The economic impact of the assisted reproductive technologies

Autonomous decisions by couples in reproductive care

Background

Preconception Expanded Carrier Screening (ECS) is a genetic test offered to a general population or to couples who have no known risk of recessive and X-linked genetic diseases and are interested in becoming parents. A test may screen for carrier status of several autosomal recessive diseases at one go. Such a program has been piloted in the Netherlands and may become a reality in more European countries in the future. The ethical rationale for such tests is that they enhance reproductive autonomy. The dominant conception of autonomy is individual-based. However, at the clinic, people deciding on preconception ECS will be counselled together and are expected to make a joint decision, as a couple. The aim of the present study was to develop an understanding of autonomous decisions made by couples in the context of reproductive technologies in general and of preconception ECS in particular. Further, to shed light on what occurs in reproductive clinics and suggest concrete implications for healthcare professionals.

Main text

Based on the shift in emphasis from individual autonomy to relational autonomy, a notion of couple autonomy was suggested and some features of this concept were outlined. First, that both partners are individually autonomous and that the decision is reached through a communicative process. In this process each partner should feel free to express his or her concerns and preferences, so no one partner dominates the discussion. Further, there should be adequate time for the couple to negotiate possible differences and conclude that the decision is right for them. The final decision should be reached through consensus of both partners without coercion, manipulation or miscommunication. Through concrete examples, the suggested notion of couple autonomy was applied to diverse clinical situations.

Conclusions

A notion of couple autonomy can be fruitful for healthcare professionals by structuring their attention to and support of a couple who is required to make an autonomous joint decision concerning preconception ECS. A normative implication for healthcare staff is to allow the necessary time for decision-making and to promote a dialogue that can increase the power of the weaker part in a relationship.

On-chip oocyte denudation from cumulus-oocyte complexes for assisted reproductive therapy

Human infertility can be treated using assisted reproductive technology (ART) such as intracytoplasmic sperm injection (ICSI). But current ART techniques suffer from multiple cumbersome processes requiring technically skilled personnel. Microfluidics technologies offer unique opportunities to streamline ART procedures, reduce stress imposed upon gametes and embryos, and minimize the operator-to-operator variability. However, there have been no automated and continuous processing systems that can reduce the dependence on well-trained embryologists to obtain ICSI-ready oocytes from patients. In this study, using mouse models, we developed a microfluidic device to denude oocytes from the surrounding cumulus-corona cell mass, facilitating the evaluation of oocyte quality and the injection of sperm. Enzyme-treated cumulus-oocyte complexes pass through a series of jagged-surface constriction microchannels of optimized geometries. The jagged inner wall of constriction channels facilitates stripping off of the cumulus-corona cell mass. Oocytes that were denuded by the device showed comparable fertilization and developmental competence compared with mechanical pipetting. The device developed in this study achieves the automation of a manual process for oocyte denudation in a continuous flow, as well as improving standardization and ease-of-use. Our denudation-on-a-chip approach requires inexpensive and simple equipment, which represents one step forward towards improving the accessibility and affordability of assisted reproductive therapy.

Impact of ART on pregnancies in California: an analysis of maternity outcomes and insights into the added burden of neonatal intensive care

OBJECTIVE

We reviewed the occurrence of prematurity, low birth weight, multiple gestations, frequency of stillbirths and maternity care-associated variables including hospital stay and hospital charges of women conceiving using assisted reproductive technology (ART) or artificial insemination (AI) compared with women with a history of infertility who conceived naturally, and all other naturally conceived pregnancies in California at non-federal hospitals between 2009 and 2011. At a single center, infants born after ART/AI were compared with infants provided care in the normal nursery.

STUDY DESIGN

Publically available inpatient data sets from the California Office of Statewide Health Planning and Development for years 2009-2011 using data from all California non-federal hospitals were used to determine the impact of ART on a variety of pregnancy-related outcomes and infant characteristics. Infant data from a single center was used to determine hospital charges for infants delivered over an 18-month period to compare the hospital and physician charges indexed to similar charges for infants admitted to the 'normal' newborn nursery.

RESULT

Among ART/AI pregnancies, there was a 4-5-fold increase in stillbirths, compared with a 2-3-fold increase among women with infertility compared with other naturally conceiving women. ART/AI pregnancies underwent more cesarean sections (fourfold), and a near fourfold increase in the rate of preterm deliveries. Multiple gestations were increased 24-27-fold compared with naturally conceived pregnancies. Maternal hospital stay and hospital charges were increased among those undergoing ART/AI. Infant charges were increased multi-fold for singletons, twins and triplets delivered after ART/AI compared with naturally conceived infants.

CONCLUSION

Multiple births, preterm births and a higher overall rate of fetal anomalies were found in California after ART/AI for 2009-2011. Cesarean section rates, longer length of maternal stay and hospital charges among women receiving ART/AI could be lowered if emphasis on elective single embryo transfers was a higher priority among providers. Charges for the care of infants delivered after ART/AI are substantially higher than among naturally conceived infants born late preterm or at term. Families seeking ART/AI need to be informed of the impact of these adverse pregnancy outcomes, including neonatal outcomes and charges for medical care for their infant(s), when considering ART/AI.

Eurycomanone, the major quassinoid in Eurycoma longifolia root extract increases spermatogenesis by inhibiting the activity of phosphodiesterase and aromatase in steroidogenesis

ETHNOPHARMACOLOGICAL RELEVANCE

Eurycoma longifolia Jack (Simaroubaceae family), known locally as 'Tongkat Ali' by the ethnic population, is popularly taken as a traditional remedy to improve the male libido, sexual prowess and fertility. Presently, many tea, coffee and carbonated beverages, pre-mixed with the root extract are available commercially for the improvement of general health and labido. Eurycomanone, the highest concentrated quassinoid in the root extract of E. longifolia improved fertility by increasing testosterone and spermatogenesis of rats through the hypothalamus-pituitary-gonadal axis, but the mechanisms underlying the effects are not totally clear.

AIM OF THE STUDY

To provide evidences on the plant ethnopharmacological use and the involvement of eurycomanone, the major indigenous plant quassinoid in testosterone steroidogenesis and spermatogenesis increase.

MATERIAL AND METHODS

The rat testicular Leydig cell-rich interstitial cells were isolated and incubated in the culture medium M199. The viability of the cells was determined with trypan blue staining and the concentration of the viable cells was counted with a haemocytometer. The 3β-hydroxysteroid dehydrogenase (HSD) staining method was used to measure the abundance of Leydig cells in the preparation. Eurycomanone and the standard steroidogenesis inhibitors were incubated with 1.0 × 10(5) cells, and after 2h, the testosterone and the oestrogen concentrations were determined by the ELISA method. Computational molecular docking was performed to determine the binding affinity of the compound at the respective steroidogenesis enzymes.

RESULTS

Eurycomanone (EN) significantly increased testosterone production dose-dependently at 0.1, 1.0 and 10.0 μM (P<0.05), but the two lower doses when combined with 3-isobutyl-1-methylxanthine (IBMX), the phosphodiesterase inhibitor were not significantly higher than EN or IBMX alone, except at a higher concentration. The molecular docking studies indicated EN and IBMX were binding at different sites of the enzyme. EN has no reversal of inhibition by aminoglutethimide, ketoconazole or nifedipine at the respective steroidogenesis enzyme. The quassinoid was also non-responsive to the inhibition of oestrogen receptor by tamoxifen, but displayed improved formestane inhibition of aromatase in reducing oestrogen production. The molecular docking studies further supported that EN and formestane bound to aromatase with similar orientations and free energy binding values.

CONCLUSION

Eurycomanone enhanced testosterone steroidogenesis at the Leydig cells by inhibiting aromatase conversion of testosterone to oestrogen, and at a high concentration may also involve phosphodiesterase inhibition. The quassinoid may be worthy for further development as a phytomedicine to treat testosterone-deficient idiopathic male infertility and sterility.

Standardized quassinoid-rich Eurycoma longifolia extract improved spermatogenesis and fertility in male rats via the hypothalamic-pituitary-gonadal axis

ETHNOPHARMACOLOGICAL RELEVANCE

Eurycoma longifolia Jack, a small Simaroubaceae tree, known locally as 'Tongkat Ali' is popularly used as a sexual tonic in traditional medicine for aphrodisiac activity and improvement of fertility and male libido.

AIM OF THE STUDY

To investigate the effects of the standardized bioactive fraction of E. longifolia and its chemical constituents on the male fertility and the mechanisms of action involved.

MATERIAL AND METHODS

The powdered roots of E. longifolia were extracted separately with methanol and water. The organic extract upon further fractionation on HP 20 resin and elution with the methanol/water mixture afforded four fractions (F1-F4). These fractions, together with the crude aqueous (W) and organic extracts were standardized following their respective major quassinoid content and profile. The effects of the fractions on the rat spermatogenesis were compared with that of the aqueous extract (W) to determine the bioactive fraction. The effects of the bioactive fraction on the sperm count and quality, the histological morphometric changes on the spermatogenesis cycle, fertility and hormonal changes of plasma testosterone, luteinizing hormone (LH), follicle stimulating hormone (FSH) and estrogen in the animals upon oral administration were determined. The effects of the bioactive quassinoids on the testosterone release from the isolated testicular interstitial cells rich in Leydig cells, were also described.

RESULTS

The male rats orally administered with 25mg/kg of F2 and 250mg/kg of W, significantly increased the sperm concentration when compared with that of the control animals (P<0.05). High performance liquid chromatography analysis revealed that 25mg/kg of F2 and 250mg/kg of W were almost similar in concentration of eurycomanone, the major and most potent quassinoid. Microscopic morphometrical analysis of the rat testis following treatment with F2, showed significant increase in the number of spermatocytes and round spermatids at Stage VII of the spermatogenesis cycle when compared to that of the control (P<0.05). The estimated spermatozoa production rate and the number of Leydig cells were also elevated (P<0.001). The fertility index, fecundity index and the pup litter size delivered from the females after mating with the males treated with F2 were increased. The plasma testosterone level of the animals given 25mg/kg of F2 orally was significantly different at day-26 (p<0.05) and day-52 (P<0.01) from those of control but was not different at day-104. The testicular testosterone also peaked in the animals treated with 25mg/kg F2 and was higher than that in the plasma. The plasma LH and FSH levels of the rats treated with 25mg/kg of F2 were higher than those of the control (P<0.001). In contrast, the plasma estrogen level was significantly lower than that of the untreated control. Amongst the isolated quassinoids of F2, eurycomanone and 13α(21)-dihydroeurycomaone significantly increased the testosterone level from the Leydig cells of the testicular interstitial cells cultured in vitro (P<0.05).

CONCLUSION

The standardised extract F2 of E. longifolia and its major quassinoids especially eurycomanone improved the rat spermatogenesis by affecting the hypothalamic-pituitary-gonadal axis and the potential efficacy may be worthy of further investigation.

Costs of infertility treatment: results from an 18-month prospective cohort study

OBJECTIVE

To examine resource use (costs) by women presenting for infertility evaluation and treatment over 18 months, regardless of treatment pursued.

DESIGN

Prospective cohort study in which women were followed for 18 months.

SETTING

Eight infertility practices.

PATIENT(S)

Three hundred ninety-eight women recruited from infertility practices.

INTERVENTION(S)

Women completed interviews and questionnaires at baseline and after 4, 10, and 18 months of follow-up. Medical records were abstracted after 18 months to obtain details of services used.

MAIN OUTCOME MEASURE(S)

Per-person and per-successful-outcome costs.

RESULT(S)

Treatment groups were defined as highest intensity treatment use. Twenty percent of women did not pursue cycle-based treatment; approximately half pursued IVF. Median per-person costs ranged from $1,182 for medications only to $24,373 and $38,015 for IVF and IVF-donor egg groups, respectively. Estimates of costs of successful outcomes (delivery or ongoing pregnancy by 18 months) were higher--$61,377 for IVF, for example--reflecting treatment success rates. Within the time frame of the study, costs were not significantly different for women whose outcomes were successful and women whose outcomes were not.

CONCLUSION(S)

Although individual patient costs vary, these cost estimates developed from actual patient treatment experiences may provide patients with realistic estimates to consider when initiating infertility treatment.

Infertility service use among U.S. women: 1995 and 2002

OBJECTIVE

To examine trends in use of medical services for infertility, by individual characteristics of women.

DESIGN

Pooled data from two cycles (1995 and 2002) of the National Survey of Family Growth, a periodically conducted, nationally representative, cross-sectional survey of women 15-44 years of age.

PARTICIPANT(S)

The analysis sample was composed of 2,005 women 22-44 years of age with current fertility problems.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Ever having used infertility services, and highest level of services used.

RESULT(S)

Between 1995 and 2002, ever-use of infertility services by fertility-impaired women age 22-44 years continued to be closely associated with older age, nulliparity, formal marital status, and higher socioeconomic status (education, household income, and private health insurance). Net of these factors, race and Hispanic origin, showed no significant association with either the use of services overall or the highest level of services used. After controlling for compositional changes in these individual characteristics, a slight decline was seen in ever-use of services overall from 1995 to 2002. No effect of survey year was noted in the highest level of services.

CONCLUSION(S)

Infertility service use among fertility-impaired women remains closely tied with socioeconomic factors. The "threshold effect" of these factors has shifted upward to the receipt of more costly services such as assisted reproductive technologies. These higher level services remain a relatively small fraction of the services reported in a general population sample of fertility-impaired women.

The Effect of Eurycoma longifolia on Sperm Quality of Male Rats

The present study investigated the effects of a standardized methanol extract of E. longifolia Jack containing the major quassinoid constituents of 13α(21)-epoxyeurycomanone (1), eurycomanone (2), 13α,21-dihydroeurycomanone (3) and eurycomanol (4) on the epididymal spermatozoa profile of normal and Andrographis paniculata induced infertile rats. The standardized MeOH extract at doses of 50, 100 and 200 mg/kg, the EtOAc fraction (70 mg/kg), and standardized MeOH extract at 200 mg/kg co-administered with the EtOAc fraction of A. paniculata at 70 mg/kg were each given orally to male Sprague-Dawley albino rats for 48 consecutive days. The spermatozoa count, morphology, motility, plasma testosterone level and Leydig cell count of the animals were statistically analyzed by ANOVA with a post-hoc Tukey HSD test. The results showed that the sperm count of rats given the standardized MeOH extract alone at doses of 50, 100 and 200 mg/kg were increased by 78.9, 94.3 and 99.2 %, respectively when compared with that of control (p < 0.01). The low count, poor motility and abnormal morphology of the spermatozoa induced by the A. paniculata fraction were significantly reversed by the standardized MeOH extract of E. longifolia (p < 0.001). The plasma testosterone level of the rats treated with the standardized MeOH extract at 200 mg/kg was significantly increased (p < 0.01) when compared with that of the control and infertile animals. The spermatocytes in the seminiferous tubules and the Leydig cells appeared normal. Testosterone level was significantly higher in the testes (p < 0.01) than in the plasma after 30 days of oral treatment with the standardized MeOH extract. Interestingly, eurycomanone (2) alone was detected in the rat testis homogenates by HPLC-UV and confirmed by LC/MS, and may have contributed towards the improvement of sperm quality. Thus, the plant may potentially be suitable for the management of male infertility.

Protein intake and ovulatory infertility

OBJECTIVE

The objective of the study was to evaluate whether intake of protein from animal and vegetable origin is associated with ovulatory infertility.

STUDY DESIGN

A total of 18,555 married women without a history of infertility were followed up as they attempted a pregnancy or became pregnant during an 8 year period. Dietary assessments were related to the incidence of ovulatory infertility.

RESULTS

During follow-up, 438 women reported ovulatory infertility. The multivariate-adjusted relative risk (RR) (95% confidence interval [CI]; P for trend) of ovulatory infertility comparing the highest to the lowest quintile of animal protein intake was 1.39 (1.01 to 1.90; 0.03). The corresponding RR (95% CI; P for trend) for vegetable protein intake was 0.78 (0.54 to 1.12; 0.07). Furthermore, consuming 5% of total energy intake as vegetable protein rather than as animal protein was associated with a more than 50% lower risk of ovulatory infertility (P =.007).

CONCLUSION

Replacing animal sources of protein with vegetable sources of protein may reduce ovulatory infertility risk.

Use of multivitamins, intake of B vitamins, and risk of ovulatory infertility

OBJECTIVE

To examine whether use of multivitamins and intake of specific nutrients in multivitamins is associated with ovulatory infertility.

DESIGN

A prospective cohort study.

SETTING

The Nurses' Health Study II.

PATIENT(S)

Eighteen thousand five hundred fifty-five married, premenopausal women without a history of infertility who attempted a pregnancy or became pregnant between 1991 and 1999.

INTERVENTION(S)

None, observational study.

MAIN OUTCOME MEASURE(S)

Incident reports of infertility caused by anovulation.

RESULT(S)

During 8 years of follow-up, 438 women reported infertility caused by ovulatory disorder. There was an inverse association between frequency of multivitamin use and ovulatory infertility. The multivariate-adjusted relative risk (95% confidence interval) of ovulatory infertility was 0.88 (0.60, 1.28) for women consuming two tablets per week or less, 0.69 (0.51, 0.95) for women consuming three to five tablets per week, and 0.59 (0.46, 0.75) for women consuming six or more tablets per week, when compared with women who did not use these supplements (P, trend <.001). Folic acid appeared to explain part of the association between multivitamin supplement use and risk of ovulatory infertility.

CONCLUSION(S)

Regular use of multivitamin supplements may decrease the risk of ovulatory infertility.

Dietary fatty acid intakes and the risk of ovulatory infertility

BACKGROUND

Pharmacologic activation of the peroxisome proliferator-activated receptor gamma (PPAR-gamma) improves ovulatory function in women with polycystic ovary syndrome, and specific dietary fatty acids can affect PPAR-gamma activity.

OBJECTIVE

The objective of the study was to assess whether the intakes of total fat, cholesterol, and major types of fatty acids affect the risk of ovulatory infertility.

DESIGN

We conducted a prospective cohort study of 18 555 married, premenopausal women without a history of infertility who attempted a pregnancy or became pregnant between 1991 and 1999. Diet was assessed twice during follow-up by using a food-frequency questionnaire.

RESULTS

During follow-up, 438 incidents of ovulatory infertility were reported. In logistic regression analyses, intakes of total fat, cholesterol, and most types of fatty acids were not related to ovulatory infertility. Each 2% increase in the intake of energy from trans unsaturated fats, as opposed to that from carbohydrates, was associated with a 73% greater risk of ovulatory infertility after adjustment for known and suspected risk factors for this condition [relative risk (RR) = 1.73; 95% CI: 1.09, 2.73]. Obtaining 2% of energy intake from trans fats rather than from n-6 polyunsaturated fats was associated with a similar increase in the risk of ovulatory infertility (RR = 1.79; 95% CI: 1.11, 2.89). In addition, obtaining 2% of energy from trans fats rather than from monounsaturated fats was associated with a more than doubled risk of ovulatory infertility (RR = 2.31; 95% CI: 1.09, 4.87).

CONCLUSION

trans Unsaturated fats may increase the risk of ovulatory infertility when consumed instead of carbohydrates or unsaturated fats commonly found in nonhydrogenated vegetable oils.

Health disparities and infertility: impacts of state-level insurance mandates

OBJECTIVE

To determine whether important racial, ethnic, or socioeconomic status (SES) health disparities exist in infertility, impaired fecundity, or infertility treatment.

DESIGN

Four waves of the National Survey of Family Growth (NSFG) were pooled. Measures were compared across various race/ethnicity, education, and age groups.

PARTICIPANT(S)

Data for 31,047 women 15-44 years old from the NSFG were pooled.

INTERVENTION(S)

Outcomes were compared by whether the women's states of residence had a mandate in place (at least 1 year before the interview) to compel insurers to cover or offer to cover infertility treatment.

MAIN OUTCOME MEASURE(S)

Infertility status, impaired fecundity, ever having sought infertility treatment.

RESULT(S)

Infertility is more common for non-Hispanic black women, non-Hispanic other race women, and Hispanic women than for non-Hispanic white women, and both infertility and impaired fecundity are more common for high school dropouts and high school graduates with no college than for 4-year college graduates, and for older women compared with women 29 and younger. Older women, non-Hispanic white women, and women who are more educated (with at least some college) are more likely to have ever received treatment. No evidence has been found that the racial, ethnic, or education disparities are ameliorated by the health insurance mandates.

CONCLUSION(S)

Racial, ethnic, and educational disparities exist in infertility status and treatment, and educational disparities in impaired fecundity. More study of the impact of infertility treatment mandates on these disparities is needed.