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Si Y, Tan T, Pu K. Systematic review of the economic evaluation model of assisted reproductive technology. HEALTH ECONOMICS REVIEW 2024; 14:34. [PMID: 38767759 PMCID: PMC11103951 DOI: 10.1186/s13561-024-00509-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 04/26/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND With the increasing demand for fertility services, it is urgent to select the most cost-effective assisted reproductive technology (ART) treatment plan and include it in medical insurance. Economic evaluation reports are an important reference for medical insurance negotiation. The aim of this study is to systematically evaluate the economic evaluation research of ART, analyze the existing shortcomings, and provide a reference for the economic evaluation of ART. METHODS PubMed, EMbase, Web of Science, Cochrane Library and ScienceDirect databases were searched for relevant articles on the economic evaluation of ART. These articles were screened, and their quality was evaluated based on the Comprehensive Health Economics Evaluation Report Standard (CHEERS 2022), and the data on the basic characteristics, model characteristics and other aspects of the included studies were summarized. RESULTS One hundred and two related articles were obtained in the preliminary search, but based on the inclusion criteria, 12 studies were used for the analysis, of which nine used the decision tree model. The model parameters were mainly derived from published literature and included retrospective clinical data of patients. Only two studies included direct non-medical and indirect costs in the cost measurement. Live birth rate was used as an outcome indicator in half of the studies. CONCLUSION Suggesting the setting of the threshold range in the field of fertility should be actively discussed, and the monetary value of each live birth is assumed to be in a certain range when the WTP threshold for fertility is uncertain. The range of the parameter sources should be expanded. Direct non-medical and indirect costs should be included in the calculation of costs, and the analysis should be carried out from the perspective of the whole society. In the evaluation of clinical effect, the effectiveness and safety indexes should be selected for a comprehensive evaluation, thereby making the evaluation more comprehensive and reliable. At least subgroup analysis based on age stratification should be considered in the relevant economic evaluation.
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Affiliation(s)
- Yuxin Si
- School of Medical Informatics, Chongqing Medical University, Chongqing, 400016, China
| | - Tao Tan
- Chongqing Health Statistics Information Center, Chongqing, 401120, China.
| | - Kexue Pu
- School of Medical Informatics, Chongqing Medical University, Chongqing, 400016, China.
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Guner JZ, Monsivais D, Yu H, Stossi F, Johnson HL, Gibbons WE, Matzuk MM, Palmer S. Oral follicle-stimulating hormone receptor agonist affects granulosa cells differently than recombinant human FSH. Fertil Steril 2023; 120:1061-1070. [PMID: 37532169 PMCID: PMC10659100 DOI: 10.1016/j.fertnstert.2023.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 08/04/2023]
Abstract
OBJECTIVE To determine whether TOP5300, a novel oral follicle-stimulating hormone (FSH) receptor (FSHR) allosteric agonist, elicits a different cellular response than recombinant human FSH (rh-FSH) in human granulosa cells from patients undergoing in vitro fertilization. DESIGN Basic science research with a preclinical allosteric FSHR agonist. SETTING University hospital. PATIENT(S) Patients with infertility at a single academic fertility clinic were recruited under an Institutional Review Board-approved protocol. Primary granulosa cell cultures were established for 41 patients, of whom 8 had normal ovarian reserve (NOR), 17 were of advanced reproductive age (ARA), 12 had a diagnosis of polycystic ovary syndrome (PCOS), and 4 had a combination of diagnoses, such as ARA and PCOS. INTERVENTION(S) Primary granulosa-lutein (GL) cell cultures were treated with rh-FSH, TOP5300, or vehicle. MAIN OUTCOME MEASURE(S) Estradiol (E2) production using enzyme-linked immunosorbent assay, steroid pathway gene expression of StAR and aromatase using quantitative polymerase chain reaction, and FSHR membrane localization using immunofluorescence were measured in human GL cells. RESULT(S) TOP5300 consistently stimulated E2 production among patients with NOR, ARA, and PCOS. Recombinant FSH was the more potent ligand in GL cells from patients with NOR but was ineffective in cells from patients with ARA or PCOS. The lowest level of FSHR plasma membrane localization was seen in patients with ARA, although FSHR localization was more abundant in cells from patients with PCOS; the highest levels were present in cells from patients with NOR. The localization of FSHR was not affected by TOP5300 relative to rh-FSH in any patient group. TOP5300 stimulated greater expression of StAR and CYP19A1 across cells from all patients with NOR, ARA, and PCOS combined, although rh-FSH was unable to stimulate StAR and aromatase (CYP19A1) expression in cells from patients with PCOS. TOP5300-induced expression of StAR and CYP19A1 mRNA among patients with ARA and NOR was consistently lower than that observed in cells from patients with PCOS. CONCLUSION(S) TOP5300 appears to stimulate E2 production and steroidogenic gene expression from GL cells more than rh-FSH in PCOS, relative to patients with ARA and NOR. It does not appear that localization of FSHR at cell membranes is a limiting step for TOP5300 or rh-FSH stimulation of steroidogenic gene expression and E2 production.
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Affiliation(s)
- Joie Z Guner
- Center for Drug Discovery, Baylor College of Medicine, Houston, Texas; Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California
| | - Diana Monsivais
- Center for Drug Discovery, Baylor College of Medicine, Houston, Texas; Department of Pathology and Immunology, Baylor College of Medicine, One Baylor Plaza, Houston, Texas
| | - Henry Yu
- CanWell Pharma, Wellesley, Massachusetts
| | - Fabio Stossi
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, Texas; Integrated Microscopy Core and GCC Center for Advanced Microscopy and Image Informatics, Baylor College of Medicine, Houston, Texas
| | - Hannah L Johnson
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, Texas; Integrated Microscopy Core and GCC Center for Advanced Microscopy and Image Informatics, Baylor College of Medicine, Houston, Texas
| | - William E Gibbons
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Baylor College of Medicine, and Texas Children's Hospital Family Fertility Center, Houston, Texas
| | - Martin M Matzuk
- Center for Drug Discovery, Baylor College of Medicine, Houston, Texas; Department of Pathology and Immunology, Baylor College of Medicine, One Baylor Plaza, Houston, Texas
| | - Stephen Palmer
- Center for Drug Discovery, Baylor College of Medicine, Houston, Texas; Department of Pathology and Immunology, Baylor College of Medicine, One Baylor Plaza, Houston, Texas.
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Van Muylder A, D'Hooghe T, Luyten J. Economic Evaluation of Medically Assisted Reproduction: A Methodological Systematic Review. Med Decis Making 2023; 43:973-991. [PMID: 37621143 DOI: 10.1177/0272989x231188129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
BACKGROUND Medically assisted reproduction (MAR) is a challenging application area for health economic evaluations, entailing a broad range of costs and outcomes, stretching out long-term and accruing to several parties. PURPOSE To systematically review which costs and outcomes are included in published economic evaluations of MAR and to compare these with health technology assessment (HTA) prescriptions about which cost and outcomes should be considered for different evaluation objectives. DATA SOURCES HTA guidelines and systematic searches of PubMed Central, Embase, WOS CC, CINAHL, Cochrane (CENTRAL), HTA, and NHS EED. STUDY SELECTION All economic evaluations of MAR published from 2010 to 2022. DATA EXTRACTION A predetermined data collection form summarized study characteristics. Essential costs and outcomes of MAR were listed based on HTA and treatment guidelines for different evaluation objectives. For each study, included costs and outcomes were reviewed. DATA SYNTHESIS The review identified 93 cost-effectiveness estimates, of which 57% were expressed as cost-per-(healthy)-live-birth, 19% as cost-per-pregnancy, and 47% adopted a clinic perspective. Few adopted societal perspectives and only 2% used quality-adjusted life-years (QALYs). Broader evaluations omitted various relevant costs and outcomes related to MAR. There are several cost and outcome categories for which available HTA guidelines do not provide conclusive directions regarding inclusion or exclusion. LIMITATIONS Studies published before 2010 and of interventions not clearly labeled as MAR were excluded. We focus on methods rather than which MAR treatments are cost-effective. CONCLUSIONS Economic evaluations of MAR typically calculate a short-term cost-per-live-birth from a clinic perspective. Broader analyses, using cost-per-QALY or BCRs from societal perspectives, considering the full scope of reproduction-related costs and outcomes, are scarce and often incomplete. We provide a summary of costs and outcomes for future research guidance and identify areas requiring HTA methodological development. HIGHLIGHTS The cost-effectiveness of MAR procedures can be exceptionally complex to estimate as there is a broad range of costs and outcomes involved, in principle stretching out over multiple generations and over many stakeholders.We list 21 key areas of costs and outcomes of MAR. Which of these needs to be accounted for alters for different evaluation objectives (determined by the type of economic evaluation, time horizon considered, and perspective).Published studies mostly investigate cost-effectiveness in the very short-term, from a clinic perspective, expressed as cost-per-live-birth. There is a lack of comprehensive economic evaluations that adopt a broader perspective with a longer time horizon. The broader the evaluation objective, the more relevant costs and outcomes were excluded.For several costs and outcomes, particularly those relevant for broader, societal evaluations of MAR, the inclusion or exclusion is theoretically ambiguous, and HTA guidelines do not offer sufficient guidance.
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Affiliation(s)
- Astrid Van Muylder
- Department Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium (AVM, JL); Research Group Reproductive Medicine, Department of Development and Regeneration, Organ Systems, Group Biomedical Sciences, KU Leuven (University of Leuven), Belgium (TD); Department of Obstetrics, Gynecology and Reproductive Sciences Yale School of Medicine, New Haven, CT, USA (TD); Global Medical Affairs Fertility, Research and Development, Merck Healthcare KGaA, Darmstadt, Germany (TD). The review was written at the Leuven Institute for Healthcare Policy. It was presented at the ESHRE 38th Annual Meeting (Milan 2022). The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Astrid Van Muylder and Jeroen Luyten have no conflicting interests to declare. The participation of Thomas D'Hooghe to this publication is part of his academic work; he does not see a conflict of interest as Merck KGaA was not involved in writing this article. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We acknowledge an internal funding from KU Leuven for this study. The funding agreement ensured the authors' independence in designing the study, interpreting the data, writing, and publishing the report. The following authors are employed by the sponsor: Astrid Van Muylder and Jeroen Luyten
| | - Thomas D'Hooghe
- Department Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium (AVM, JL); Research Group Reproductive Medicine, Department of Development and Regeneration, Organ Systems, Group Biomedical Sciences, KU Leuven (University of Leuven), Belgium (TD); Department of Obstetrics, Gynecology and Reproductive Sciences Yale School of Medicine, New Haven, CT, USA (TD); Global Medical Affairs Fertility, Research and Development, Merck Healthcare KGaA, Darmstadt, Germany (TD). The review was written at the Leuven Institute for Healthcare Policy. It was presented at the ESHRE 38th Annual Meeting (Milan 2022). The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Astrid Van Muylder and Jeroen Luyten have no conflicting interests to declare. The participation of Thomas D'Hooghe to this publication is part of his academic work; he does not see a conflict of interest as Merck KGaA was not involved in writing this article. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We acknowledge an internal funding from KU Leuven for this study. The funding agreement ensured the authors' independence in designing the study, interpreting the data, writing, and publishing the report. The following authors are employed by the sponsor: Astrid Van Muylder and Jeroen Luyten
| | - Jeroen Luyten
- Department Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium (AVM, JL); Research Group Reproductive Medicine, Department of Development and Regeneration, Organ Systems, Group Biomedical Sciences, KU Leuven (University of Leuven), Belgium (TD); Department of Obstetrics, Gynecology and Reproductive Sciences Yale School of Medicine, New Haven, CT, USA (TD); Global Medical Affairs Fertility, Research and Development, Merck Healthcare KGaA, Darmstadt, Germany (TD). The review was written at the Leuven Institute for Healthcare Policy. It was presented at the ESHRE 38th Annual Meeting (Milan 2022). The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Astrid Van Muylder and Jeroen Luyten have no conflicting interests to declare. The participation of Thomas D'Hooghe to this publication is part of his academic work; he does not see a conflict of interest as Merck KGaA was not involved in writing this article. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We acknowledge an internal funding from KU Leuven for this study. The funding agreement ensured the authors' independence in designing the study, interpreting the data, writing, and publishing the report. The following authors are employed by the sponsor: Astrid Van Muylder and Jeroen Luyten
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Tang Y, He YX, Ye Y, Zhang TT, Wang JJ, He QD. Pregnancy outcomes of intrauterine insemination without ovarian stimulation in couples affected by unilateral tubal occlusion and male infertility. BMC Pregnancy Childbirth 2023; 23:376. [PMID: 37226105 DOI: 10.1186/s12884-023-05705-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/15/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Information available to date regarding the pregnancy outcomes of intrauterine insemination (IUI) without ovarian stimulation (OS) in infertile patients with unilateral tubal occlusion remains scarce. The objectives of this study were to investigate for couples affected by unilateral tubal occlusion (diagnosed via hysterosalpingography (HSG)/transvaginal real-time three-dimensional hysterosalpingo-contrast sonography (TVS RT-3D-HyCoSy)) and male infertility: (1) whether significant differences exist in pregnancy outcomes between IUI with or without OS cycles, and (2) whether the pregnancy outcomes of IUI without OS in women with unilateral tubal occlusion were similar to those of women with bilateral patent tubes. METHODS 258 couples affected by male infertility completed 399 IUI cycles. The cycles were divided into three groups: group A, IUI without OS in women with unilateral tubal occlusion; group B, IUI with OS in women with unilateral tubal occlusion; and group C, IUI without OS in women with bilateral patent tubes. The main outcome measures, including clinical pregnancy rate (CPR), live birth rate (LBR), and first trimester miscarriage rate, were compared between either groups A and B or groups A and C. RESULTS Although the number of dominant follicles > 16 mm were significantly higher in group B than that in group A (group B vs. group A: 1.6 ± 0.6 vs. 1.0 ± 0.2, P < 0.001), the CPR, LBR, and first trimester miscarriage rate were comparable between these two groups. When comparing group C to group A, the duration of infertility was significantly longer in group C than that in group A (group A vs. group C: 2.3 ± 1.2 (year) vs. 2.9 ± 2.1 (year), P = 0.017). Except for the first trimester miscarriage rate, which was significantly higher in group A (42.9%, 3/7) than that in group C (7.1%, 2/28) (P = 0.044), no significant differences were observed in the CPR and LBR in these two groups. After adjusting for female age, body mass index, and the duration of infertility, similar results were obtained between groups A and C. CONCLUSIONS In couples affected by unilateral tubal occlusion (diagnosed via HSG/TVS RT-3D-HyCoSy) and male infertility, IUI without OS might be an alternative treatment strategy. However, when compared to patients with bilateral patent tubes, the patients with unilateral tubal occlusion showed a higher first trimester miscarriage rate following IUI without OS cycles. Further studies are warranted to clarify this relationship.
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Affiliation(s)
- Yan Tang
- Center for Reproductive Medicine, Department of Gynecology and Obstetrics, Zhongshan City People's Hospital, Zhongshan, 528403, Guangdong Province, China
| | - Yu-Xia He
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Guangdong Provincial Key Laboratory of Major Obstetric Diseases, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, Guangdong Province, China
| | - Yun Ye
- Center for Reproductive Medicine, Department of Gynecology and Obstetrics, Zhongshan City People's Hospital, Zhongshan, 528403, Guangdong Province, China
| | - Ting-Ting Zhang
- Center for Reproductive Medicine, Department of Gynecology and Obstetrics, Zhongshan City People's Hospital, Zhongshan, 528403, Guangdong Province, China
| | - Jing-Jing Wang
- Center for Reproductive Medicine, Department of Gynecology and Obstetrics, Zhongshan City People's Hospital, Zhongshan, 528403, Guangdong Province, China
| | - Qian-Dong He
- Center for Reproductive Medicine, Department of Gynecology and Obstetrics, Zhongshan City People's Hospital, Zhongshan, 528403, Guangdong Province, China.
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5
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Wessel JA, Mochtar MH, Besselink DE, Betjes H, de Bruin JP, Cantineau AEP, Groenewoud ER, Hooker AB, Lambalk CB, Kwee J, Kaaijk EM, Louwé LA, Maas JWM, Mol BWJ, van Rumste MME, Traas MAF, Goddijn M, van Wely M, Mol F. Expectant management versus IUI in unexplained subfertility and a poor pregnancy prognosis (EXIUI study): a randomized controlled trial. Hum Reprod 2022; 37:2808-2816. [PMID: 36331493 PMCID: PMC9712943 DOI: 10.1093/humrep/deac236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/31/2022] [Indexed: 11/06/2022] Open
Abstract
STUDY QUESTION For couples with unexplained subfertility and a poor prognosis for natural conception, is 6 months expectant management (EM) inferior to IUI with ovarian stimulation (IUI-OS), in terms of live births? SUMMARY ANSWER In couples with unexplained subfertility and a poor prognosis for natural conception, 6 months of EM is inferior compared to IUI-OS in terms of live births. WHAT IS KNOWN ALREADY Couples with unexplained subfertility and a poor prognosis are often treated with IUI-OS. In couples with unexplained subfertility and a relatively good prognosis for natural conception (>30% in 12 months), IUI-OS does not increase the live birth rate as compared to 6 months of EM. However, in couples with a poor prognosis for natural conception (<30% in 12 months), the effectiveness of IUI-OS is uncertain. STUDY DESIGN, SIZE, DURATION We performed a non-inferiority multicentre randomized controlled trial within the infrastructure of the Dutch Consortium for Healthcare Evaluation and Research in Obstetrics and Gynaecology. We intended to include 1091 couples within 3 years. The couples were allocated in a 1:1 ratio to 6 months EM or 6 months IUI-OS with either clomiphene citrate or gonadotrophins. PARTICIPANTS/MATERIALS, SETTING, METHODS We studied heterosexual couples with unexplained subfertility and a poor prognosis for natural conception (<30% in 12 months). The primary outcome was ongoing pregnancy leading to a live birth. Non-inferiority would be shown if the lower limit of the one-sided 90% risk difference (RD) CI was less than minus 7% compared to an expected live birth rate of 30% following IUI-OS. We calculated RD, relative risks (RRs) with 90% CI and a corresponding hazard rate for live birth over time based on intention-to-treat and per-protocol (PP) analysis. MAIN RESULTS AND THE ROLE OF CHANCE Between October 2016 and September 2020, we allocated 92 couples to EM and 86 to IUI-OS. The trial was halted pre-maturely owing to slow inclusion. Mean female age was 34 years, median duration of subfertility was 21 months. Couples allocated to EM had a lower live birth rate than couples allocated to IUI-OS (12/92 (13%) in the EM group versus 28/86 (33%) in the IUI-OS group; RR 0.40 90% CI 0.24 to 0.67). This corresponds to an absolute RD of minus 20%; 90% CI: -30% to -9%. The hazard ratio for live birth over time was 0.36 (95% CI 0.18 to 0.70). In the PP analysis, live births rates were 8 of 70 women (11%) in the EM group versus 26 of 73 women (36%) in the IUI-OS group (RR 0.32, 90% CI 0.18 to 0.59; RD -24%, 90% CI -36% to -13%) in line with inferiority of EM. LIMITATIONS, REASONS FOR CAUTION Our trial did not reach the planned sample size, therefore the results are limited by the number of participants. WIDER IMPLICATIONS OF THE FINDINGS This study confirms the results of a previous trial that in couples with unexplained subfertility and a poor prognosis for natural conception, EM is inferior to IUI-OS. STUDY FUNDING/COMPETING INTEREST(S) The trial was supported by a grant of the SEENEZ healthcare initiative. The subsidizing parties were The Dutch Organisation for Health Research and Development (ZonMW 837004023, www.zonmw.nl) and the umbrella organization of 10 health insurers in The Netherlands. E.R.G. receives personal fees from Titus Health care outside the submitted work. M.G. declares unrestricted research and educational grants from Guerbet, Merck and Ferring not related to the presented work, paid to their institution VU medical centre. A.B.H. reports receiving travel and speakers fees from Nordic Pharma and Merck and he is member of the Nordic Pharma ANGEL group and of the Safety Monitoring Board of Womed. C.B.L. reports speakers fee from Inmed and Yingming, and his department receives research grants from Ferring, Merck and Guerbet paid to VU medical centre. B.W.J.M. is supported by a NHMRC Investigator grant (GNT1176437) and reports consultancy for ObsEva and Merck. M.v.W. received a grant from the Netherlands Organisation for Health Research and Development ZonMW (80-8520098-91072). F.M. received two grants from the Netherlands Organisation for Health Research and Development ZonMW (NTR 5599 and NTR 6590). The other authors report no competing interest. TRIAL REGISTRATION NUMBER Dutch Trial register NL5455 (NTR5599). TRIAL REGISTRATION DATE 18 December 2015. DATE OF FIRST PATIENT’S ENROLMENT 26 January 2017.
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Affiliation(s)
- J A Wessel
- Department of Obstetrics and Gynaecology, Centre for Reproductive Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands,Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - M H Mochtar
- Department of Obstetrics and Gynaecology, Centre for Reproductive Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands,Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - D E Besselink
- Department of Obstetrics & Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - H Betjes
- Department Obstetrics and Gynaecology, Flevo Hospital, Almere, The Netherlands
| | - J P de Bruin
- Department of Gynaecology & Obstetrics, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - A E P Cantineau
- Department of Obstetrics and Gynaecology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - E R Groenewoud
- Department of Obstetrics, Gynaecology & Reproductive Medicine, Noordwest Ziekenhuisgroep, Den Helder, The Netherlands
| | - A B Hooker
- Department of Obstetrics and Gynaecology, Zaans Medical Center, Zaandam, The Netherlands
| | - C B Lambalk
- Department of Reproductive Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - J Kwee
- Department of Obstetrics and Gynaecology, OLVG West, Amsterdam, The Netherlands
| | - E M Kaaijk
- Department of Obstetrics and Gynaecology, OLVG Oost, Amsterdam, The Netherlands
| | - L A Louwé
- Department of Gynaecology, Leiden University Medical Center, Leiden, The Netherlands
| | - J W M Maas
- Department of Obstetrics and Gynaecology MUMC+ and Grow-school of Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - B W J Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia,Aberdeen Centre for Women’s Health Research, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - M M E van Rumste
- Department of Gynaecology, Catharina Hospital, Eindhoven, The Netherlands
| | - M A F Traas
- Department of Gynaecology, Gelre Hospital, Apeldoorn, The Netherlands
| | - M Goddijn
- Department of Obstetrics and Gynaecology, Centre for Reproductive Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands,Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - M van Wely
- Department of Obstetrics and Gynaecology, Centre for Reproductive Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands,Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - F Mol
- Correspondence address. Department of Obstetrics and Gynaecology, Centre for Reproductive Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands. E-mail:
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6
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Villani MT, Morini D, Spaggiari G, Furini C, Melli B, Nicoli A, Iannotti F, La Sala GB, Simoni M, Aguzzoli L, Santi D. The (decision) tree of fertility: an innovative decision-making algorithm in assisted reproduction technique. J Assist Reprod Genet 2022; 39:395-408. [PMID: 35084638 PMCID: PMC8793814 DOI: 10.1007/s10815-021-02353-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 11/05/2021] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Several mathematical models have been developed to estimate individualized chances of assisted reproduction techniques (ART) success, although with limited clinical application. Our study aimed to develop a decisional algorithm able to predict pregnancy and live birth rates after controlled ovarian stimulation (COS) phase, helping the physician to decide whether to perform oocytes pick-up continuing the ongoing ART path. METHODS A single-center retrospective analysis of real-world data was carried out including all fresh ART cycles performed in 1998-2020. Baseline characteristics, ART parameters and biochemical/clinical pregnancies and live birth rates were collected. A seven-steps systematic approach for model development, combining linear regression analyses and decision trees (DT), was applied for biochemical, clinical pregnancy, and live birth rates. RESULTS Of fresh ART cycles, 12,275 were included. Linear regression analyses highlighted a relationship between number of ovarian follicles > 17 mm detected at ultrasound before pick-up (OF17), embryos number and fertilization rate, and biochemical and clinical pregnancy rates (p < 0.001), but not live birth rate. DT were created for biochemical pregnancy (statistical power-SP:80.8%), clinical pregnancy (SP:85.4%), and live birth (SP:87.2%). Thresholds for OF17 entered in all DT, while sperm motility entered the biochemical pregnancy's model, and female age entered the clinical pregnancy and live birth DT. In case of OF17 < 3, the chance of conceiving was < 6% for all DT. CONCLUSION A systematic approach allows to identify OF17, female age, and sperm motility as pre-retrieval predictors of ART outcome, possibly reducing the socio-economic burden of ART failure, allowing the clinician to perform or not the oocytes pick-up.
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Affiliation(s)
- Maria Teresa Villani
- Department of Obstetrics and Gynaecology, Fertility Centre, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | - Daria Morini
- Department of Obstetrics and Gynaecology, Fertility Centre, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | - Giorgia Spaggiari
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Ospedale Civile of Baggiovara, Via Giardini 1355, 41126, Modena, Italy.
| | - Chiara Furini
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Ospedale Civile of Baggiovara, Via Giardini 1355, 41126, Modena, Italy.,Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Beatrice Melli
- Department of Obstetrics and Gynaecology, Fertility Centre, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Alessia Nicoli
- Department of Obstetrics and Gynaecology, Fertility Centre, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | - Francesca Iannotti
- Department of Obstetrics and Gynaecology, Fertility Centre, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | - Giovanni Battista La Sala
- Department of Obstetrics and Gynaecology, Fertility Centre, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | - Manuela Simoni
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Ospedale Civile of Baggiovara, Via Giardini 1355, 41126, Modena, Italy.,Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Lorenzo Aguzzoli
- Department of Obstetrics and Gynaecology, Fertility Centre, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | - Daniele Santi
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Ospedale Civile of Baggiovara, Via Giardini 1355, 41126, Modena, Italy.,Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
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Wessel JA, Danhof NA, van Eekelen R, Diamond MP, Legro RS, Peeraer K, D’Hooghe TM, Erdem M, Dankert T, Cohlen BJ, Thyagaraju C, Mol BWJ, Showell M, van Wely M, Mochtar MH, Wang R. OUP accepted manuscript. Hum Reprod Update 2022; 28:733-746. [PMID: 35587030 PMCID: PMC9434229 DOI: 10.1093/humupd/dmac021] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 03/23/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Intrauterine insemination with ovarian stimulation (IUI-OS) is a first-line treatment for unexplained infertility. Gonadotrophins, letrozole and clomiphene citrate (CC) are commonly used agents during IUI-OS and have been compared in multiple aggregate data meta-analyses, with substantial heterogeneity and no analysis on time-to-event outcomes. Individual participant data meta-analysis (IPD-MA) is considered the gold standard for evidence synthesis as it can offset inadequate reporting of individual studies by obtaining the IPD, and allows analyses on treatment–covariate interactions to identify couples who benefit most from a particular treatment. OBJECTIVE AND RATIONALE We performed this IPD-MA to compare the effectiveness and safety of ovarian stimulation with gonadotrophins, letrozole and CC and to explore treatment–covariate interactions for important baseline characteristics in couples undergoing IUI. SEARCH METHODS We searched electronic databases including MEDLINE, EMBASE, CENTRAL, CINAHL, and PsycINFO from their inception to 28 June 2021. We included randomized controlled trials (RCTs) comparing IUI-OS with gonadotrophins, letrozole and CC among couples with unexplained infertility. We contacted the authors of eligible RCTs to share the IPD and established the IUI IPD-MA Collaboration. The primary effectiveness outcome was live birth and the primary safety outcome was multiple pregnancy. Secondary outcomes were other reproductive outcomes, including time to conception leading to live birth. We performed a one-stage random effects IPD-MA. OUTCOMES Seven of 22 (31.8%) eligible RCTs provided IPD of 2495 couples (62.4% of the 3997 couples participating in 22 RCTs), of which 2411 had unexplained infertility and were included in this IPD-MA. Six RCTs (n = 1511) compared gonadotrophins with CC, and one (n = 900) compared gonadotrophins, letrozole and CC. Moderate-certainty evidence showed that gonadotrophins increased the live birth rate compared to CC (6 RCTs, 2058 women, RR 1.30, 95% CI 1.12–1.51, I2 = 26%). Low-certainty evidence showed that gonadotrophins may also increase the multiple pregnancy rate compared to CC (6 RCTs, 2058 women, RR 2.17, 95% CI 1.33–3.54, I2 = 69%). Heterogeneity on multiple pregnancy could be explained by differences in gonadotrophin starting dose and choice of cancellation criteria. Post-hoc sensitivity analysis on RCTs with a low starting dose of gonadotrophins (≤75 IU) confirmed increased live birth rates compared to CC (5 RCTs, 1457 women, RR 1.26, 95% CI 1.05–1.51), but analysis on only RCTs with stricter cancellation criteria showed inconclusive evidence on live birth (4 RCTs, 1238 women, RR 1.15, 95% CI 0.94–1.41). For multiple pregnancy, both sensitivity analyses showed inconclusive findings between gonadotrophins and CC (RR 0.94, 95% CI 0.45–1.96; RR 0.81, 95% CI 0.32–2.03, respectively). Moderate certainty evidence showed that gonadotrophins reduced the time to conception leading to a live birth when compared to CC (6 RCTs, 2058 women, HR 1.37, 95% CI 1.15–1.63, I2 = 22%). No strong evidence on the treatment–covariate (female age, BMI or primary versus secondary infertility) interactions was found. WIDER IMPLICATIONS In couples with unexplained infertility undergoing IUI-OS, gonadotrophins increased the chance of a live birth and reduced the time to conception compared to CC, at the cost of a higher multiple pregnancy rate, when not differentiating strategies on cancellation criteria or the starting dose. The treatment effects did not seem to differ in women of different age, BMI or primary versus secondary infertility. In a modern practice where a lower starting dose and stricter cancellation criteria are in place, effectiveness and safety of different agents seem both acceptable, and therefore intervention availability, cost and patients’ preferences should factor in the clinical decision-making. As the evidence for comparisons to letrozole is based on one RCT providing IPD, further RCTs comparing letrozole and other interventions for unexplained infertility are needed.
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Affiliation(s)
- J A Wessel
- Amsterdam UMC location University of Amsterdam, Centre for Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - N A Danhof
- Amsterdam UMC location University of Amsterdam, Centre for Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - R van Eekelen
- Amsterdam UMC location University of Amsterdam, Centre for Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - M P Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, GA 30912, USA
| | - R S Legro
- Department of Obstetrics and Gynecology, Penn State College of Medicine, Hershey, PA 17033, USA
| | - K Peeraer
- UZ Leuven, Leuven University Fertility Center, Leuven 3000, Belgium
| | - T M D’Hooghe
- Merck Healthcare KGaA, Darmstadt 64293, Germany
- Department of Development and Regeneration, Group Biomedical Sciences, KU Leuven/University of Leuven, Leuven 3000, Belgium
- Department of Obstetrics and Gynecology, Yale University, New Haven, CT 06520, USA
| | - M Erdem
- Faculty of Medicine, Department of Obstetrics & Gynecology, Gazi University, Ankara 06560, Turkey
| | - T Dankert
- Department of Obstetrics and Gynecology, Rijnstate Hospital Arnhem, 06560 Ankara, The Netherlands
| | - B J Cohlen
- Department of Obstetrics and Gynaecology, Isala Fertility Center, 8025 AB Zwolle, The Netherlands
| | - C Thyagaraju
- Department of OBG, Jawaharlal Institute of Postgraduate Medical education and Research (JIPMER), Pondicherry 605006, India
| | - B W J Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia
- Aberdeen Centre for Women’s Health Research, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB24 3FX, UK
| | - M Showell
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland 1142, New Zealand
| | - M van Wely
- Amsterdam UMC location University of Amsterdam, Centre for Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - M H Mochtar
- Amsterdam UMC location University of Amsterdam, Centre for Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - R Wang
- Correspondence address. Department of Obstetrics and Gynaecology, Monash University, Level 5, Monash Medical Centre, 246 Clayton Road, Clayton, VIC 3168, Australia. E-mail:
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