Should IVF be used as first-line treatment or as a last resort? A debate presented at the 2013 Canadian Fertility and Andrology Society meeting

Multimodal learning system integrating electronic medical records and hysteroscopic images for reproductive outcome prediction and risk stratification of endometrial injury: a multicenter diagnostic study

OBJECTIVE

To develop a multimodal learning application system that integrates electronic medical records (EMR) and hysteroscopic images for reproductive outcome prediction and risk stratification of patients with intrauterine adhesions (IUAs) resulting from endometrial injuries.

MATERIALS AND METHODS

EMR and 5014 revisited hysteroscopic images of 753 post hysteroscopic adhesiolysis patients from the multicenter IUA database we established were randomly allocated to training, validation, and test datasets. The respective datasets were used for model development, tuning, and testing of the multimodal learning application. MobilenetV3 was employed for image feature extraction, and XGBoost for EMR and image feature ensemble learning. The performance of the application was compared against the single-modal approaches (EMR or hysteroscopic images), DeepSurv and ElasticNet models, along with the clinical scoring systems. The primary outcome was the 1-year conception prediction accuracy, and the secondary outcome was the assisted reproductive technology (ART) benefit ratio after risk stratification.

RESULTS

The multimodal learning system exhibited superior performance in predicting conception within 1-year, achieving areas under the curves of 0.967 (95% CI: 0.950-0.985), 0.936 (95% CI: 0.883-0.989), and 0.965 (95% CI: 0.935-0.994) in the training, validation, and test datasets, respectively, surpassing single-modal approaches, other models and clinical scoring systems (all P<0.05). The application of the model operated seamlessly on the hysteroscopic platform, with an average analysis time of 3.7±0.8 s per patient. By employing the application's conception probability-based risk stratification, mid-high-risk patients demonstrated a significant ART benefit (odds ratio=6, 95% CI: 1.27-27.8, P=0.02), while low-risk patients exhibited good natural conception potential, with no significant increase in conception rates from ART treatment (P=1).

CONCLUSIONS

The multimodal learning system using hysteroscopic images and EMR demonstrates promise in accurately predicting the natural conception of patients with IUAs and providing effective postoperative stratification, potentially contributing to ART triage after IUA procedures.

Intrauterine insemination + controlled ovarian hyperstimulation versus in vitro fertilisation in unexplained infertility: a systematic review and meta-analysis

BACKGROUND

IUI + COH is widely used in cases of unexplained infertility before resorting to IVF. Debate continues about what should be the first-line treatment for couples with unexplained infertility.

OBJECTIVES

This systematic review assessed the relative efficacy of IUI + COH compared with IVF in couples with unexplained infertility.

SEARCH STRATEGY

We searched Medline, Embase, CIHNL, Pscy Info, and Cochrane Library from 1980 to November 2019.

SELECTION CRITERIA

Only RCTs published articles in full text with female patients aged 18-43 years and diagnosed with unexplained infertility were included.

DATA COLLECTION AND ANALYSIS

Two authors reviewed citations from primary search independently and any disagreement was resolved by mutual discussion and consultation with a third author.

MAIN RESULT

In total, eight RCTs were included. The quality of evidence was moderate to low due to inconsistency across the trials and imprecision. The pooled result showed that IVF was associated with a statistically significant higher live birth rate (RR 1.53, 95% CI 1.01-2.32, P < 0.00001 I² = 86%) with no significant difference in multiple pregnancy rate or OHSS rate. Sensitivity analysis based on women's age and a history of previous IUI or IVF treatment showed no significant difference in the live birth rates (RR 1.01, 95% CI 0.88-1.15, I² = 0%, 3 RCTs) in treatment-naïve women younger than 38 years. In women over 38 years, the live birth rates were significantly higher in the IVF group (RR 2.15, 95% CI 1.16-4.0, I² = 42%, 1 RCT).

CONCLUSION

Further research using a standardised treatment protocol and taking into account important prognostic variables and cumulative live birth rates from fresh IVF and all sibling frozen embryos is required to further guide clinical practice.

Real-world experience with intravaginal culture using INVOCELL: an alternative model for infertility treatment

Objective

To describe the current practice indications, methodology, and outcomes from a real-world experience of intravaginal culture (IVC) using INVOCELL.

Design

A descriptive study outlining real-world experience with INVOCELL that addresses patient selection, ovarian stimulation, embryology laboratory practices, and outcomes.

Setting

Five fertility centers in Missouri, Texas, North Carolina, South Carolina, and Virginia.

Patients

Four hundred sixty-three patients undergoing 526 cycles.

Intervention

IVC using INVOCELL.

Main Outcome Measures

Cumulative pregnancy rate and live births. Secondary outcomes of interest included percent good quality embryos.

Results

IVC with INVOCELL was primarily used in women <38 years with anti-Mullerian hormone level >0.8 ng/mL. The mean numbers of retrieved oocytes ranged from 9.2 to 16. Mean numbers of oocytes and sperm-injected oocytes loaded per INVOCELL ranged from a mean of 6.4–9.5 with a reported maximum of 34 oocytes loaded into the device. Most (95%) of the embryos were transferred on day 5. The mean blastocyst recovery per oocyte loaded into the device ranged from 19% to 34%; mean cumulative live birth plus ongoing pregnancy rates ranged from 29% to 53% per cycle start and 40% to 61% per transfer.

Conclusions

This study of IVC using INVOCELL as an alternative model for infertility treatment confirms its utility as a viable alternative to standard incubator-based in vitro fertilization. The technology is compatible within the current framework of practice patterns and, when appropriately used, results in acceptable blastocyst recovery and live birth rates. Further use of INVOCELL in other clinical situations is warranted.

Treatment of Infertile Women with Unilateral Tubal Occlusion Diagnosed by Hysterosalpingography: The Role of Intrauterine Insemination

The optimal assisted reproductive treatment strategy for infertile women with unilateral tubal obstruction remains uncertain. To investigate the role of intrauterine insemination (IUI) in the treatment of infertile women with unilateral tubal occlusion, the data of 148 couples were retrospectively collected and analyzed. Seventy-eight infertile women with unilateral occlusion diagnosed by hysterosalpingography (HSG) were categorized as the study group and 70 others with unexplained infertility as the control group. The study group was divided into a proximal occlusion subgroup and a mid-distal occlusion subgroup for further analysis. The main outcomes, namely the clinical pregnancy rate (CPR), ongoing pregnancy rate (OPR), and live birth rate (LBR) per cycle, were analyzed. Our results showed a tendency of lower CPR, OPR, and LBR in the study group than in the control group, without statistical significance. Further investigations revealed that the unilateral proximal occlusion subgroup had similar CPR, OPR, and LBR as the control group, while the unilateral mid-distal occlusion subgroup had significantly lower CPR (5.1% vs. 20.0%, P=0.035), OPR (5.1% vs. 20.0%, P=0.035), and LBR (5.1% vs. 20.0%, P=0.035) than the control group. In conclusion, the clinical outcomes of IUI were worse in patients with unilateral tubal occlusion than in those with unexplained infertility. This might be primarily caused by the worse outcome of patients with unilateral mid-distal tubal occlusion instead of proximal occlusion.

Effect of paternal age on treatment outcomes in couples undergoing assisted reproductive technology for non-male factor infertility: a retrospective analysis of 809 cycles

Background

Worldwide, there is an increase in uptake of assisted reproductive technology (ART) treatment. The impact of paternal age on ART outcomes is unclear. In view of the conflicting results reported by studies evaluating effect of paternal age on ART outcomes, we planned a study to investigate the impact of advanced paternal age in couples undergoing ART for non-male factor infertility. We conducted a retrospective cohort study at a university-level teaching hospital in South India. All couples who underwent ART for non-male factor infertility were included. The couples were divided into two groups based on the age of the male partner. Group I included couples with male partner’s age less than 40 years, taken as reference group. Group II included couples with male partners age more than or equal to 40 years. The primary outcome was live birth rate. Secondary outcomes included clinical pregnancy, miscarriage, fertilization, embryo development, and blastulation rates.

Results

A total of 809 cycles were included for the study. Following exclusion of 39 cycles, 770 cycles were analyzed for outcomes. Group I comprised of 556 (72%) cycles and group II comprised of 214 (28%) cycles. There was no significant difference in live birth rate per embryo transfer between groups I and II (31.8% vs. 29.4%; odds ratio, OR, 0.89; 95% CI 0.63 to 1.26). After adjustment for potential confounders, the live birth rate did not differ significantly (adjusted odds ratio, aOR, 1.10; 95% CI 0.74 to 1.65). The clinical pregnancy (39.4% vs. 36%; aOR 1.06; 95% CI 0.72 to 1.56) and the miscarriage rates (18.3% vs. 15.6%; aOR 0.73; 95% CI 0.32 to 1.66) were also similar between the two groups. There was significant decrease in the blastulation rate (36.8% vs. 32.1%; P 0.002) in the advanced paternal age group as compared to the reference group.

Conclusion

The current study suggests that in couples undergoing ART for non-male factor, there is no detrimental effect of increasing paternal age on treatment outcomes.

Endometriosis and in vitro fertilisation

The aim of the present review was to discuss a matter of concern in the clinical field of obstetrics/gynecology, namely the potency of in vitro fertilization (IVF) in the management of endometriosis-associated infertility. Endometriosis is a medical condition affecting one tenth of women in their fertile years, and accounts for up to 50% of infertile women. Thus, such high prevalence has established the necessity for investigating the effectiveness of available techniques in eradicating the disease and constraining infertility as well as the accompanying pain symptoms of endometriosis. The underlying mechanisms connecting endometriosis with low fecundity have been extensively studied, both in terms of genetic alterations and epigenetic events that contribute to the manifestation of an infertility phenotype in women with the disease. Several studies have dealt with the impact of IVF in pregnancy rates (PRs) on patients with endometriosis, particularly regarding women who wish to conceive. Results retrieved from studies and meta-analyses depict a diverse pattern of IVF success, underlining the involvement of individual parameters in the configuration of the final outcome. The ultimate decision on undergoing IVF treatment should be based on objective criteria and clinicians' experience, customized according to patients' individual needs.

Predictors of in vitro fertilization outcomes in women with highest follicle-stimulating hormone levels ≥ 12 IU/L: a prospective cohort study

Objective

The purpose of this study is to evaluate factors predictive of outcomes in women with highest follicle-stimulating hormone (FSH) levels ≥12 IU/L on basal testing, undergoing in vitro fertilization (IVF).

Methods

A prospective cohort study was conducted at Stanford University Hospital in the Reproductive Endocrinology and Infertility Center for 12 months. Women age 21 to 43 undergoing IVF with highest FSH levels on baseline testing were included. Donor/Recipient and frozen embryo cycles were excluded from this study. Prognostic factors evaluated in association with clinical pregnancy rates were type of infertility diagnosis and IVF stimulation parameters.

Results

The current study found that factors associated with clinical pregnancy were: increased number of mature follicles on the day of triggering, number of oocytes retrieved, number of Metaphase II oocytes if intracytoplasmic sperm injection was done, and number of embryos developed 24 hours after retrieval.

Conclusions

Our findings suggest that it would be beneficial for women with increased FSH levels to attempt a cycle of IVF. Results of ovarian stimulation, especially embryo quantity appear to be the best predictors of IVF outcomes and those can only be obtained from a cycle of IVF. Therefore, increased basal FSH levels should not discourage women from attempting a cycle of IVF.