Evaluation of the relative cost-effectiveness of treatments for infertility in the UK

Unexplained subfertility: active or conservative management?

OBJECTIVES

Unexplained subfertility (UEI) describes a couple whose standard subfertility workout consider acceptable but unable to conceived.

METHODS

This retrospective study was conducted in the Advanced Reproductive Centre, UKM Hospital, Kuala Lumpur, from January 2016 to December 2019. The data of 268 UEI couples were obtained from the clinical database. Women aged 21-45 years old was included and further divided into four groups according to the female partner's age and subfertility duration: group A (age <35 years and subfertility <2 years), group B (age <35 years and subfertility >2 years), group C (age >35 years and subfertility <2 years), and group D (age >35 years and subfertility <2 years). All statistical analyses were performed using SPSS 22.0 for Windows.

RESULTS

A total of 255 cases were included in this study. The mean age of the women was 32.9 ± 4.04 years, and the mean subfertility duration was 5.04 ± 2.9 years. A total of 51 (20 %) cases underwent timed sexual intercourse, 147 (57.6 %) cases had intrauterine insemination (IUI), whereas 57 (22.4 %) cases opted for in vitro fertilization (IVF). A total of 204 cases underwent active management (IUI/IVF), which showed a significant difference (p<0.05). Out of eight clinical pregnancies, half of them were from group B.

CONCLUSIONS

Active management in younger women with a shorter subfertility duration revealed a better pregnancy outcome. Otherwise, individualized treatment should be considered in selecting a suitable treatment plan.

In vitro fertilization: a cross-sectional analysis of 58 US insurance companies

PURPOSE

Infertility affects one in eight women in the USA. In vitro fertilization (IVF) is an effective but costly treatment that lacks uniform insurance coverage. We evaluated the current insurance coverage landscape for IVF in America.

METHODS

We conducted a cross-sectional analysis of 58 insurance companies with the greatest state enrollment and market share, calculated to represent the majority of Americans with health insurance. Individual companies were evaluated for a publicly available policy on IVF services by web-based search, telephone interview, or email to the insurer. Coverage status, required criteria, qualifying risk factors, and contraindications to coverage were extracted from available policies.

RESULTS

Fifty-one (88%) of the fifty-eight companies had a policy for IVF services. Thirty-five (69%) of these policies extended coverage. Case-by-case coverage was stated in seven policies (14%), while coverage was denied in the remaining nine (18%). The most common criterion to receive coverage was a documented diagnosis of infertility (n = 23, 66%), followed by care from a reproductive endocrinologist (n = 9, 26%). Twenty-three (45%) of the companies with a policy had at least one contraindication to coverage. Three companies (6%) limited the number of IVF cycles to be covered, capping payments after 3-4 lifetime cycles.

CONCLUSION

Most Americans with health insurance are provided a public policy regarding IVF. However, there is great variation in coverage and requirements to receive coverage between insurers. Coupled with inconsistencies in state-level mandates and available choices for employer-sponsored plans, this may limit coverage of IVF services and, therefore, access to infertility treatment.

IUI: review and systematic assessment of the evidence that supports global recommendations

BACKGROUND

IUI with or without ovarian stimulation (OS) has become a first-line treatment option for many infertile couples, worldwide. The appropriate treatment modality for couples and their clinical management through IUI or IUI/OS cycles must consider maternal and perinatal outcomes, most notably the clinical complication of higher-order multiple pregnancies associated with IUI-OS. With a current global emphasis to continue to decrease maternal and perinatal mortality and morbidity, the World Health Organization (WHO) had established a multi-year project to review the evidence for the establishment of normative guidance for the implementation of IUI as a treatment to address fertility problems, and to consider its cost-effectiveness for lower resource settings.

OBJECTIVE AND RATIONALE

The objective of this review is to provide a review of the evidence of 13 prioritized questions that cover IUI with and without OS. We provide summary recommendations for the development of global, evidence-based guidelines based upon methodology established by the WHO.

SEARCH METHODS

We performed a comprehensive search using question-specific relevant search terms in May 2015. For each PICO (Population, Intervention, Comparison and Outcomes) drafted by WHO, specific search terms were used to find the available evidence in MEDLINE (1950 to May 2015) and The Cochrane Library (until May 2015). After presentation to an expert panel, a further hand search of references in relevant reviews was performed up to January 2017. Articles that were found to be relevant were read and analysed by two investigators and critically appraised using the Cochrane Collaboration's tool for assessing risk of bias, and AMSTAR in case of systematic reviews. The quality of the evidence was assessed using the GRADE system. An independent expert review process of our analysis was conducted in November 2016.

OUTCOMES

This review provides an assessment and synthesis of the evidence that covers 13 clinical questions including the indications for the use of IUI versus expectant management, the sperm parameters required, the best and optimal method of timing and number of inseminations per cycle, prevention strategies to decrease multiple gestational pregnancies, and the cost-effectiveness of IUI versus IVF. We provide an evidence-based formulation of 20 recommendations, as well as two best practice points that address the integration of methods for the prevention of infection in the IUI laboratory. The quality of the evidence ranges from very low to high, with evidence that may be decades old but of high quality, however, we further discuss where critical research gaps in the evidence remain.

WIDER IMPLICATIONS

This review presents an evidence synthesis assessment and includes recommendations that will assist health care providers worldwide with their decision-making when considering IUI treatments, with or without OS, for their patients presenting with fertility problems.

Chlamydia sequelae cost estimates used in current economic evaluations: does one-size-fit-all?

BACKGROUND

Current evidence suggests that chlamydia screening programmes can be cost-effective, conditional on assumptions within mathematical models. We explored differences in cost estimates used in published economic evaluations of chlamydia screening from seven countries (four papers each from UK and the Netherlands, two each from Sweden and Australia, and one each from Ireland, Canada and Denmark).

METHODS

From these studies, we extracted management cost estimates for seven major chlamydia sequelae. In order to compare the influence of different sequelae considered in each paper and their corresponding management costs on the total cost per case of untreated chlamydia, we applied reported unit sequelae management costs considered in each paper to a set of untreated infection to sequela progression probabilities. All costs were adjusted to 2013/2014 Great British Pound (GBP) values.

RESULTS

Sequelae management costs ranged from £171 to £3635 (pelvic inflammatory disease); £953 to £3615 (ectopic pregnancy); £546 to £6752 (tubal factor infertility); £159 to £3341 (chronic pelvic pain); £22 to £1008 (epididymitis); £11 to £1459 (neonatal conjunctivitis) and £433 to £3992 (neonatal pneumonia). Total cost of sequelae per case of untreated chlamydia ranged from £37 to £412.

CONCLUSIONS

There was substantial variation in cost per case of chlamydia sequelae used in published chlamydia screening economic evaluations, which likely arose from different assumptions about disease management pathways and the country perspectives taken. In light of this, when interpreting these studies, the reader should be satisfied that the cost estimates used sufficiently reflect the perspective taken and current disease management for their respective context.

First line fertility treatment strategies regarding IUI and IVF require clinical evidence

The advent of intracytoplasmic sperm injection (ICSI) has contributed to a significant growth in the delivery of assisted conception technique, such that IVF/ICSI procedures are now recommended over other interventions. Even the UK National Institute for Health Care Excellence (NICE) guidelines controversially recommends against intrauterine insemination (IUI) procedures in favour of IVF. We reflect on some of the clinical, economic, financial and ethical realities that have been used to selectively promote IVF over IUI, which is less intrusive and more patient friendly, obviates the need for embryo storage and has a global application. The evidence strongly favours IUI over IVF in selected couples and national funding strategies should include IUI treatment options. IUI, practised optimally as a first line treatment in up to six cycles, would also ease the pressures on public funds to allow the provision of up to three IVF cycles for couple who need it. Fertility clinics should also strive towards ISO15189 accreditation standards for basic semen diagnosis for male infertility used to triage ICSI treatment, to reduce the over-diagnosis of severe male factor infertility. Importantly, there is a need to develop global guidelines on inclusion policies for IVF/ICSI procedures. These suggestions are an ethically sound basis for constructing the provision of publicly funded fertility treatments.

Cost of fertility treatment and live birth outcome in women of different ages and BMI

STUDY QUESTION

What is the impact of different age and BMI groups on total investigation and treatment costs in women attending a secondary/tertiary care fertility clinic?

SUMMARY ANSWER

Women in their early to mid-30s and women with normal BMI had higher cumulative investigation and treatment costs, but also higher probability of live birth.

WHAT IS KNOWN ALREADY

Female age and BMI have been used as criteria for rationing publically funded fertility treatments. Population-based data on the costs of investigating and treating infertility are lacking.

STUDY DESIGN, SIZE AND DURATION

A retrospective cohort study of 2463 women was conducted in a single secondary/tertiary care fertility clinic in Aberdeen, Scotland from 1998 to 2008.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants included all women living in a defined geographical area referred from primary care to a specialized fertility clinic over an 11-year period. Women were followed up for 5 years or until live birth if this occurred sooner. Mean discounted cumulative National Health Service costs (expressed in 2010/2011 GBP) of fertility investigations, treatments (including all types of assisted reproduction), and pregnancy (including delivery episode) and neonatal admissions were calculated and summarized by age (≤ 30, 31-35, 36-40, >40 years) and BMI groupings (<18.50, 18.50-24.99 (normal BMI), 25.00-29.99, 30.00-34.99, ≥ 35.00 kg/m(2)). Further multivariate modelling was carried out to estimate the impact of age and BMI on investigation and treatment costs and live birth outcome, adjusting for covariates predictive of the treatment pathway and live birth.

MAIN RESULTS AND THE ROLE OF CHANCE

Of the 2463 women referred, 1258 (51.1%) had a live birth within 5 years, with 694 (55.1%) of these being natural conceptions. The live birth rate was highest among women in the youngest age group (64.3%), and lowest in those aged >40 years (13.4%). Overall live birth rates were generally lower in women with BMI >30 kg/m(2). The total costs of investigations were generally highest among women younger than 30 years (£491 in those with normal BMI), whilst treatment costs tended to be higher in 31-35 year olds (£1,840 in those with normal BMI). Multivariate modelling predicted a cost increase associated with treatment which was highest among women in the lowest BMI group (across all ages), and also highest among women aged 31-35 years. The increase in the predicted probability of live birth with exposure to treatment was consistent across age and BMI categories (∼ 10%), except in the oldest age group where a slightly smaller increase in the probability of live birth was observed. The ratio of increased costs to the increased probability of live birth in women who were treated increased markedly in women over the age of 40 years, but tended to fall as BMI increased within all age groups.

LIMITATIONS AND REASON FOR CAUTION

Our results, based on retrospective observational data from a single centre, have limited generalizability and are not free from clinician and clinic selection bias which can influence the choice of treatments as well as their costs.

WIDER IMPLICATIONS OF THE FINDINGS

Spontaneous live birth rates were particularly high in younger women with unexplained infertility, suggesting that expectant management is a reasonable option in this group. The policy of not over-investigating older women and offering early treatment where appropriate still incurred the highest costs per additional live birth associated with treatment, owing to the lower probability of treatment success. The increased additional cost for each live birth associated with treatment for women with decreasing BMI across all age groups, suggests that it may be possible to identify a more targeted approach to treatment.

STUDY FUNDING/COMPETING INTERESTS

This study was partly funded by an NHS endowment grant (Grant Number 12/48) and D.J.M. by a Chief Scientist Office Postdoctoral Fellowship (Ref PDF/12/06). There are no conflicts of interest to declare.

The need for new methods of ovarian stimulation

It is easy to diagnose sterility but much harder to diagnose subfertility, because minor defects are not necessarily associated with consistent impairment of fertility. Correct evaluation of the background fertility can avoid needless treatment of couples. Ovarian stimulation is a powerful strategy frequently used to re-establish or improve fertility in infertile couples, but it is often the cause of twin pregnancy. The risks and costs of multiple gestation are important factors that must be taken into full account in the pro-fertility decision. To avoid twins, inseminations should preferably be done in unstimulated cycles or in association with induced mono-ovulatory cycles. For the same reason, it is probably time to follow the policy of favouring single embryo transfer in young women undergoing IVF and intracytoplasmic sperm injection programmes. In addition, there is an urgent need to avoid an invasive multiple transfer policy in women over 38 and to select new strategies to improve the well-known age-related lower implantation rate.

In vitro fertilisation for unexplained subfertility

BACKGROUND

In vitro fertilisation (IVF) is a widely accepted treatment for unexplained infertility (NICE 2004), which affects up to a third of all infertile couples. With estimated live birth rates (LBRs) per cycle varying from 33.1% in women aged under 35 years down to 12.5% in women aged between 40 and 42 years (HFEA 2011), its effectiveness has not been rigorously evaluated in comparison with other treatments. With increasing awareness of the role of expectant management, less-invasive procedures such as intrauterine insemination (IUI), and concerns about multiple pregnancies and costs associated with IVF, it is important to evaluate the effectiveness of IVF against other treatment options in couples with unexplained infertility.

OBJECTIVES

To evaluate the effectiveness and safety of IVF compared to expectant management, clomiphene citrate, IUI alone and intrauterine insemination plus controlled ovarian stimulation (IUI+SO).

SEARCH METHODS

Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched July 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, first quarter), MEDLINE (1970 to July 2011), EMBASE (1985 to July 2011) and reference lists of articles were searched. Relevant conference proceedings were handsearched. Authors were contacted.

SELECTION CRITERIA

Randomised controlled trials (RCTs) were included. LBR per woman was the primary outcome.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility and quality of trials.

MAIN RESULTS

Six RCTs were included in the final analysis. LBR per woman was significantly higher with IVF (45.8%) than expectant management (3.7%) (odds ratio (OR) 22.00, 95% confidence interval (CI) 2.56 to 189.37, 1 RCT, 51 women). There were no comparative data for clomiphene citrate. There was no evidence of a significant difference in LBR between IVF and IUI alone (OR 1.96, 95% CI 0.88 to 4.36, 1 RCT, 113 women), 40.7% with IVF versus 25.9% with IUI. In studies comparing IVF versus IUI+SO, LBR per woman did not differ significantly between the groups among treatment-naive women (OR 1.09, 95% CI 0.74 to 1.59, 2 RCTs, 234 women) but was significantly higher in a large RCT of women pretreated with IUI + clomiphene citrate (OR 2.66, 95% CI 1.94 to 3.63, 1 RCT, 341 women). These three studies could not be pooled due to high heterogeneity (I(2) = 84%). There was no evidence of a significant difference in multiple pregnancy rate (MPR) or ovarian hyperstimulation syndrome (OHSS) between the two treatments (OR 0.64, 95% CI 0.31 to 1.29, 3 RCTs, 351 women; OR 1.53, 95% CI 0.25 to 9.49, 1 RCT, 118 women, respectively).

AUTHORS' CONCLUSIONS

IVF may be more effective than IUI+SO. Due to paucity of data from RCTs the effectiveness of IVF for unexplained infertility relative to expectant management, clomiphene citrate and IUI alone remains unproven. Adverse events and the costs associated with these interventions have not been adequately assessed.

The role of intrauterine insemination in male infertility

Male infertility is a common condition and intrauterine insemination (IUI) is used to treat the mild to moderate forms. Male subfertility determination is usually based on routine semen analysis but recent publications have questioned its diagnostic and prognostic accuracy as well as the effectiveness of IUI itself, as a treatment modality. We carried out a structured review of the literature to assess the current evidence regarding the diagnosis of male infertility, the effectiveness and cost effectiveness of IUI in male infertility and factors that affect the outcome of IUI. There is still uncertainty regarding the criteria for diagnosing male infertility and predicting treatment outcome based on standard semen parameters. The presence of seminal defects compromises the outcome of IUI in comparison with unexplained infertility. The total motile sperm count (TMSC) appears to have a consistent, direct relationship with treatment outcome, but there is no definite predictive threshold for success. However, it is reasonable to offer IUI as first-line treatment if TMSC is greater than 10 million when balancing the risk and cost of alternate treatments, such as in vitro fertilization (IVF). Sperm DNA studies and sperm preparation techniques warrant further studies in order to establish their clinical relevance. There are limited data on the clinical and cost-effectiveness of IUI in male infertility and large high-quality randomized controlled trials are warranted. However the difficulties in organizing such a study, at the present time, are a matter for discussion.

A critical appraisal of the evidence for improved fertility indices in undescended testes after gonadotrophin-releasing hormone therapy and orchidopexy

Male fertility depends on the transformation of gonocytes into dark adult spermatogonia, during the first 3 months of postnatal life, and this is an androgen-dependent process. This essential developmental step appears to be defective in undescended testes, and in many patients orchidopexy alone (at the age it is currently performed) does not improve fertility indices, either because it does not address the underlying pathophysiology or the surgery is performed too late. Hormone therapy with gonadotrophin-releasing hormone creates a rise in testosterone levels, copying the postnatal gonadotrophin surge. This can improve germ cell numbers, with the implication of enhanced longer-term fertility. The role of hormone therapy has been controversial, and although favoured at the European Society of Paediatric Urologists' workshops in 2008 and 2009, it is not routine clinical practice in the UK or other countries. We performed a critical appraisal of the key papers in the world literature to evaluate the level of evidence for improved fertility indices, semen analysis and paternity rates following hormone therapy in undescended testes. We suggest that the evidence is sufficiently strong to recommend a change in clinical practice.

Direct health services costs of providing assisted reproduction services in older women

OBJECTIVE

To assess the total health service costs incurred for each live birth achieved by older women undergoing IVF compared with costs in younger women.

DESIGN

Retrospective cross-sectional analysis.

SETTING

In vitro fertilization unit and maternity hospital in a tertiary care setting.

PATIENT(S)

Women who underwent their first cycle of IVF between 1997 and 2006.

INTERVENTION(S)

Bottom-up costs were calculated for all interventions in the IVF cycle. Early pregnancy and antenatal care costs were obtained from National Health Service reference costs, Information Services Division Scotland, and local departmental costs.

MAIN OUTCOME MEASURE(S)

Cost per live birth.

RESULT(S)

The mean cost per live birth (95% confidence interval [CI]) in women undergoing IVF at the age of > or =40 years was pound 40,320 (pound 27,105- pound 65,036), which is >2.5 times higher than those aged 35-39 years (pound 17,096 [pound 15,635- pound 18,937]). The cost per ongoing pregnancy was almost three times in women aged > or =40 (pound 31,642 [pound 21,241- pound 58,979]) compared with women 35-39 years of age (pound 11,300 [pound 10,006- pound 12,938]).

CONCLUSION(S)

The cost of a live birth after IVF rises significantly at the age of 40 years owing to lower success rates. Most of the extra cost is due to the low success of IVF treatment, but some of it is due to higher rates of early pregnancy loss.

"Public" perceptions of gamete donation: a research review

This paper reviews the literature on "public" perceptions of the practice of gamete (egg and sperm) donation in the treatment of infertility. Despite regular "consultation" exercises in the UK on the manner in which infertility treatments should be regulated, there is little sense of how a range of public groups respond to developments in this area. The key themes from thirty-three articles, chapters and reports are discussed. The review reveals the limited nature of our current knowledge of public understandings of and attitudes towards gamete donation as a form of infertility treatment which has been readily available and widely practiced for many years. The review is critical of the methodological and epistemological basis of much of the work in this area and argues that there is a strong case for social scientific research to attempt to capture the perceptions of a wider range of people who are rarely included in formal public consultations and often similarly excluded from research studies.

Strategies to reduce multiple pregnancies due to ovulation stimulation

OBJECTIVE

To review factors associated with high-order multiple births (HOMB) due to ovulation induction (OI) and the efficacy of strategies to reduce their occurrence.

DESIGN

Retrospective analysis of published studies of OI with intrauterine insemination (IUI) where patient and cycle characteristics were fully documented.

RESULT(S)

High-order multiple pregnancies (HOMP) were positively related to use of high doses of gonadotropin, number of 7-10 mm preovulatory follicles, and E(2), and inversely related to age and number of treatment cycles. Strategies successful in reducing HOMP include: use of clomiphene (CC) before gonadotropins, minimal gonadotropin doses, cancellation for more than three follicles >10-15 mm, and aspiration of excess follicles. Depending on the strategy used, 5%-20% of cycles may be canceled but HOMP rates can be less than 2% and pregnancy rates can average 10%-20% per cycle. Pregnancy rates per patient need not be reduced if low doses are continued for 4-6 cycles.

CONCLUSION(S)

High-order multiple pregnancies due to OI can be reduced to 2% or less by less aggressive stimulation without reducing overall chances of pregnancy for most patients.

Stimulated intrauterine insemination (SIUI) and donor insemination (DI) as first line management for a selected subfertile population: the Manchester experience

PURPOSE

The objective of our study is to investigate the optimum number of stimulated intrauterine insemination (SIUI) or donor insemination (DI) cycles that can be offered to the couples prior to in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) in a tertiary referral unit for assisted reproduction.

METHODS

This is a retrospective analysis of 408 SIUI and 704 DI cycles performed in a tertiary referral unit for assisted reproduction. SIUI's were performed by controlled ovarian hyperstimulation and ovulation induction followed by insemination 36 h later. DI's were performed in natural or stimulated cycles after thawing frozen donor sperm. The main outcome measured was cumulative live birth rate (CLBR) per couple.

RESULTS

A maximum CLBR of 26.1% was achieved after the fourth cycle of SIUI. The CLBR of DI increased to 60.1% in the sixth cycle.

CONCLUSIONS

This study, in line with a number of other studies, is unable to demonstrate unequivocally whether increasing numbers of IUI or DI cycles are justified clinically or financially. There is a need for larger datasets from multiple centres along with rigorous randomised trials to compare treatment pathways. Until then, the resources spent on the provision of extra SIUI cycles may be better utilized by early referral to IVF.

Infertility and the provision of infertility medical services in developing countries

BACKGROUND

Worldwide more than 70 million couples suffer from infertility, the majority being residents of developing countries. Negative consequences of childlessness are experienced to a greater degree in developing countries when compared with Western societies. Bilateral tubal occlusion due to sexually transmitted diseases and pregnancy-related infections is the most common cause of infertility in developing countries, a condition that is potentially treatable with assisted reproductive technologies (ART). New reproductive technologies are either unavailable or very costly in developing countries. This review provides a comprehensive survey of all important papers on the issue of infertility in developing countries.

METHODS

Medline, PubMed, Excerpta Medica and EMBASE searches identified relevant papers published between 1978 and 2007 and the keywords used were the combinations of 'affordable, assisted reproduction, ART, developing countries, health services, infertility, IVF, simplified methods, traditional health care'.

RESULTS

The exact prevalence of infertility in developing countries is unknown due to a lack of registration and well-performed studies. On the other hand, the implementation of appropriate infertility treatment is currently not a main goal for most international non-profit organizations. Keystones in the successful implementation of infertility care in low-resource settings include simplification of diagnostic and ART procedures, minimizing the complication rate of interventions, providing training-courses for health-care workers and incorporating infertility treatment into sexual and reproductive health-care programmes.

CONCLUSIONS

Although recognizing the importance of education and prevention, we believe that for the reasons of social justice, infertility treatment in developing countries requires greater attention at National and International levels.

Distributive justice and infertility treatment in Canada

An exploration of distributive justice in Canadian infertility treatment requires the integration of ethical, clinical, and economic principles. In 1971, American philosopher John Rawls proposed a theoretical model for fair decision-making in which "rational" and "self-interested" citizens are behind a "veil of ignorance" with respect to both their own position and the position of other decision-makers. Rawls proposed that these self-interested decision-makers, fearing that they are among the least advantaged persons who could be affected by the decision, will agree only upon rules that encode equality of opportunity and that bestow the greatest benefit on the least advantaged citizens. Regarding health policy decision-making, Rawls' model is best illustrated by Canadian philosopher Warren Bourgeois in his panel of "volunteers." These rational and self-interested volunteers receive an amnestic drug that renders them unaware of their health, social, and financial position, but they know that they are representative of diverse spheres of citizens whose well-being will be affected by their decision. After describing fair decision-making, Bourgeois considers the lack of a distributive justice imperative in Canada's Assisted Human Reproduction Act, in contrast to legislation in European nations and Australia, summarizes the economic and clinical considerations that must be provided to the decision-makers behind the "veil of ignorance" for fair decisions to occur, and considers altruism in relation to equality of access. He concludes by noting that among countries with legislation governing assisted reproduction Canada is alone in having legislation that is void of distributive justice in providing access to clinically appropriate infertility care.

Comparison of single versus double intrauterine insemination

OBJECTIVE

To compare the outcomes of single versus double intrauterine insemination.

MATERIALS AND METHODS

This prospective randomized study was carried out in 100 infertile patients. One intrauterine insemination was applied 36 hours after human chorionic gonadotropin (hCG) injection to 50 patients in the first group. To 50 patients in the second group, two intrauterine inseminations were applied, of which the first was applied 24 hours after and the second 48 hours after the hCG injection.

RESULTS

In the first group, pregnancies were detected in eight patients (pregnancy rate per patient was 16%, pregnancy rate per cycle was 10.6%). In the second group, pregnancies were detected in five patients (pregnancy rate per patient was 10%, pregnancy rate per cycle was 6.4%). There was no statistically significant difference between the two groups ( p > 0.05).

CONCLUSION

Single intrauterine insemination can be considered to be more reasonable than double intrauterine insemination treatment, taking into consideration the economic cost and the psychologic trauma to the patients. However, further studies with larger sample sizes are needed in order to reveal any actual differences between the two methods.

The cost effectiveness of intracyctoplasmic sperm injection (ICSI)

PURPOSE

To estimate the incremental cost effectiveness of ICSI, and total costs for the population of Australia.

METHODS

Treatment effects for three patient groups were drawn from a published systematic review and meta-analysis of trials comparing fertilisation outcomes for ICSI. Incremental costs derived from resource-based costing of ICSI and existing practice comparators for each patient group.

RESULTS

Incremental cost per live birth for patients unsuited to IVF is estimated between A$8,500 and 13,400. For the subnormal semen indication, cost per live birth could be as low as A$3,600, but in the worst case scenario, there would just be additional incremental costs of A$600 per procedure. Multiplying out the additional costs of ICSI over the relevant target populations in Australia gives potential total financial implications of over A$31 million per annum.

CONCLUSION

While there are additional benefits from ICSI procedure, particularly for those with subnormal sperm, the additional cost for the health care system is substantial.

Cost-effectiveness analysis of guidelines for antihypertensive care in Finland

BACKGROUND

Hypertension is one of the major causes of disease burden affecting the Finnish population. Over the last decade, evidence-based care has emerged to complement other approaches to antihypertensive care, often without health economic assessment of its costs and effects. This study looks at the extent to which changes proposed by the 2002 Finnish evidence-based Current Care Guidelines concerning the prevention, diagnosis, and treatment of hypertension (the ACCG scenario) can be considered cost-effective when compared to modelled prior clinical practice (the PCP scenario).

METHODS

A decision analytic model compares the ACCG and PCP scenarios using information synthesised from a set of national registers covering prescription drug reimbursements, morbidity, and mortality with data from two national surveys concerning health and functional capacity. Statistical methods are used to estimate model parameters from Finnish data. We model the potential impact of the different treatment strategies under the ACCG and PCP scenarios, such as lifestyle counselling and drug therapy, for subgroups stratified by age, gender, and blood pressure. The model provides estimates of the differences in major health-related outcomes in the form of life-years and costs as calculated from a 'public health care system' perspective. Cost-effectiveness analysis results are presented for subgroups and for the target population as a whole.

RESULTS

The impact of the use of the ACCG scenario in subgroups (aged 40-80) without concomitant cardiovascular and related diseases is mainly positive. Generally, costs and life-years decrease in unison in the lowest blood pressure group, while in the highest blood pressure group costs and life-years increase together and in the other groups the ACCG scenario is less expensive and produces more life-years. When the costs and effects for subgroups are combined using standard decision analytic aggregation methods, the ACCG scenario is cost-saving and more effective.

CONCLUSION

The ACCG scenario is likely to reduce costs and increase life-years compared to the PCP scenario in many subgroups. If the estimated trade-offs between the subgroups in terms of outcomes and costs are acceptable to decision-makers, then widespread implementation of the ACCG scenario is expected to reduce overall costs and be accompanied by positive outcomes overall.

The cost effectiveness of opportunistic chlamydia screening in England

BACKGROUND/AIM

The National Chlamydia Screening Programme (NCSP) is being implemented in England. This study aims to estimate the cost effectiveness of (a) the NCSP strategy (annual screening offer to men and women aged under 25 years) and (b) alternative screening strategies.

METHODS

A stochastic, individual based, dynamic sexual network model was combined with a cost effectiveness model to estimate the complications and associated costs of chlamydial infection. The model was constructed and parameterised from the perspective of the National Health Service (NHS) (England), including the direct costs of infection, complications and screening. Unit costs were derived from standard data sources and published studies. The average and incremental cost effectiveness ratio (cost per major outcome averted or quality adjusted life year (QALY) gained) of chlamydia screening strategies targeting women and/or men of different age groups was estimated. Sensitivity analyses were done to explore model uncertainty.

RESULTS

All screening strategies modelled are likely to cost the NHS money and improve health. If pelvic inflammatory disease (PID) progression is less than 10% then screening at any level is unlikely to be cost effective. However, if PID progression is 10% or higher the NCSP strategy compared to no screening appears to be cost effective. The incremental cost effectiveness analysis suggests that screening men and women aged under 20 years is the most beneficial strategy that falls below accepted thresholds. There is a high degree of uncertainty in the findings.

CONCLUSIONS

Offering an annual screening test to men and women aged under 20 years may be the most cost effective strategy (that is, under accepted thresholds) if PID progression is 10% or higher.

Endometriosis: cost estimates and methodological perspective

This article aims to provide a systematic review of estimates and methodology of studies quantifying the costs of endometriosis. Included studies were cost-of-illness analyses quantifying the economic impact of endometriosis and cost analyses calculating diagnostic and treatment costs of endometriosis. Annual healthcare costs and costs of productivity loss associated with endometriosis have been estimated at $2801 and $1023 per patient, respectively. Extrapolating these findings to the US population, this study calculated that annual costs of endometriosis attained $22 billion in 2002 assuming a 10% prevalence rate among women of reproductive age. These costs are considerably higher than those related to Crohn's disease or to migraine. To date, it is not possible to determine whether a medical approach is less expensive than a surgical approach to treating endometriosis in patients presenting with chronic pelvic pain. Evidence of endometriosis costs in infertile patients is largely lacking. Cost estimates were biased due to the absence of a control group of patients without endometriosis, inadequate consideration of endometriosis recurrence and restricted scope of costs. There is a need for more and better-designed studies that carry out longitudinal analyses of patients until the cessation of their symptoms or that model the chronic nature of endometriosis.

Tubal disease: towards a classification

Tubal disease is a major cause of infertility. The amount of damage can vary greatly in extent, anatomical location and nature. For women with infertility due to tubal disease, prognostication for pregnancy often remains unclear and there is no universally accepted classification. A classification system that reliably distinguishes infertile patients with tubal disease into favourable and unfavourable groups would be useful if subsequent management could depend on this assessment, especially if the classification is able to define which group of patients would benefit most from interventions such as surgery. The progress of IVF questions the contribution of the Fallopian tube to the successful achievement of pregnancy in infertile women. Nonetheless, several studies reveal that severity is the key factor in the determining outcome, and the classifications reviewed in this paper imply that women with tubal disease could be categorized into prognostic groups using a simple classification system based on severity. However, prospective trials are needed to validate and assert the usefulness of any particular classification.

Coste de las técnicas de reproducción asistida en un hospital público

OBJECTIVES

Most studies on the costs of assisted reproductive technologies (ART) identify the total cost of the procedure with the direct cost, without considering important items such as overhead or intermediate costs. The objective of this study was to determine the cost per ART procedure in a public hospital in 2003 and to compare the results with those in the same hospital in 1998.

METHODS

Data from the Human Reproduction Unit of the Virgen de las Nieves University Hospital in Granada (Spain) from 1998 and 2003 were analyzed. Since the total costs of the unit were known, the cost of the distinct ART procedures performed in the hospital was calculated by means of a methodology for cost distribution.

RESULTS

Between 1998 and 2003, the activity and costs of the Human Reproduction Unit analyzed evolved differently. Analysis of activity showed that some techniques, such as intracytoplasmic sperm injection, were consolidated while others, such as stimulation without assisted reproduction or intracervical insemination were abandoned. In all procedures, unit costs per cycle and per delivery decreased in the period analyzed.

CONCLUSIONS

Important changes took place in the structure of costs of ART in the Human Reproduction Unit of the Virgen de las Nieves University Hospital between 1998 and 2003. Some techniques were discontinued, while others gained importance. Technological advances and structural innovations, together with a "learning effect," modified the structure of ART-related costs.

Cost-effectiveness of primary offer of IVF vs. primary offer of IUI followed by IVF (for IUI failures) in couples with unexplained or mild male factor subfertility

Background

In unexplained and mild male factor subfertility, both intrauterine insemination (IUI) and in-vitro fertilisation (IVF) are indicated as first line treatments. Because the success rate of IUI is low, many couples failing IUI subsequently require IVF treatment. In practice, it is therefore important to examine the comparative outcomes (live birth-producing pregnancy), costs, and cost-effectiveness of primary offer of IVF, compared with primary offer of IUI followed by IVF for couples failing IUI.

Methods

Mathematical modelling was used to estimate comparative clinical and cost effectiveness of either primary offer of one full IVF cycle (including frozen cycles when applicable) or "IUI + IVF" (defined as primary IUI followed by IVF for IUI failures) to a hypothetical cohort of subfertile couples who are eligible for both treatment strategies. Data used in calculations were derived from the published peer-reviewed literature as well as activity data of local infertility units.

Results

Cost-effectiveness ratios for IVF, "unstimulated-IUI (U-IUI) + IVF", and "stimulated IUI (S-IUI) + IVF" were £12,600, £13,100 and £15,100 per live birth-producing pregnancy respectively. For a hypothetical cohort of 100 couples with unexplained or mild male factor subfertility, compared with primary offer of IVF, 6 cycles of "U-IUI + IVF" or of "S-IUI + IVF" would cost an additional £174,200 and £438,000, representing an opportunity cost of 54 and 136 additional IVF cycles and 14 to 35 live birth-producing pregnancies respectively.

Conclusion

For couples with unexplained and mild male factor subfertility, primary offer of a full IVF cycle is less costly and more cost-effective than providing IUI (of any modality) followed by IVF.

Predictive value of the hemizona assay for pregnancy outcome in patients undergoing controlled ovarian hyperstimulation with intrauterine insemination

OBJECTIVE

The hemizona assay (HZA) is an established functional test that examines in vitro sperm-zona pellucida binding capacity with high predictive power for fertilization outcome in IVF. The objective of this study was to evaluate the value of the HZA as a predictor of pregnancy in patients undergoing controlled ovarian hyperstimulation (COH) and intrauterine insemination (IUI).

DESIGN

Prospective clinical study.

SETTING

Academic center.

PATIENT(S)

Eighty-two couples with unexplained or male factor infertility that underwent 313 IUI cycles.

INTERVENTION(S)

Basic semen analysis and HZA were performed within three months of starting COH/IUI therapy.

MAIN OUTCOME MEASURE(S)

Hemizona index (HZI) and clinical pregnancy.

RESULT(S)

Overall, patients with an HZI of <30 had a significantly lower pregnancy rate compared to patients with an HZI of > or =30 (11.1% vs. 40.6%, respectively; P<.05; relative risk for failure to conceive: 1.5 (confidence interval 1.2-1.9)). In all patients combined, and in the range of HZI 0-60, the duration of infertility (P=.000) and the HZI (P=.004) were significant determinants of conception (receiver operating characteristics (ROC) analysis). In couples with male infertility, the average path velocity and HZI were significant predictors of conception (P=.001 and P=.005, respectively, ROC analysis). The negative and positive predictive values of the HZA for pregnancy were 93% and 69%, respectively. Logistic regression analysis provided models of HZI (P=.021) and duration of infertility (P=.037) with highest predictability of conception in male factor and unexplained infertility groups, respectively.

CONCLUSION(S)

The HZA predicted pregnancy in the IUI setting with high sensitivity and negative predictive value in couples with male infertility. Results of this sperm function test are useful in counseling couples before allocating them into COH/IUI therapy.

Perinatal outcome of 12,021 singleton and 3108 twin births after non-IVF-assisted reproduction: a cohort study

Perinatal outcome of pregnancies caused by assisted reproduction technique (ART) is substantially worse when compared with pregnancies following natural conception. We investigated the possible risks of non-IVF ART on perinatal health. We conducted a retrospective cohort study with two exposure groups: a study group of pregnancies after controlled ovarian stimulation (COS), with or without artificial insemination (AI), and a naturally conceived comparison group. We used the data from the regional registry of all hospital deliveries in the Dutch-speaking part of Belgium during the period from January 1993 until December 2003 to investigate differences in perinatal outcome of singleton and twin pregnancies. 12 021 singleton and 3108 twin births could be selected. Naturally conceived subjects were matched for maternal age, parity, fetal sex and year of birth. The main outcome measures were duration of pregnancy, birth weight, perinatal morbidity and perinatal mortality. Our overall results showed a significantly higher incidence of prematurity (<32 and <37 weeks), low and very low birth weight, transfer to the neonatal intensive care unit and most neonatal morbidity parameters for COS/AI singletons. Twin pregnancies resulting from COS/AI showed an increased rate of neonatal mortality, assisted ventilation and respiratory distress syndrome. After excluding same-sex twin sets, COS/AI twin pregnancies were at increased risk for extreme prematurity and very low birth weight. In conclusion, COS/AI singleton and twin pregnancies are significantly disadvantaged compared to naturally conceived children.

Should endometriomas be treated before IVF–ICSI cycles?

The laparoscopic excision of ovarian endometriomas appears to increase the chances of spontaneous conception, but the value of this treatment in women selected for IVF-ICSI cycles is debated. Studies recruiting women with unilateral disease and comparing ovarian responsiveness in the affected and contralateral intact gonads indicate that excision of endometriomas is associated with a quantitative damage to ovarian reserve. There are no randomized trials comparing laparoscopic excision to expectant management before IVF-ICSI cycles. The idea that surgery increases IVF pregnancy rates is not supported by the available evidence. However, the chance of conception is not the only issue that has to be considered. Some potential drawbacks are associated with both therapeutical strategies. Specifically, costs and hazard of surgical complications support expectant management whereas oocyte retrieval risks, the possibility of missing occult malignancy and endometriosis progression due to ovarian stimulation would favour surgical treatment. Alternative therapeutical options include medical treatment and ultrasound-guided aspiration. Whereas prolonged GnRH agonist down-regulation may be beneficial, data on ultrasound aspiration are more controversial.

Diagnosing infertility in a district general hospital: a case-note and cost analysis

This study aimed to observe diagnostic work-up and cost evaluation of infertile couples to identify opportunities for improvement. One hundred and seventy-four new referrals to the gynaecology clinic in a District General Hospital during 1996 and 1997 provided the cohort for analysis. Data from case notes were transferred on to data collection sheets. Data were inputted into SPSS for analysis. Primary infertility accounted for 62% of couples. One hundred and forty-two couples (81.6%) had a definitive diagnosis, and the analyses relate to these couples only. There was no single investigation performed on the whole cohort studied. Semen analysis was undertaken in 80.3% of the couples; couples with suspected male infertility were over four times more likely to have had more than two semen tests (P = 0.0005); 77.5% of couples had FSH and LH tests; and midluteal progesterone was tested in 76.1%. An increased intensity of FSH-LH hormone testing was associated with couples with anovulation (chi(2) = 6.79, P = 0.03). Serial repeat progesterone tended to be given to women with irregular or prolonged cycles (35 days or more), although this tendency was not statistically significant. The most common test for tubal patency was hysterosalpingography. Higher costs are generally associated with diagnosing endometriosis and tubal factor because of the relatively high cost of laparoscopy. The average cost of diagnosis for each patient was pound 365 and ranged from pound 64 to pound 851. In conclusion, a standard protocol of basic investigative procedures should be offered in secondary centres to all couples. Avoiding duplication and unnecessary investigations (for example, serial progesterone) may reduce costs, although offering all couples a standard protocol of tests would probably offset this observation.

In vitro fertilisation for unexplained subfertility

BACKGROUND

In vitro fertilisation (IVF) is now a widely accepted treatment for unexplained infertility (RCOG 1998). However, with estimated live-birth rates per cycle varying between 13% and 28%, its effectiveness has not been rigorously evaluated in comparison with other treatments. With increasing awareness of the role of expectant management and less invasive procedures such as intrauterine insemination, concerns about multiple complications and costs associated with IVF, it is extremely important to evaluate the effectiveness of IVF against other treatment options in couples with unexplained infertility.

OBJECTIVES

The aim of this review is to determine, in the context of unexplained infertility, whether IVF improves the probability of live-birth compared with (1) expectant management, (2) clomiphene citrate (CC), (3) intrauterine insemination (IUI) alone, (4) IUI with controlled ovarian stimulation, and (5) gamete intrafallopian transfer (GIFT).

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched 23 March 2004), the Cochrane Central Register of Controlled Trials (Cochrane Library Issue 3, 2004), MEDLINE (1970 to August 2004), EMBASE (1985 to August 2004) and reference lists of articles. We also handsearched relevant conference proceedings and contacted researchers in the field.

SELECTION CRITERIA

Only randomised controlled trials were included. Live-birth rate per woman was the primary outcome of interest.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed eligibility and quality of trials.

MAIN RESULTS

Ten randomised controlled trials were identified. In two we could not extract data separately for unexplained infertility cases, two were non-randomised, one did not report valid rates (included in the review but not in the meta-analysis); leaving four trials for analysis. One trial compared two different interventions (IVF versus IUI with or without ovarian stimulation) and one study compared three interventions (IVF versus IUI with ovarian stimulation and GIFT). The numbers of trials assessing the effectiveness of IVF with the other treatments were as follows: IVF versus expectant management (two), IVF versus IUI (one), IVF versus IUI with ovarian stimulation (two) and IVF versus GIFT (three). Live-birth rate per woman was reported in three studies and three studies determined clinical pregnancy rate per woman. Multiple pregnancy rate was reported in three trials. Two studies reported ovarian hyperstimulation syndrome (OHSS) as an outcome measure. There were no comparative data for clomiphene citrate and no comparative data on live-birth rates for GIFT. There was no evidence of a difference in live-birth rates between IVF and IUI either without (OR 1.96; 95% CI 0.88 to 4.4) or with (OR 1.15; 95% CI 0.55 to 2.4) ovarian stimulation. There were significantly higher clinical pregnancy rates with IVF in comparison to expectant management (OR 3.24; 95% CI 1.07 to 9.80). There was no significant difference between IVF and GIFT for the one RCT that reported live-birth rates (OR 2.57; 95% CI 0.93 to 7.08). However, there was a significant difference in the clinical pregnancy rates between IVF and GIFT, with pregnancy rates greater for IVF (OR 2.14; 95% CI 1.08 to 4.2). There was no evidence of a difference in the multiple pregnancy rates between IVF and IUI with ovarian stimulation (OR 0.63; 95% CI 0.27 to 1.5), however, IVF had a higher rate than GIFT (OR 6.3; 95% CI 1.7 to 23). Clinical heterogeneity was present among the studies included. However, there was no evidence of statistical heterogeneity, which allowed the studies to be combined for statistical analysis.

AUTHORS' CONCLUSIONS

Any effect of IVF relative to expectant management, clomiphene citrate, IUI with or without ovarian stimulation and GIFT in terms of live-birth rates for couples with unexplained subfertility remains unknown. The studies included are limited by their small sample size so that even large differences might be hidden. Live-birth rates are seldom reported. Periods of follow up are inadequate and unequal. Adverse effects such as multiple pregnancies and ovarian hyperstimulation syndrome have also not been reported in most studies. Larger trials with adequate power are warranted to establish the effectiveness of IVF in these women. Future trials should not only report rates per woman/couple but also include adverse effects and costs of the treatments as outcomes. Factors that have a major effect on these outcomes such as fertility treatment, female partner's age, duration of infertility and previous pregnancy history should also be considered.

The reproductive performance of women with hypogonadotropic hypogonadism in an in vitro fertilization and embryo transfer program

PURPOSE

To evaluate the outcome of women with hypogonadotropic hypogonadism undergoing in-vitro fertilization (IVF).

METHODS

We retrospectively assessed outcomes in 58 women with hypogonadotropic hypogonadism (HH) and, as matched controls, in 116 women with tubal factor (TF) infertility who underwent assisted reproduction treatment (ART). For ovulation induction, human menopausal gonadotropin (hMG) was used in HH patients and a combination of hMG and gonadotropin releasing hormone (GnRH) agonist was used in TF patients. Conception and implantation rates, as well as duration of stimulation and number of oocytes retrieved, were the main outcome measures.

RESULTS

Of the 58 HH patients, 53 (91.3%) responded adequately to ovulation induction and underwent ET. A larger amount of gonadotropins and a longer duration of ovarian stimulation were needed in HH patients than in TF patients. The mean number of retrieved oocytes and implantation rates did not differ between the groups. In addition, there were no differences between the HH and TF groups in pregnancy (53.8 vs. 48.6%) and multiple pregnancy (63.4 vs. 48.4%) rates. In the HH group, the miscarriage rate was 3.4%, and none of these patients developed severe OHSS.

CONCLUSION

IVF in HH patients, in which there was a background of previous failed ovulation induction, was as successful as in women with TF infertility.

Impact of isolated teratozoospermia on the outcome of intrauterine insemination

One thousand six hundred forty-one IUI cycles performed in 615 couples were categorized, depending on the semen analysis of the male partner, in three groups of: normozoospermia, teratozoospermia, and male factor infertility. Clinical pregnancies and live births per cycle were significantly decreased in the teratozoospermia group when compared to the normozoospermia group, with the exception of the first IUI attempt (comparable outcomes), whereas the cumulative live birth rate after four IUI attempts was significantly lower in the teratozoospermia and male factor infertility groups.

Should We Continue Performing Intrauterine Inseminations in the Year 2004?

This review summarizes the existing evidence regarding intrauterine insemination (IUI) as a treatment for cervical hostility, male and unexplained subfertility. IUI in natural cycles has been proven effective in patients with cervical hostility and moderate male subfertility. IUI in cycles with mild ovarian hyperstimulation (MOH) should be the treatment of choice in couples with mild male subfertilty (average total motile sperm count above 10 million) and unexplained subfertilty. When MOH is applied, gonadotropins have been proven more effective compared with clomiphene citrate. Further large trials comparing clomiphene citrate with gonadotropins are mandatory. Prevention of multiple pregnancies in MOH/IUI programs is of paramount importance. A strategy with a low-dose step-up protocol and strict cancellation criteria is proposed. When multiple pregnancies are kept to a minimum, MOH/IUI is more cost-effective compared with in vitro fertilization and embryo transfer. Future research should focus on prediction models to predict the outcome of MOH/IUI treatment for individual couples before starting treatment.

Multiple gestation and infertility treatment: registration, reflection and reaction—the Belgian project

Multiple pregnancies associated with infertility treatment are recognized as an adverse outcome and are responsible for morbidity and mortality related to prematurity and very low birthweight population. Due to the epidemic of iatrogenic multiple births, the incidence of maternal, perinatal and childhood morbidity and mortality has increased. This results in a hidden healthcare cost of infertility therapy and this may lead to social and political concern. Reducing the number of embryos transferred and the use of natural cycle IVF will surely decrease the number of multiple gestations. Consequently, optimized cryopreservation programmes will be essential. For non-IVF hormonal stimulation, responsible for more than one-third of all multiple pregnancies after infertility treatment, a strict ovarian stimulation protocol aiming at mono-ovulation is crucial. Multifetal pregnancy reduction is an effective method to reduce high order multiplets but carries its own risk of medical and emotional complications. Excellent data collection of all infertility treatments is needed in our discussion with policy makers. The Belgian project, in which reimbursement of assisted reproduction technology-related laboratory activities is linked to a transfer policy aiming at substantial multiple pregnancy reduction, is a good example of cost-efficient health care through responsible, well considered clinical practice.

Low dose recombinant FSH treatment may reduce multiple gestations caused by controlled ovarian hyperstimulation and intrauterine insemination

OBJECTIVE

To evaluate the rate of multiple pregnancies in intrauterine insemination cycles stimulated with a minimal dose of recombinant follicle stimulating hormone (rec-FSH).

DESIGN

Retrospective study.

SETTING

University Medical Center.

POPULATION

A total of 1256 patients underwent 3219 consequent intrauterine insemination cycles with minimal ovarian stimulation.

METHODS

Patients received 50 or 75 IU of rec-FSH from day four to day seven. The dose was adjusted according to oestradiol (E(2)) levels in order to achieve a maximum of two follicles on the day of hCG administration.

MAIN OUTCOME MEASURES

Peak E(2) levels, the number of follicles >15 mm and pregnancy rates were calculated. The predictive value of E(2) levels for multiple gestations was also estimated.

RESULTS

Of 3219 cycles, 334 resulted in pregnancies (10%). Of these, 238 (91%) were singletons, 28 (8%) twins and 1 (0.3%) was a triplet. The cumulative overall pregnancy rate was 43%. Patients over 40 years old had a significantly lower pregnancy rate per cycle and overall live birth rate (P < 0.05). Most pregnancies (83%) occurred during the first three cycles. Pregnancy rates per cycle varied from 8% for tubal factor to 14% for anovulation infertility.

CONCLUSIONS

Minimal FSH stimulation in intrauterine insemination cycles may reduce the rates of twins and high order multiple pregnancies without affecting overall pregnancy rates.

Insémination intra-utérine : état des lieux chez l’humain

Despite its being used for a long time, intrauterine insemination (i.u.i.) remains debated as to its precise place and efficacy among assisted reproductive technologies. Data issued from the French Health Ministry inquiries are strictly limited to the number of cycles and the pregnancies and births including the multiple ones. Concerning 2000, more than 44,000 cycles were registered with 8% deliveries per cycle and 12% multiple pregnancies. Apart from the cervical female infertility which is considered to have the best prognosis with i.u.i., literature data remain controversial with male and unexplained infertility. Prospective randomized studies are rather scarce, particularly when considering the inclusion of untreated control population. Meta-analyses have been published for ten years, which allowed to better define the place of i.u.i. in patient management. However one may notice that the sperm cut-off parameters for male infertility and the respective contribution of i.u.i. and ovulation treatment do not allow develop some evidence-based guidelines for i.u.i. good practice. Quite all meta-analyses modulated their conclusions by addressing the need for large randomized controlled studies. Such a need seems now quite reinforced since results were until now expressed as pregnancy rate per cycle or pregnancy rate per couple, whereas single live birth rate and drop out rate are claimed to be taken into account nowadays. Moreover the level of controlled hyperstimulation is highly questionable with both hyperstimulation ovary syndrome and multiple pregnancy risks. Patients facing with failed i.u.i. cycles may turn to i.v.f. or i.c.s.i.. Interestingly data coming from the French national register (FIVNAT) did not show major differences between couples turning to i.v.f. (i.c.s.i.) after previously failed i.u.i. cycles or using directly i.v.f. (i.c.s.i.). Moreover the prognostic as evaluated on pregnancy rate per cycle was unchanged between such patients, which does not support some selection of patients by i.u.i. failure. Thus, although i.u.i. seems likely a cost-effective treatment in infertile couples, the precise conditions of its management (spontaneous or stimulated cycle, mono-, pauci- or multi-follicular induction) remain to be assessed. Indeed large controlled randomized studies including untreated group are required even if such design might have a non negligible cost. However these rather common treatments do have a high cost and any effort to rationalise them will have some economical impact. Another practical approach, although less ambitious, might consist in developing a per cycle registry which should allow to precise the French practice at a large national level.