The combined effect of age and basal follicle-stimulating hormone on the cost of a live birth at assisted reproductive technology

When is clomiphene or gonadotropin intrauterine insemination futile? Results of the Fast Track and Standard Treatment Trial and the Forty and Over Treatment Trial, two prospective randomized controlled trials

OBJECTIVE

To determine whether day 3 FSH and E2 levels at the upper limits of normal affect live-birth rates and treatment trajectory in a conventional versus "fast track" treatment program for IVF.

DESIGN

Secondary analysis of two randomized controlled trials, FASTT and FORT-T.

SETTING

Not applicable.

PATIENT(S)

Infertile women ages 21-42 years randomized to conventional or accelerated treatment with controlled ovarian hyperstimulation (COH)-IUI and/or IVF (n=603 patients contributing 2,717 total cycles).

INTERVENTION(S)

Patients were stratified according to basal FSH and E2: FSH<10 mIU/mL and E2<40 pg/mL (group 1A), FSH<10 mIU/mL and E2≥40 pg/mL (group 1B), FSH, 10-15 mIU/mL and E2<40 pg/mL (group 2A), and FSH, 10-15 mIU/mL and E2≥40 pg/mL (group 2B).

MAIN OUTCOME MEASURE(S)

Number of cancelled cycles, disenrollment for poor response, and cumulative live-birth rates per couple.

RESULT(S)

Women in groups 2A and 2B were more likely to have cancelled cycles and be disenrolled for poor response. While no live births occurred in group 2B during COH-IUI (0/19 couples, 0/58 cycles), IVF still afforded these patients a reasonable chance of success (6/18 couples, 6/40 cycles, 33.3% live-birth rate per couple). The specificity and positive predictive value of basal FSH of 10-15 mIU/mL and E2≥40 pg/mL for no live birth during COH-IUI treatment were both 100%.

CONCLUSION(S)

Women who initiated infertility treatment with FSH of 10-15 mIU/mL and E2≥40 pg/mL on day 3 testing were unlikely to achieve live birth after COH-IUI treatment.

Expensive but worth it: older parents' attitudes and opinions about the costs and insurance coverage for in vitro fertilization

OBJECTIVE

To describe older parents' attitudes and opinions about the costs and insurance coverage for IVF.

DESIGN

Qualitative interview study.

SETTING

Two Northern California IVF practices.

PATIENT(S)

Sixty women and 35 male partners in which the woman had delivered her first child after the age of 40 years using IVF.

INTERVENTION(S)

Two in-depth interviews over 3 months.

MAIN OUTCOME MEASURE(S)

Thematic analysis of interview transcripts.

RESULT(S)

We found that although the costs of IVF were perceived as high, even by those with insurance or who could afford them, the cost of IVF relative to other expenses in life was dwarfed by the value attributed to having a child. Women were twice as likely as men to support insurance coverage for IVF. Both men and women with complete or partial IVF insurance coverage were more likely to support insurance than those without coverage. There was a broad range of attitudes and opinions about the appropriateness of IVF insurance coverage, which addressed questions of age, gender equality, reproductive choice, whether infertility is a medical illness, and the role of personal and societal economic equity and responsibility.

CONCLUSION(S)

Despite a generally favorable opinion about the appropriateness of insurance coverage by those who have successfully undergone IVF treatment, the affordability of IVF remains an unresolved dilemma in the United States.

Outcome of assisted reproductive technology in women aged 40 years and older

BACKGROUND

Human fertility has been declined all over the world. Advanced women's age is one of the most important factors in determining the success of reproduction and ageing has negative impact on ART outcome and advanced female age decreases the chance of live birth rates achieved using ART, especially after 40 years of age.

OBJECTIVE

To evaluate ART outcomes regarding to pregnancy, abortion, cycle cancellation and live birth rates in women 40 years and older.

MATERIALS AND METHODS

A retrospective study was performed on three hundred-thirteen women undergoing ART cycles in the Madar Hospital in Yazd. Women with age ≥ 40 years who indicated for ART enrolled the study regardless of the infertility type or etiology. In this study, we used data from IVF or ICSI cycles using fresh embryo transfer. Follow up was performed in regard to pregnancy, abortion, cycle cancellation and live birth rates.

RESULTS

The mean age of women was 41.87±1.97 years. Chemical pregnancy rate was 8.6% (27/313) per cycle. Clinical pregnancy rate was 3.8% (12/313) per cycle. Spontaneous abortion was observed in 63% (17/27) of patients with positive pregnancy test. The overall cancellation rate was 23.3% per oocytes retrieval. The overall live birth rate per cycle for all women who initiated an ART cycle at age ≥40 years was 3.2% (10/313) that eight of those women were under 42 years old.

CONCLUSION

Based on our results, we suggest that women with age 42 years and above should be advised to use other options, including oocyte donation or adoption.

The costs and consequences of assisted reproductive technology: an economic perspective

BACKGROUND

Despite the growing use of assisted reproductive technologies (ART) worldwide, there is only a limited understanding of the economics of ART to inform policy about effective, safe and equitable financing of ART treatment.

METHODS

A review was undertaken of key studies regarding the costs and consequences of ART treatment, specifically examining the direct and indirect costs of treatment, economic drivers of utilization and clinical practice and broader economic consequences of ART-conceived children.

RESULTS

The direct costs of ART treatment vary substantially between countries, with the USA standing out as the most expensive. The direct costs generally reflect the costliness of the underlying healthcare system. If unsubsidized, direct costs represent a significant economic burden to patients. The level of affordability of ART treatment is an important driver of utilization, treatment choices, embryo transfer practices and ultimately multiple birth rates. The costs associated with caring for multiple-birth ART infants and their mothers are substantial, reflecting the underlying morbidity associated with such pregnancies. Investment analysis of ART treatment and ART-conceived children indicates that appropriate funding of ART services appears to represent sound fiscal policy.

CONCLUSIONS

The complex interaction between the cost of ART treatment and how treatments are subsidized in different healthcare settings and for different patient groups has far-reaching consequences for ART utilization, clinical practice and infant outcomes. A greater understanding of the economics of ART is needed to inform policy decisions and to ensure the best possible outcomes from ART treatment.

Ultrasound tests of ovarian reserve; a systematic review of accuracy in predicting fertility outcomes

We conducted a systematic review of studies evaluating the diagnostic accuracy of all the ultrasound based tests of ovarian reserve, including antral follicle count (AFC), ovarian volume and stromal blood flow in predicting fertility outcomes and, where appropriate, performed a meta-analysis to determine the predictive_value at each cut-off value described in the literature. Included in the analysis were 17 studies for AFC, six studies for ovarian volume and six studies for stromal blood flow. Meta-analyses showed that women with AFC less than four were 8.7 times more likely not to get pregnant after IVF (two studies; 95% CI, 2.4-31.7) than women with AFC four or more. The sensitivity and specificity of AFC to predict cycle cancellation was 66.7% and 94.7%, respectively. Women with an AFC of less than four were 37 times (two studies; 95% CI, 13.68-100.45) more likely to have their cycle cancelled than women with AFC of four o r more. Ovarian volume measurement, at a cut off value of 3 cm3, showed specificity for prediction of cycle cancellation and non-pregnancy of 92% (three studies, 95% CI, 89-94) and 93% (three studies, 95% CI, 87-97), respectively. The clinical value of Doppler studies for ovarian stromal blood flow was unclear.

Ovarian aging: mechanisms and clinical consequences

Menopause is the final step in the process referred to as ovarian ageing. The age related decrease in follicle numbers dictates the onset of cycle irregularity and the final cessation of menses. The parallel decay in oocyte quality contributes to the gradual decline in fertility and the final occurrence of natural sterility. Endocrine changes mainly relate to the decline in the negative feedback from ovarian factors at the hypothalamo-pituitary unit. The declining cohort of antral follicles with age first results in gradually elevated FSH levels, followed by subsequent stages of overt cycle irregularity. The gradual decline in the size of the antral follicle cohort is best represented by decreasing levels of anti-Mullerian hormone. The variability of ovarian ageing among women is evident from the large variation in age at menopause. The identification of women who have severely decreased ovarian reserve for their age is clinically relevant. Ovarian reserve tests have appeared to be fairly accurate in predicting response to ovarian stimulation in the assisted reproductive technology (ART) setting. The capacity to predict the chances for spontaneous pregnancy or pregnancy after ART appears very limited. As menopause and the preceding decline in oocyte quality seem to have a fixed time interval, tests that predict the age at menopause may be useful to assess individual reproductive lifespan. Especially genetic studies, both addressing candidate gene and genome wide association, have identified several interesting loci of small genetic variation that may determine fetal follicle pool development and subsequent wastage of his pool over time. Improved knowledge of the ovarian ageing mechanisms may ultimately provide tools for prediction of menopause and manipulation of the early steps of folliculogenesis for the purpose of contraception and fertility lifespan extension.

Individual patient data meta-analysis of diagnostic and prognostic studies in obstetrics, gynaecology and reproductive medicine

Background

In clinical practice a diagnosis is based on a combination of clinical history, physical examination and additional diagnostic tests. At present, studies on diagnostic research often report the accuracy of tests without taking into account the information already known from history and examination. Due to this lack of information, together with variations in design and quality of studies, conventional meta-analyses based on these studies will not show the accuracy of the tests in real practice. By using individual patient data (IPD) to perform meta-analyses, the accuracy of tests can be assessed in relation to other patient characteristics and allows the development or evaluation of diagnostic algorithms for individual patients.

In this study we will examine these potential benefits in four clinical diagnostic problems in the field of gynaecology, obstetrics and reproductive medicine.

Methods/design

Based on earlier systematic reviews for each of the four clinical problems, studies are considered for inclusion. The first authors of the included studies will be invited to participate and share their original data. After assessment of validity and completeness the acquired datasets are merged. Based on these data, a series of analyses will be performed, including a systematic comparison of the results of the IPD meta-analysis with those of a conventional meta-analysis, development of multivariable models for clinical history alone and for the combination of history, physical examination and relevant diagnostic tests and development of clinical prediction rules for the individual patients. These will be made accessible for clinicians.

Discussion

The use of IPD meta-analysis will allow evaluating accuracy of diagnostic tests in relation to other relevant information. Ultimately, this could increase the efficiency of the diagnostic work-up, e.g. by reducing the need for invasive tests and/or improving the accuracy of the diagnostic workup. This study will assess whether these benefits of IPD meta-analysis over conventional meta-analysis can be exploited and will provide a framework for future IPD meta-analyses in diagnostic and prognostic research.

Testing for Ovarian Reserve in Assisted Reproduction programs: the current point of view

Age related fertility decline varies considerably among women. Therefore, chronological female age, though informative on pregnancy prospects in assisted reproduction, will often not correctly express a woman's reproductive potential. The value of quantitative ovarian reserve tests prior to IVF/ICSI treatment is still subject of debate. From a series of systematic reviews it has become clear that the added value of these tests upon knowing female age has not been clearly established. Still, several tests, like the AFC and AMH are considered adequate in predicting the response to ovarian stimulation. This claim seems to be truer for poor response prediction, compared to hyper response. Prediction of the outcome pregnancy has repeatedly shown to be cumbersome. As management options for predicted poor or hyper responders-- are not fully investigated to date, routine ovarian reserve testing is not to be recommended. A first cycle poor response to adequate stimulation in cases with otherwise no signs of advanced ovarian ageing (based on female-- age and ovarian reserve tests) may offer a tool to identify cases with sufficient prospects for continuation of ART treatment--.

A new approach to ovarian reserve testing

OBJECTIVE

To critically examine ovarian reserve testing before assisted reproduction.

DESIGN

A PUBMED computer search to identify relevant literature.

SETTING

Multiple sites.

PATIENT(S)

Patients undergoing assisted reproduction.

INTERVENTION(S)

Testing for ovarian reserve.

MAIN OUTCOME MEASURE(S)

Assisted reproductive technology (ART) and pregnancy outcomes.

RESULT(S)

The prevalence of ovarian insufficiency varies significantly for women aged 30-45 years. Generalization or averaging of threshold values across different aged women leads to very poor sensitivity, specificity, and positive predictive value for all tests of ovarian reserve. Because of the changing prevalence of ovarian insufficiency, there is no single, suitable threshold value for any screening test of ovarian reserve. Our analysis supports dividing impaired ovarian reserve into two groups: age-dependent ovarian aging (physiologic) and premature (nonphysiologic) reductions in the oocyte pool. Interpretation of any screening test used requires that age is considered as a variable. To guide clinical interpretation of test results, we suggest using a nomogram of FSH values versus expected delivery rate-per-cycle-start with ART for a given age.

CONCLUSION(S)

Proper interpretation of screening tests for ovarian insufficiency in couples considering ART is important as the presence of impaired ovarian reserve is associated with a low likelihood of pregnancy. The condition of premature (nonphysiologic) ovarian insufficiency warrants additional research.