional Kruskal-Wallis analysis was performed to determine which services varied significantly by infertility cause. Diagnostics (H=37.66, p<0.001) and procedures (H=22.09, p<0.001) showed highly significant between-group variation. In contrast, consultations (H=7.01, p=0.135) and laboratory tests (H=6.60, p=0.159) did not vary significantly across groups. This finding reveals an important distinction: while consultations are the strongest overall cost driver (R²=0.535), they do not vary by diagnosis. Infertility cause-specific cost differences are driven by diagnostics and procedures, whereas consultations drive overall cost magnitude irrespective of aetiology.

Table 4. Determinants of total treatment cost.

Component	Spearman ρ	Strength	R²	β	F-statistic	P value
Consultations	0.792	Strong	0.535	1.356	571.88	<0.001
Diagnostics	0.528	Moderate	0.353	1.800	271.45	<0.001
Procedures	0.510	Moderate	0.320	1.107	233.87	<0.001
Lab Tests	0.624	Moderate	0.233	1.922	150.97	<0.001

Note: All associations significant at p<0.001. R² from simple linear regression (each component as sole predictor). Ranked by R².

64.8%of our participants had undergone IUI. The patients underwent average two cycles of IUI. The cost of one cycle of IUI ranged from Rs. 8272 ($94) and Rs. 8887 ($101). The median costs (IQR) in public and private hospitals respectively were Rs. 17 084 (16 581, 23 063) ($195 (189 264)) and Rs. 10 343 (9212, 11 474) ($118 (105 131)). For patients undergoing IUI, this will be an additional health system cost for infertility treatment. In the cost of IUI, sonography constituted 71%, medicines 18%, consumables 7% and human resources cost constituted 4% of the total cost. IUI, intrauterine insemination.

Discussion

This is the first study to estimate the cost of infertility management from health system perspective in India. The study provides valuable information regarding cost of infertility management in tertiary healthcare facilities in India. The present study is a part of larger study that aimed to estimate the cost of diagnosis of infertility and its management including IVF and quality of life among infertile couples in India.

The results show that infertility treatment takes years and couples visit multiple hospitals in the course of this treatment. This suggests that infertility treatment must have a huge financial burden on couples and their families through direct and indirect expenditures. As per a systematic review of financial costs of ART for patients in low- and middle-income countries, medical costs of one ART cycle are significantly higher (166.4%) than patients’ average annual income in India.⁵

Infertility is a very patient-centric treatment guided by parameters like factor(s) of infertility, age, pre-existing comorbidities, and couple choices among others. Thus, it is difficult to expect a standardised treatment for patients with same causes of infertility. But this paper gives an estimate of the services that constitute the majority share of infertility treatment.

Among the participants, PCOS was the most common cause of infertility followed by tubal factor. This matches with the available evidence from a tertiary care centre in India that found PCOS to be the leading cause of infertility among infertile patients.³ This highlights the need to focus on treating the causes of infertility before focusing on more technologically advanced options like IVF. Ensuring the treatment of infertility factors at primary and secondary levels of care will also ease the burden of infertility treatment on patients. Moreover, focusing on treatment of causes of infertility does not require any additional infrastructure or manpower as these services are already being provided in all tertiary hospitals of India. But providing these services at primary and secondary levels will reduce the overall economic burden of healthcare systems towards infertility treatment by cost-saving in avoidable IVF cycles.

The results provide insights into the cost structure of infertility management. The high frequency of outpatient consultations and diagnostic investigations, coupled with their substantial contribution to total costs, indicates that infertility care is predominantly outpatient- and monitoring-intensive rather than procedure-driven. This reflects the iterative nature of infertility treatment, which requires repeated clinical evaluations, hormonal monitoring and imaging over extended periods. The relatively lower contribution of surgical procedures to overall costs suggests that, although clinically important for selected patients, they are not the primary drivers of resource utilisation at the population level.

Our findings regarding the dominance of outpatient consultations and diagnostic services in the overall cost structure of infertility care are consistent with evidence from other settings. A study on the cost burden of male infertility reported that repeated outpatient visits and laboratory investigations constitute a substantial component of total expenditure, reflecting the investigation-intensive nature of infertility management.⁹ Similarly, a time-driven activity-based costing study from the Netherlands found that laboratory tests accounted for the largest share of the total cost of an IUI cycle, despite differences in costing methodology and healthcare delivery context.¹⁰ These findings have important policy implications, as improving efficiency in outpatient and diagnostic services—such as through standardised treatment protocols or rationalised follow-up schedules—could significantly reduce overall costs of infertility care within the health system.

In addition to public–private differences, substantial heterogeneity in cost estimates and composition was observed across facilities, reflecting variations in service delivery, resource utilisation and infrastructure. Public hospitals were driven by HR and infrastructure costs, suggesting underutilisation, whereas private hospitals showed higher contributions from consumables and diagnostics, indicating more intensive service use. This variability, compounded by non-standardised treatment practices and 1 year cross-sectional data, highlights the need for national guidelines to improve efficiency and reduce cost variation across settings.

Despite revolutionary advances like IVF, still IUI remains an inexpensive, non-invasive and effective first line therapy for selected patients with cervical factor, moderate male factor, unexplained infertility, immunological infertility. The cost of IUI derived from the study is significantly lower than the cost of IVF. Studies from many countries suggest IUI before IVF is a cost-effective approach.¹¹ One observational retrospective study from UK compared the success rates, associated risks and cost-effectiveness between IUI and IVF. The study found IUI to be more cost-effective in delivering one live birth and associated with lower risk of maternal and neonatal complications.¹² Further cost-effectiveness studies will be required to derive the number of IUI cycles before IVF that will be cost-effective in Indian context.

Our results show that for majority of factors of infertility, the health system cost in public hospitals is higher than that of private hospitals. One multisite costing study (CHSI) also had similar finding.¹³ This might be due to differences in efficiency of resource utilisation in both the settings especially of HR and infrastructure. This difference can also be due to different rates of service utilisation in both the settings. Such differences in healthcare delivery systems should be considered while conducting any cost-effectiveness study.

Fertility treatments present a challenge for health economists and policymakers in determining whether they offer good value for money compared with alternative allocations of healthcare resources. But countries such as UK are recognising that under most clinically appropriate circumstances access to ART treatment represents good value for money from a societal perspective.¹⁴

There are no standard treatment guidelines for infertility treatment in India. As a result, it is difficult to estimate the quality of treatment in the study. We noticed significant differences in the clinical treatment practices across study sites. In view of lack of standardised guidelines, we have costed the services as is practised at the study sites. Moreover, the cost estimates do not include the cost of medicines as most of the medicines were purchased from the market by spending out of their pockets. The estimated costs do not represent the full treatment pathway for individual patients but reflect costs within the observation window which may be driven by their treatment stage and care pathway. Studies with longitudinal data are needed to identify clinical characteristics as cost drivers of infertility treatment.

Conclusion

The health system cost of infertility management varies across the causes of the infertility. The study findings provide useful insights to policymakers while considering infertility treatment including IUI for public health insurance packages. The results can be an important resource for researchers to conduct economic evaluations on infertility treatment, technologies or pathways.

Data availability statement

Data are available upon reasonable request.