Elusive fertility: fecundability and assisted conception in perspective

Infertility: from a personal to a public health problem

The inability to conceive a child is most often viewed as a private matter, but public health perspectives and skills can contribute greatly to our knowledge about infertility, and the development of effective and rational public policy for prevention, access to health care, and regulation of new technologies. We offer a primer of public health aspects of infertility in an effort to encourage the broad spectrum of public health professionals to become more knowledgeable about these topics and join in the national debate about preventive strategies, cost-benefit assessment, resource allocation, and ethics.

Factors that affect outcome of in-vitro fertilisation treatment

BACKGROUND

The effectiveness of in-vitro fertilisation (IVF) treatment depends both on the overall success rate in the treating clinic and on the characteristics of the couple seeking treatment. Since 1991, the Human Fertilisation and Embryology Authority (HFEA) has been collecting information on all IVF cycles carried out in the UK. This database has been analysed to identify the factors that affect the outcome of treatment.

METHODS

All IVF treatment cycles and outcomes registered between August, 1991, and April, 1994, were identified (52507). Cycles that involved gamete or embryo donation, frozen embryo transfer, or micromanipulation and unstimulated cycles were excluded. Thus, 36961 cycles (70% of those registered) were included in the analysis. The main outcome measure was liverbirth rate per cycle started. The relation between age and outcome was investigated by fitting of different fractional polynomials of age with logistic regression models. All other factors were analysed by logistic regression with age included in the model.

FINDINGS

The overall livebirth rate per cycle of treatment was 13.9%. The highest livebirth rates were in the age-group 25-30 years; younger women had lower rates and there was a sharp decline in older women. At all ages over 30, use of donor eggs was associated with a significantly higher livebirth rate than use of the woman's own eggs, but there was also a downward trend in success rate with age (p = 0.04). After adjustment for age, there was a significant decrease in livebirth rate with increasing duration of infertility from 1 to 12 years (p < 0.001). The medical indication for treatment had no significant effect on the outcome. Previous pregnancy and livebirth significantly increased treatment success. The possibility of success decreased with each IVF treatment cycle.

INTERPRETATION

We were able to identify by logistic regression the factors that significantly affect the outcome of IVF treatment, and to measure the magnitude of that effect. These factors should be taken into account in assessment of IVF results. After allowance for background clinic success rates, these factors can be used to predict outcome in individual cases.

The economics of infertility: developing an infertility managed-care plan

Infertility is a natural disorder for developing a managed-care plan. Infertility has a clearly defined end point. The treatment regimens and protocols used for treating infertile couples have predictable outcomes; it is possible to develop rational treatment plans over a limited period of time. It is not unreasonable for infertile couples to share the cost of treatment and for the physician-providers to share the economic risk by providing a bundle of optimal services at a fixed price. We present the theoretic basis for an infertility managed-care plan and the requirements for developing a plan that can be sold in the marketplace. Finally, we discuss some of the consequences of an infertility managed-care plan on physician relationships, physician manpower, research, and education.