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Au LS, Feng Q, Shingshetty L, Maheshwari A, Mol BW. Evaluating prognosis in unexplained infertility. Fertil Steril 2024; 121:717-729. [PMID: 38423380 DOI: 10.1016/j.fertnstert.2024.02.044] [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] [Received: 02/19/2024] [Accepted: 02/21/2024] [Indexed: 03/02/2024]
Abstract
IMPORTANCE The diagnosis of unexplained infertility presents a dilemma as it signifies both uncertainty about the cause of infertility and the potential for natural conception. Immediate treatment of all would result in overtreatment. Prediction models estimating the likelihood of natural conception and subsequent live birth can guide treatment decisions. OBJECTIVE To evaluate if in couples with unexplained infertility, prediction models are effective in guiding treatment decisions. EVIDENCE REVIEW This review examines 25 studies that assess prediction models for natural conception in couples with unexplained infertility in terms of derivation, validation, and impact analysis. FINDINGS The largest prediction models have been integrated in the synthesis models of Hunault, which includes female age and infertility duration, having been pregnant before and motile sperm percentage. Despite its limited discriminative capacity, this model demonstrates excellent calibration. Importantly, the impact of the Hunault model has been evaluated in randomized clinical trials, and shows that in couples with unexplained infertility and 12-month natural conception chances exceeding 30%, immediate treatment with intrauterine insemination (IUI) and controlled ovarian hyperstimulation is not better than expectant management for 6 months. Below the threshold of 30%, treatment with IUI is superior over expectant management, but immediate in vitro fertilization was not better than IUI. CONCLUSION In couples with unexplained infertility and a good prognosis for natural conception, treatment can be delayed, whereas in couples with a poor prognosis, immediate treatment (with IUI-controlled ovarian hyperstimulation) is warranted. RELEVANCE These data indicate that in couples with unexplained infertility, integration of prediction models into clinical decision making can optimize treatment selection and maximize fertility outcomes while limiting unnecessary treatment.
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Affiliation(s)
- Ling Shan Au
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Qian Feng
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Laxmi Shingshetty
- Aberdeen Centre of Reproductive Medicine, NHS Grampian, Aberdeen, United Kingdom
| | - Abha Maheshwari
- Aberdeen Centre of Reproductive Medicine, NHS Grampian, Aberdeen, United Kingdom
| | - Ben W Mol
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia; Department of Obstetrics and Gynaecology, Monash Health, Melbourne, Victoria, Australia; Aberdeen Centre for Women's Health Research, University of Aberdeen, Aberdeen, United Kingdom.
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2
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Hall JA, Barrett G, Stephenson J, Rocca CH, Edelman N. Predictive ability of the Desire to Avoid Pregnancy scale. Reprod Health 2023; 20:144. [PMID: 37749640 PMCID: PMC10521409 DOI: 10.1186/s12978-023-01687-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 09/11/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND A longstanding gap in the reproductive health field has been the availability of a screening instrument that can reliably predict a person's likelihood of becoming pregnant. The Desire to Avoid Pregnancy Scale is a new measure; understanding its sensitivity and specificity as a screening tool for pregnancy as well as its predictive ability and how this varies by socio-demographic factors is important to inform its implementation. METHODS This analysis was conducted on a cohort of 994 non-pregnant participants recruited in October 2018 and followed up for one year. The cohort was recruited using social media as well as advertisements in a university, school, abortion clinic and outreach sexual health service. Almost 90% of eligible participants completed follow-up at 12 months; those lost to follow-up were not significantly different on key socio-demographic factors. We used baseline DAP score and a binary variable of whether participants experienced pregnancy during the study to assess the sensitivity, specificity, area under the ROC curve (AUROC) and positive and negative predictive values (PPV and NPV) of the DAP at a range of cut-points. We also examined how the predictive ability of the DAP varied according to socio-demographic factors and by the time frame considered (e.g., pregnancy within 3, 6, 9 and 12 months). RESULTS At a cut-point of 2 on the 0-4 range of the DAP scale, the DAP had a sensitivity of 0.78, a specificity of 0.81 and an excellent AUROC of 0.87. In this sample the cumulative incidence of pregnancy was 16% (95%CI 13%, 18%) making the PPV 43% and the NPV 95% at this cut-point. The DAP score was the factor most strongly associated with pregnancy, even after age and number of children were taken into account. The association between baseline DAP score and pregnancy did not differ across time frames. CONCLUSIONS This is the first study to assess the DAP scale as a screening tool and shows that its predictive ability is superior to the limited pre-existing pregnancy prediction tools. Based on our findings, the DAP could be used with a cut-point selected according to the purpose.
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Affiliation(s)
- Jennifer A Hall
- Reproductive Health Research Department, UCL Elizabeth Garrett Anderson Institute for Women's Health, London, UK.
| | - Geraldine Barrett
- Reproductive Health Research Department, UCL Elizabeth Garrett Anderson Institute for Women's Health, London, UK
| | - Judith Stephenson
- Reproductive Health Research Department, UCL Elizabeth Garrett Anderson Institute for Women's Health, London, UK
| | - Corinne H Rocca
- San Francisco (UCSF) School of Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Advancing New Standards in Reproductive Health (ANSIRH), University of California, San Francisco, USA
| | - Natalie Edelman
- Independent Researcher and Trauma-Informed Consultant at TRuST, Brighton, UK
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Fertility-related quality of life in subfertile women undergoing tubal testing with transvaginal hydrolaparoscopy or hysterosalpingography. Eur J Obstet Gynecol Reprod Biol 2022; 274:19-22. [PMID: 35561566 DOI: 10.1016/j.ejogrb.2022.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 02/19/2022] [Accepted: 04/09/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Both subfertility and its management can have significant impact on quality of life (QoL). Tubal patency testing as part of the fertility work-up, is considered to cause more physical complaints and stress than other tests. Pain scores for HSG are higher than for THL, but acceptability of the procedures was found to be comparable. Fertility-related QoL has not yet been studied in women undergoing tubal patency testing. STUDY DESIGN We performed a standardized questionnaire study alongside a previously reported randomized controlled trial comparing THL and HSG in subfertile women, in which 24-month live birth rates occurred in 58.5% versus 55.4%, respectively. We randomly assigned 300 subfertile women to THL or HSG between May 2013 and October 2016. Women were eligible if they were undergoing a fertility work-up with an indication for evaluation of tubal patency. Fertility-related QoL was measured six weeks after the procedure with the validated FertiQoL questionnaire. The scores for the Core scale and subscales between THL and HSG were compared using Mann-Whitney-U test and multiple linear regression analysis. RESULTS The questionnaire was completed by 84 women in the THL group (56%) and 96 women in the HSG group (64%). Core scores were 74.6 ± 12.8 for THL and 73.4 ± 12.4 for HSG (p = 0.39). Scores for the Emotional domain were 64.5 ± 19.0 for THL versus 66.0 ± 16.3 (p = 0.67) for HSG. Scores for the 'Mind-body' domain for THL were 76.9 ± 15.6 versus 74.1 ± 18.0 for HSG (p = 0.42), while scores for the Relational domain were 79.2 ± 12.9 for THL and 76.9 ± 15.6 for HSG (p = 0.21). Scores for the Social domain for THL were 77.9 ± 15.1 versus 76.7 ± 14.1, (p = 0.42). The multiple linear regression analysis showed only a statistical significant positive effect of older age on the score for the Emotional domain (p = 0.015). CONCLUSION In a preselected group of women with low risk for tubal pathology we did not find differences in fertility-related QoL between tubal patency testing with THL versus HSG.
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4
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Rosielle K, Kamphuis D, van Welie N, Roest I, Mozes A, van Santbrink EJP, van de Laar T, Hooker AB, Huppelschoten AG, Li W, Bongers MY, Stoker J, van Wely M, Koks C, Lambalk CB, Hemingway A, Mol BWJ, Dreyer K, Mijatovic V. Oil-based versus water-based contrast media for hysterosalpingography in infertile women of advanced age, with ovulation disorders or a high risk for tubal pathology: study protocol of a randomized controlled trial (H2Oil2 study). BMC Womens Health 2022; 22:123. [PMID: 35436944 PMCID: PMC9016997 DOI: 10.1186/s12905-022-01707-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 04/07/2022] [Indexed: 11/30/2022] Open
Abstract
Background In women with unexplained infertility, tubal flushing with oil-based contrast during hysterosalpingography (HSG) increases ongoing pregnancy and subsequent live birth rates when compared to tubal flushing with water-based contrast. It is currently unclear whether an HSG with oil-based contrast also results in more ongoing pregnancies and live births in women of advanced age, women with ovulation disorders, and women with potential tubal pathology when compared to an HSG with water-based contrast. Methods We plan an international, multicentre, open-label, randomized controlled trial (RCT) studying three groups of infertile women who have an indication for tubal patency testing according to their treating physician and additionally; (1) are 39 years of age or older, (2) have an ovulation disorder or (3) have a high risk for tubal pathology based on their medical history. Women with an allergy for iodinated contrast medium are excluded, as are women with diabetes, hyperprolactinemia or untreated hyper- or hypothyroidism, and women with a partner with severe male infertility. After informed consent, women will be randomly allocated to the intervention, tubal flushing with the use of oil-based contrast during HSG or the control group, tubal flushing with the use of water-based contrast during HSG in a 1:1 ratio by the web-based system Castor. The primary endpoint will be ongoing pregnancy leading to live birth with conception within six months after randomization. Secondary outcomes are other pregnancy outcomes, used fertility treatments, adverse events and cost-effectiveness. Based on the expected ongoing pregnancy rate of 17% in the control group and 27% in the intervention group, the sample size will be 930 women (465 per group). Study inclusion is expected to be complete in four years. Discussion This multicentre RCT will establish whether, for women of advanced age, women with ovulatory disease, and women who have a high risk for tubal pathology, there is a fertility enhancing effect of tubal flushing with oil-based contrast during HSG and whether the use of this contrast medium is cost-effective. Trial Registration The study was prospectively registered in the Netherlands Trial Register on August 1st 2019 as ‘H2Oil2’ (reference number NL7925, https://www.trialregister.nl/trial/7925). Supplementary Information The online version contains supplementary material available at 10.1186/s12905-022-01707-z.
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Affiliation(s)
- K Rosielle
- Department of Reproductive Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands. .,Amsterdam Reproduction and Development, Amsterdam, The Netherlands.
| | - D Kamphuis
- Department of Reproductive Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.,Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - N van Welie
- Department of Reproductive Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.,Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - I Roest
- Department of Reproductive Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.,Amsterdam Reproduction and Development, Amsterdam, The Netherlands.,Grow Research School for Oncology and Reproduction, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, The Netherlands.,Department of Obstetrics and Gynaecology, Máxima MC, De Run 4600, 5504 DB, Veldhoven, Eindhoven, The Netherlands
| | - A Mozes
- Department of Obstetrics and Gynaecology, Ziekenhuis Amstelland, Laan van de Helende Meesters 8, 1186 AM, Amstelveen, The Netherlands
| | - E J P van Santbrink
- Department of Reproductive Medicine, Reinier de Graaf Gasthuis, Reinier de Graafweg 5, 2625 AD, Delft, The Netherlands
| | - T van de Laar
- Department of Obstetrics and Gynaecology, Elkerliek Ziekenhuis, Wesselmanlaan 25, 5707 HA, Helmond, The Netherlands
| | - A B Hooker
- Department of Obstetrics and Gynaecology, Zaans Medisch Centrum, Koningin Julianaplein 58, 1502 DV, Zaandam, The Netherlands
| | - A G Huppelschoten
- Department of Obstetrics and Gynaecology, Catharina Ziekenhuis, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - W Li
- Department of Obstetrics and Gynaecology, Monash University, 246 Clayton Rd, Clayton, VIC, 3168, Australia
| | - M Y Bongers
- Grow Research School for Oncology and Reproduction, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, The Netherlands.,Department of Obstetrics and Gynaecology, Máxima MC, De Run 4600, 5504 DB, Veldhoven, Eindhoven, The Netherlands
| | - J Stoker
- Department of Radiology and Nuclear Medicine, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - M van Wely
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands.,Centre for Reproductive Medicine, Amsterdam Reproduction and Development, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - C Koks
- Department of Obstetrics and Gynaecology, Máxima MC, De Run 4600, 5504 DB, Veldhoven, Eindhoven, The Netherlands
| | - C B Lambalk
- Department of Reproductive Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.,Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - A Hemingway
- Department of Radiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, DuCane Road, London, W12 0HS, England
| | - B W J Mol
- Department of Obstetrics and Gynaecology, Monash University, 246 Clayton Rd, Clayton, VIC, 3168, Australia
| | - K Dreyer
- Department of Reproductive Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.,Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - V Mijatovic
- Department of Reproductive Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.,Amsterdam Reproduction and Development, Amsterdam, The Netherlands
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Yland JJ, Wang T, Zad Z, Willis SK, Wang TR, Wesselink AK, Jiang T, Hatch EE, Wise LA, Paschalidis IC. Predictive models of pregnancy based on data from a preconception cohort study. Hum Reprod 2022; 37:565-576. [PMID: 35024824 PMCID: PMC8888990 DOI: 10.1093/humrep/deab280] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 11/30/2021] [Indexed: 01/16/2023] Open
Abstract
STUDY QUESTION Can we derive adequate models to predict the probability of conception among couples actively trying to conceive? SUMMARY ANSWER Leveraging data collected from female participants in a North American preconception cohort study, we developed models to predict pregnancy with performance of ∼70% in the area under the receiver operating characteristic curve (AUC). WHAT IS KNOWN ALREADY Earlier work has focused primarily on identifying individual risk factors for infertility. Several predictive models have been developed in subfertile populations, with relatively low discrimination (AUC: 59-64%). STUDY DESIGN, SIZE, DURATION Study participants were female, aged 21-45 years, residents of the USA or Canada, not using fertility treatment, and actively trying to conceive at enrollment (2013-2019). Participants completed a baseline questionnaire at enrollment and follow-up questionnaires every 2 months for up to 12 months or until conception. We used data from 4133 participants with no more than one menstrual cycle of pregnancy attempt at study entry. PARTICIPANTS/MATERIALS, SETTING, METHODS On the baseline questionnaire, participants reported data on sociodemographic factors, lifestyle and behavioral factors, diet quality, medical history and selected male partner characteristics. A total of 163 predictors were considered in this study. We implemented regularized logistic regression, support vector machines, neural networks and gradient boosted decision trees to derive models predicting the probability of pregnancy: (i) within fewer than 12 menstrual cycles of pregnancy attempt time (Model I), and (ii) within 6 menstrual cycles of pregnancy attempt time (Model II). Cox models were used to predict the probability of pregnancy within each menstrual cycle for up to 12 cycles of follow-up (Model III). We assessed model performance using the AUC and the weighted-F1 score for Models I and II, and the concordance index for Model III. MAIN RESULTS AND THE ROLE OF CHANCE Model I and II AUCs were 70% and 66%, respectively, in parsimonious models, and the concordance index for Model III was 63%. The predictors that were positively associated with pregnancy in all models were: having previously breastfed an infant and using multivitamins or folic acid supplements. The predictors that were inversely associated with pregnancy in all models were: female age, female BMI and history of infertility. Among nulligravid women with no history of infertility, the most important predictors were: female age, female BMI, male BMI, use of a fertility app, attempt time at study entry and perceived stress. LIMITATIONS, REASONS FOR CAUTION Reliance on self-reported predictor data could have introduced misclassification, which would likely be non-differential with respect to the pregnancy outcome given the prospective design. In addition, we cannot be certain that all relevant predictor variables were considered. Finally, though we validated the models using split-sample replication techniques, we did not conduct an external validation study. WIDER IMPLICATIONS OF THE FINDINGS Given a wide range of predictor data, machine learning algorithms can be leveraged to analyze epidemiologic data and predict the probability of conception with discrimination that exceeds earlier work. STUDY FUNDING/COMPETING INTEREST(S) The research was partially supported by the U.S. National Science Foundation (under grants DMS-1664644, CNS-1645681 and IIS-1914792) and the National Institutes for Health (under grants R01 GM135930 and UL54 TR004130). In the last 3 years, L.A.W. has received in-kind donations for primary data collection in PRESTO from FertilityFriend.com, Kindara.com, Sandstone Diagnostics and Swiss Precision Diagnostics. L.A.W. also serves as a fibroid consultant to AbbVie, Inc. The other authors declare no competing interests. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- Jennifer J Yland
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA,Correspondence address. Department of Epidemiology, Boston University School of Public Health, 715 Albany Street, Boston, MA 02118, USA. E-mail:
| | - Taiyao Wang
- Center for Information and Systems Engineering, Boston University, Boston, MA, USA,Philips Research North America, Cambridge, MA, USA
| | - Zahra Zad
- Center for Information and Systems Engineering, Boston University, Boston, MA, USA,Division of Systems Engineering, Department of Electrical and Computer Engineering, Boston University, Boston, MA, USA
| | - Sydney K Willis
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Tanran R Wang
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Amelia K Wesselink
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Tammy Jiang
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Elizabeth E Hatch
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Lauren A Wise
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Ioannis Ch Paschalidis
- Center for Information and Systems Engineering, Boston University, Boston, MA, USA,Division of Systems Engineering, Department of Electrical and Computer Engineering, Boston University, Boston, MA, USA,Department of Biomedical Engineering, Boston University, Boston, MA, USA
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6
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van Welie N, van Rijswijk J, Dreyer K, van Hooff MHA, de Bruin JP, Verhoeve HR, Mol F, van Baal WM, Traas MAF, van Peperstraten AM, Manger AP, Gianotten J, de Koning CH, Koning AMH, Bayram N, van der Ham DP, Vrouenraets FPJM, Kalafusova M, van de Laar BIG, Kaijser J, Lambeek AF, Meijer WJ, Broekmans FJM, Valkenburg O, van der Voet LF, van Disseldorp J, Lambers MJ, Tros R, Lambalk CB, Stoker J, van Wely M, Bossuyt PMM, Mol BWJ, Mijatovic V. OUP accepted manuscript. Hum Reprod 2022; 37:969-979. [PMID: 35220432 PMCID: PMC9071226 DOI: 10.1093/humrep/deac034] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 01/27/2022] [Indexed: 11/30/2022] Open
Abstract
STUDY QUESTION Does hysterosalpingo-foam sonography (HyFoSy) lead to similar pregnancy outcomes, compared with hysterosalpingography (HSG), as first-choice tubal patency test in infertile couples? SUMMARY ANSWER HyFoSy and HSG produce similar findings in a majority of patients and clinical management based on the results of either HyFoSy or HSG, leads to comparable pregnancy outcomes. HyFoSy is experienced as significantly less painful. WHAT IS KNOWN ALREADY Traditionally, tubal patency testing during fertility work-up is performed by HSG. HyFoSy is an alternative imaging technique lacking ionizing radiation and iodinated contrast medium exposure which is less expensive than HSG. Globally, there is a shift towards the use of office-based diagnostic methods, such as HyFoSy. STUDY DESIGN, SIZE, DURATION This multicentre, prospective, comparative study with a randomized design was conducted in 26 hospitals in The Netherlands. Participating women underwent both HyFoSy and HSG in randomized order. In case of discordant results, women were randomly allocated to either a management strategy based on HyFoSy or one based on HSG. PARTICIPANTS/MATERIALS, SETTING, METHODS We included infertile women between 18 and 41 years old who were scheduled for tubal patency testing during their fertility work-up. Women with anovulatory cycles not responding to ovulation induction, endometriosis, severe male infertility or a known iodine contrast allergy were excluded. The primary outcome for the comparison of the HyFoSy- and HSG-based strategies was ongoing pregnancy leading to live birth within 12 months after inclusion in an intention-to-treat analysis. MAIN RESULTS AND THE ROLE OF CHANCE Between May 2015 and January 2019, 1026 women underwent HyFoSy and HSG. HyFoSy was inconclusive in 97 of them (9.5%), HSG was inconclusive in 30 (2.9%) and both were inconclusive in 9 (0.9%). In 747 women (73%) conclusive tests results were concordant. Of the 143/1026 (14%) with discordant results, 105 were randomized to clinical management based on the results of either HyFoSy or HSG. In this group, 22 of the 54 women (41%) allocated to management based on HyFoSy and 25 of 51 women (49%) allocated to management based on HSG had an ongoing pregnancy leading to live birth (Difference −8%; 95% CI: −27% to 10%). In total, clinical management based on the results of HyFoSy was estimated to lead to a live birth in 474 of 1026 women (46%) versus 486 of 1026 (47%) for management based on HSG (Difference −1.2%; 95% CI: −3.4% to 1.5%). Given the pre-defined margin of −2%, statistically significant non-inferiority of HyFoSy relative to HSG could not be demonstrated (P = 0.27). The mean pain score for HyFoSy on the 1–10 Visual Analogue Scale (VAS) was 3.1 (SD 2.2) and the mean VAS pain score for HSG was 5.4 (SD 2.5; P for difference < 0.001). LIMITATIONS, REASONS FOR CAUTION Since all women underwent both tubal patency tests, no conclusions on a direct therapeutic effect of tubal flushing could be drawn. WIDER IMPLICATIONS OF THE FINDINGS HyFoSy or HSG produce similar tubal pathology findings in a majority of infertile couples and, where they differ, a difference in findings does not lead to substantial difference in pregnancy outcome, while HyFoSy is associated with significantly less pain. STUDY FUNDING/COMPETING INTEREST(S) The FOAM study was an investigator-initiated study funded by ZonMw, The Netherlands organization for Health Research and Development (project number 837001504). ZonMw funded the whole project. IQ Medical Ventures provided the ExEm-foam® kits free of charge. The funders had no role in study design, collection, analysis and interpretation of the data. K.D. reports travel and speaker fees from Guerbet. F.J.M.B. reports personal fees as a member of the external advisory board for Merck Serono, The Netherlands, and a research support grant from Merck Serono, outside the submitted work. C.B.L. reports speakers’ fee from Ferring in the past, and his department receives research grants from Ferring, Merck and Guerbet. J.S. reports a research agreement with Takeda on MR of motility outside the submitted work. M.V.W. reports leading The Netherlands Satellite of the Cochrane Gynaecology and Fertility Group. B.W.J.M. is supported by an NHMRC Investigator grant (GNT1176437). B.W.J.M. reports consultancy for Guerbet and research funding from Merck and Guerbet. V.M. reports non-financial support from IQ medicals ventures, during the conduct of the study; grants and personal fees from Guerbet, outside the submitted work. The other authors do not report conflicts of interest. TRIAL REGISTRATION NUMBER NTR4746/NL4587 (https://www.trialregister.nl) TRIAL REGISTRATION DATE 19 August 2014 DATE OF FIRST PATIENT’S ENROLMENT 7 May 2015
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Affiliation(s)
- Nienke van Welie
- Department of Reproductive Medicine, Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Correspondence address. Department of Reproductive Medicine, Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands. E-mail:
| | - Joukje van Rijswijk
- Department of Reproductive Medicine, Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Kim Dreyer
- Department of Reproductive Medicine, Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Machiel H A van Hooff
- Department of Obstetrics and Gynaecology, Franciscus Hospital, Rotterdam, The Netherlands
| | - Jan Peter de Bruin
- Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Harold R Verhoeve
- Department of Obstetrics and Gynaecology, OLVG Oost, Amsterdam, The Netherlands
| | - Femke Mol
- Centre for Reproductive Medicine, Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Maaike A F Traas
- Department of Obstetrics and Gynaecology, Gelre Hospitals, Location Apeldoorn, Apeldoorn, The Netherlands
| | - Arno M van Peperstraten
- Department of Obstetrics and Gynaecology, Rivierenland Hospital, Tiel, The Netherlands
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Arentje P Manger
- Department of Obstetrics and Gynaecology, Diakonessenhuis, Utrecht, The Netherlands
| | - Judith Gianotten
- Department of Obstetrics and Gynaecology, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Cornelia H de Koning
- Department of Obstetrics and Gynaecology, Tergooi Hospital, Blaricum, The Netherlands
| | - Aafke M H Koning
- Department of Obstetrics and Gynaecology, Amstelland Hospital, Amstelveen, The Netherlands
| | - Neriman Bayram
- Department of Obstetrics and Gynaecology, Zaans Medical Centre, Zaandam, The Netherlands
| | - David P van der Ham
- Department of Obstetrics and Gynaecology, Martini Hospital Groningen, Groningen, The Netherlands
| | | | - Michaela Kalafusova
- Department of Obstetrics and Gynaecology, Refaja Hospital, Stadskanaal, The Netherlands
| | - Bob I G van de Laar
- Department of Obstetrics and Gynaecology, OLVG West, Amsterdam, The Netherlands
| | - Jeroen Kaijser
- Department of Obstetrics and Gynaecology, Ikazia Medical Center, Rotterdam, The Netherlands
| | - Arjon F Lambeek
- Department of Obstetrics and Gynaecology, IJsselland Hospital, Capelle aan den IJssel, The Netherlands
| | - Wouter J Meijer
- Department of Obstetrics and Gynaecology, Gelre Hospitals, Location Zutphen, Zutphen, The Netherlands
| | - Frank J M Broekmans
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Olivier Valkenburg
- Department of Reproductive Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Lucy F van der Voet
- Department of Obstetrics and Gynaecology, Deventer Hospital, Deventer, The Netherlands
| | - Jeroen van Disseldorp
- Department of Obstetrics and Gynaecology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Marieke J Lambers
- Department of Obstetrics and Gynaecology, Dijklander Hospital, Hoorn, The Netherlands
| | - Rachel Tros
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Cornelis B Lambalk
- Department of Reproductive Medicine, Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Madelon van Wely
- Centre for Reproductive Medicine, Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Epidemiology & Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Patrick M M Bossuyt
- Department of Epidemiology & Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ben Willem J Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
- Aberdeen Centre for Women’s Health Research, King’s College, University of Aberdeen, Aberdeen, UK
| | - Velja Mijatovic
- Department of Reproductive Medicine, Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Rolland L, Amar-Hoffet A, Lubin V, Préaubert L, Miquel L, Courbiere B. Unexplained infertility: A French national survey of clinical practices. J Gynecol Obstet Hum Reprod 2021; 51:102301. [PMID: 34971768 DOI: 10.1016/j.jogoh.2021.102301] [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: 08/15/2021] [Revised: 12/10/2021] [Accepted: 12/23/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The aim of our study was to carry out a national survey of French practitioners to evaluate (i) their diagnostic criteria for making a diagnosis of unexplained infertility (UEI) and (ii) their management strategy when facing UEI. MATERIALS AND METHOD An online questionnaire comprising ten multiple-choice questions was sent by mail to French reproductive practitioners in 80 fertility centres. RESULTS The response rate was 59.6% (195/327). Post coital testing was always or often prescribed by 14.8% of respondents (n=36). Chlamydia trachomatis testing was never prescribed by 31.7% (n=59) of them, 30.2% prescribed a pelvic MRI in cases of UEI and 18.4% (n=33) always or often performed laparoscopy. For 87.6% (n=169), advanced maternal age was always or often an indication of first-line IVF, with an average threshold of 37.4 years. For 68.6% (n=129), diminished AMH was an indication for first-line IVF, with an average AMH threshold of 1.2 ng/ml. With respect to the management of UEI, we did not observe a consensus between the strategies of 2 to 6 intrauterine insemination cycles before IVF or IVF as the first-line treatment. CONCLUSION There is no consensus in France on what tests should or should not be carried out to conclude UEI, and there is also no consensus on the management of UEI. UEI is one of the top 10 priorities for future infertility research. The diagnostic criteria must be standardized to enable the comparison of studies on this topic as well as to improve the translation of research into clinical practice.
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Affiliation(s)
- Lucie Rolland
- Service of Medicine and Reproductive Biology, Hôpital Saint-joseph, 26, boulevard de Louvain, 13008 Marseille, France.
| | - Aurelie Amar-Hoffet
- Service of Medicine and Reproductive Biology, Hôpital Saint-joseph, 26, boulevard de Louvain, 13008 Marseille, France.
| | - Vanessa Lubin
- Service of Medicine and Reproductive Biology, Hôpital Saint-joseph, 26, boulevard de Louvain, 13008 Marseille, France.
| | - Lise Préaubert
- Department of Gynecology, Obstetric and Reproductive Medicine, Gynepôle, AP-HM La Conception, 147 bd Baille, 13005 Marseille, France.
| | - Laura Miquel
- Department of Gynecology, Obstetric and Reproductive Medicine, Gynepôle, AP-HM La Conception, 147 bd Baille, 13005 Marseille, France.
| | - Blandine Courbiere
- Department of Gynecology, Obstetric and Reproductive Medicine, Gynepôle, AP-HM La Conception, 147 bd Baille, 13005 Marseille, France; Aix Marseille Université, CNRS, IRD, Avignon Université, IMBE UMR 7263, 13397, Marseille, France.
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Gnoth C. Natürliche Fertilität im Kontext der assistierten Reproduktion. GYNAKOLOGISCHE ENDOKRINOLOGIE 2021. [DOI: 10.1007/s10304-021-00421-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Hamilton JAM, van der Steeg JW, Hamilton CJCM, de Bruin JP. A concise infertility work-up results in fewer pregnancies. Hum Reprod Open 2021; 2021:hoab033. [PMID: 34557598 PMCID: PMC8452484 DOI: 10.1093/hropen/hoab033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 08/09/2021] [Indexed: 01/22/2023] Open
Abstract
STUDY QUESTION Is pregnancy success rate after a concise infertility work-up the same as pregnancy success rate after the traditional extensive infertility work-up? SUMMARY ANSWER The ongoing pregnancy rate within a follow-up of 1 year after a concise infertility work-up is significantly lower than the pregnancy success rate after the traditional and extensive infertility work-up. WHAT IS KNOWN ALREADY Based on cost-effectiveness studies, which have mainly focused on diagnosis, infertility work-up has become less comprehensive. Many centres have even adopted a one-stop approach to their infertility work-up. STUDY DESIGN SIZE DURATION We performed a historically controlled cohort study. In 2012 and 2013 all new infertile couples (n = 795) underwent an extensive infertility work-up (group A). In 2014 and 2015, all new infertile couples (n = 752) underwent a concise infertility work-up (group B). The follow-up period was 1 year for both groups. Complete follow-up was available for 99.0% of couples in group A and 97.5% in group B. PARTICIPANTS/MATERIALS SETTING METHODS The extensive infertility work-up consisted of history taking, a gynaecological ultrasound scan, semen analysis, ultrasonographic cycle monitoring, a timed postcoital test, a timed progesterone and chlamydia antibody titre. A hysterosalpingography (HSG) was advised routinely. The concise infertility work-up was mainly based on history taking, a gynaecological ultrasound scan and semen analysis. A HSG was only performed if tubal pathology was suspected or before the start of IUI. Laparoscopy and hormonal tests were only performed if indicated. Couples were treated according to the diagnosis with either expectant management (if the Hunault prognostic score was >30%), ovulation induction (in case of ovulation disorders), IUI in natural cycles (in case of cervical factor), IUI in stimulated cycles (if the Hunault prognostic score was <30%) or IVF/ICSI (in case of tubal factor, advanced female age, severe male factor and if other treatments remained unsuccessful). The primary outcomes were time to pregnancy and the ongoing pregnancy rates in both groups. The secondary outcomes were the number of investigations, the distribution of diagnoses made, the first treatment (started) after infertility work-up and the mode of conception. MAIN RESULTS AND THE ROLE OF CHANCE The descriptive data, such as age, duration of infertility, type of infertility and lifestyle habits, in both groups were comparable. In group A, more than twice the number of infertility investigations were performed, compared to group B. An HSG was made less frequently in group B (33% versus 42%) and at a later stage. A Kaplan-Meier curve shows a shorter time to pregnancy in group A. Also, a significantly higher overall ongoing pregnancy rate within a follow-up of 1 year was found in group A (58.7% versus 46.8%, respectively, P < 0.001). In group A, more couples conceived during the infertility work-up (14.7% versus 6.5%, respectively, P < 0.05). The diagnosis cervical infertility could only be made in group A (9.3%). The diagnosis unexplained infertility differed between groups, at 23.5% in group A and 32.2% in group B (P < 0.001). LIMITATIONS REASONS FOR CAUTION This was a historically controlled cohort study; introduction of bias cannot be ruled out. The follow-up rate was similar in the two groups and therefore could not explain the differences in pregnancy rate. WIDER IMPLICATIONS OF THE FINDINGS Re-introduction of an extensive infertility work-up should be considered as it may lead to higher ongoing pregnancy rates within a year. The therapeutic effects of HSG and timing of intercourse may improve the fertility chance. This finding should be verified in a randomized controlled trial. STUDY FUNDING/COMPETING INTERESTS No funding was obtained for this study. No conflicts of interest were declared. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- J A M Hamilton
- Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - J W van der Steeg
- Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - C J C M Hamilton
- Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - J P de Bruin
- Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
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10
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The long-term costs and effects of tubal flushing with oil-based versus water-based contrast during hysterosalpingography. Reprod Biomed Online 2020; 42:150-157. [PMID: 33077355 DOI: 10.1016/j.rbmo.2020.09.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 08/18/2020] [Accepted: 09/11/2020] [Indexed: 01/31/2023]
Abstract
RESEARCH QUESTION What are the long-term costs and effects of oil- versus water-based contrast in infertile women undergoing hysterosalpingography (HSG)? DESIGN This economic evaluation of a long-term follow-up of a multicentre randomized controlled trial involved 1119 infertile women randomized to HSG with oil- (n = 557) or water-based contrast (n = 562) in the Netherlands. RESULTS In the oil-based contrast group, 39.8% of women needed no other treatment, 34.6% underwent intrauterine insemination (IUI) and 25.6% had IVF/intracytoplasmic sperm injection (ICSI) in the 5 years following HSG. In the water-based contrast group, 35.0% of women had no other treatment, 34.2% had IUI and 30.8% had IVF/ICSI in the 5 years following HSG (P = 0.113). After 5 years of follow-up, HSG using oil-based contrast resulted in equivalent costs (mean cost difference -€144; 95% confidence interval [CI] -€579 to +€290; P = 0.515) for a 5% increase in the cumulative ongoing pregnancy rate compared with HSG using water-based contrast (80% compared with 75%, Relative Risk (RR) 1.07; 95% CI 1.00-1.14). Similarly, HSG with oil-based contrast resulted in equivalent costs (mean cost difference -€50; 95% CI -€576 to +€475; P = 0.850) for a 7.5% increase in the cumulative live birth rate compared with HSG with water-based contrast (74.8% compared with 67.3%, RR 1.11; 95% CI 1.03-1.20), making it the dominant strategy. Scenario analyses suggest that the oil-based contrast medium is the dominant strategy up to a price difference of €300. CONCLUSION Over a 5-year follow-up, HSG with an oil-based contrast was associated with a 5% increase in ongoing pregnancy rate, a 7.5% increase in live birth rate and similar costs to HSG with water-based contrast.
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11
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van Welie N, Dreyer K, van Rijswijk J, Verhoeve HR, Goddijn M, Nap AW, Smeenk JMJ, Traas MAF, Rijnsaardt-Lukassen HGM, van Dongen AJCM, Bourdrez P, de Bruin JP, Sluijmer AV, Gijsen AP, van de Ven PM, Lambalk CB, Mijatovic V, Mol BWJ. Treatment effect of oil-based contrast is related to experienced pain at HSG: a post-hoc analysis of the randomised H2Oil study. Hum Reprod 2020; 34:2391-2398. [PMID: 31887222 PMCID: PMC6995245 DOI: 10.1093/humrep/dez206] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 08/30/2019] [Indexed: 11/15/2022] Open
Abstract
STUDY QUESTION Does pain or volume of used contrast medium impact the effectiveness of oil-based contrast during hysterosalpingography (HSG)? SUMMARY ANSWER In women who report moderate to severe pain during HSG, the use of oil-based contrast resulted in more ongoing pregnancies compared to the use of water-based contrast, whereas in women who reported mild or no pain, no difference in ongoing pregnancies was found. WHAT IS KNOWN ALREADY We recently showed that in infertile women undergoing HSG, the use of oil-based contrast results in more ongoing pregnancies within 6 months as compared to the use of water-based contrast. However, the underlying mechanism of this fertility-enhancing effect remains unclear. STUDY DESIGN, SIZE, DURATION We performed a post-hoc analysis of the H2Oil study, a multicentre randomised controlled trial (RCT) evaluating the therapeutic effect of oil- and water-based contrast at HSG. Here, we evaluated the impact of pain experienced at HSG and volume of used contrast media during HSG on ongoing pregnancy. PARTICIPANTS/MATERIALS, SETTING, METHODS In a subset of 400 participating women, pain during HSG by means of the Visual Analogue Scale (VAS) (range: 0.0–10.0 cm) was reported, while in 512 women, we registered the volume of used contrast (in millilitres). We used logistic regression analyses to assess whether pain and volume of used contrast media modified the effect of oil-based contrast on ongoing pregnancy rates. Data were analysed according to intention-to-treat principle. MAIN RESULTS AND THE ROLE OF CHANCE In 400 women in whom pain scores were reported, the overall median pain score was 5.0 (Interquartile range (IQR) 3.0–6.8) (oil group (n = 199) 4.8 (IQR 3.0–6.4); water group (n = 201) 5.0 (IQR 3.0–6.7); P-value 0.28). There was a significant interaction between pain (VAS ≤5 versus VAS ≥6) and the primary outcome ongoing pregnancy (P-value 0.047). In women experiencing pain (VAS ≥6), HSG with oil-based contrast resulted in better 6-month ongoing pregnancy rates compared to HSG with water-based contrast (49.4% versus 29.6%; RR 1.7; 95% CI, 1.1–2.5), while in women with a pain score ≤5, 6-month ongoing pregnancy rates were not significantly different between the use of oil- (28.8%) versus water-based contrast (29.2%) (RR 0.99; 95% CI, 0.66–1.5). In the 512 women in whom we recorded contrast, median volume was 9.0 ml (IQR 5.7–15.0) in the oil group versus 8.0 ml (IQR 5.9–13.0) in the water group, respectively (P-value 0.72). Volume of used contrast was not found to modify the effect of oil-based contrast on ongoing pregnancy (P-value for interaction 0.23). LIMITATIONS, REASONS FOR CAUTION This was a post-hoc analysis that should be considered as hypothesis generating. The RCT was restricted to infertile ovulatory women, younger than 39 years of age and with a low risk for tubal pathology. Therefore, our results should not be generalised to infertile women who do not share these features. WIDER IMPLICATIONS OF THE FINDINGS The underlying mechanism of the fertility-enhancing effect induced by HSG with the use of oil-based contrast remains unclear. However, these findings suggest a possible mechanistic pathway, that is increasing intrauterine pressure occurring prior to dislodging pregnancy hindering debris or mucus plugs from the proximal part of otherwise normal fallopian tubes. This information might help in the search of the underlying fertility-enhancing mechanism found by using oil-based contrast during HSG. STUDY FUNDING/COMPETING INTEREST(S) The original H2Oil RCT was an investigator-initiated study that was funded by the two academic institutions (AMC and VUmc) of the Amsterdam UMC. The funders had no role in study design, collection, analysis and interpretation of the data. K.D. reports consultancy for Guerbet. H.V. reports consultancy fees from Ferring. C.B.L. reports speakers’ fees from Ferring and research grants from Ferring, Merck and Guerbet. V.M. reports receiving travel and speakers fees as well as research grants from Guerbet. B.W.M. is supported by an NHMRC Practitioner Fellowship (GNT1082548). B.W.M. reports consultancy for ObsEva, Merck KGaA and Guerbet and travel and research grants from Merck KGaA and Guerbet. The other authors do not report conflict of interests. TRIAL REGISTRATION NUMBER The H2Oil study was registered at the Netherlands Trial Registry (NTR 3270). TRIAL REGISTRATION DATE 1 February 2012. DATE OF FIRST PATIENT’S ENROLMENT 3 February 2012.
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Affiliation(s)
- N van Welie
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam 1081 HV, The Netherlands
| | - K Dreyer
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam 1081 HV, The Netherlands
| | - J van Rijswijk
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam 1081 HV, The Netherlands
| | - H R Verhoeve
- Department of Obstetrics and Gynaecology, OLVG, Amsterdam 1091 AC, The Netherlands
| | - M Goddijn
- Centre for Reproductive Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam 1105 AZ, The Netherlands
| | - A W Nap
- Department of Obstetrics and Gynaecology, Rijnstate Hospital, Arnhem 6815 AD, The Netherlands
| | - J M J Smeenk
- Department of Obstetrics and Gynaecology, Elisabeth-TweeSteden Hospital, Tilburg 5022 GC, The Netherlands
| | - M A F Traas
- Department of Obstetrics and Gynaecology, Gelre Hospital, Apeldoorn 7334 DZ, The Netherlands
| | - H G M Rijnsaardt-Lukassen
- Department of Obstetrics and Gynaecology, Albert Schweitzer Hospital, Dordrecht 3318 AT, The Netherlands
| | - A J C M van Dongen
- Department of Obstetrics and Gynaecology, Hospital Gelderse Vallei, Ede 6716 RP, The Netherlands
| | - P Bourdrez
- Department of Obstetrics and Gynaecology, VieCuri Medical Centre, Venlo 5912 BL, The Netherlands
| | - J P de Bruin
- Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, 's Hertogenbosch 5223 GZ, The Netherlands
| | - A V Sluijmer
- Department of Obstetrics and Gynaecology, Wilhelmina Hospital, Assen 9401 RK, The Netherlands
| | - A P Gijsen
- Department of Obstetrics and Gynaecology, Elkerliek Hospital, Helmond 5707 HA, The Netherlands
| | - P M van de Ven
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam 1081 HV, The Netherlands
| | - C B Lambalk
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam 1081 HV, The Netherlands
| | - V Mijatovic
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam 1081 HV, The Netherlands
| | - B W J Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3800, Australia
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McLernon DJ, Lee AJ, Maheshwari A, van Eekelen R, van Geloven N, Putter H, Eijkemans MJ, van der Steeg JW, van der Veen F, Steyerberg EW, Mol BW, Bhattacharya S. Predicting the chances of having a baby with or without treatment at different time points in couples with unexplained subfertility. Hum Reprod 2020; 34:1126-1138. [PMID: 31119290 DOI: 10.1093/humrep/dez049] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 03/17/2019] [Indexed: 11/13/2022] Open
Abstract
STUDY QUESTION Can we develop a prediction model that can estimate the chances of conception leading to live birth with and without treatment at different points in time in couples with unexplained subfertility? SUMMARY ANSWER Yes, a dynamic model was developed that predicted the probability of conceiving under expectant management and following active treatments (in vitro fertilisation (IVF), intrauterine insemination with ovarian stimulation (IUI + SO), clomiphene) at different points in time since diagnosis. WHAT IS KNOWN ALREADY Couples with no identified cause for their subfertility continue to have a realistic chance of conceiving naturally, which makes it difficult for clinicians to decide when to intervene. Previous fertility prediction models have attempted to address this by separately estimating either the chances of natural conception or the chances of conception following certain treatments. These models only make predictions at a single point in time and are therefore inadequate for informing continued decision-making at subsequent consultations. STUDY DESIGN, SIZE, DURATION A population-based study of 1316 couples with unexplained subfertility attending a regional clinic between 1998 and 2011. PARTICIPANTS/MATERIALS, SETTING, METHODS A dynamic prediction model was developed that estimates the chances of conception within 6 months from the point when a diagnosis of unexplained subfertility was made. These predictions were recomputed each month to provide a dynamic assessment of the individualised chances of conception while taking account of treatment status in each month. Conception must have led to live birth and treatments included clomiphene, IUI + SO, and IVF. Predictions for natural conception were externally validated using a prospective cohort from The Netherlands. MAIN RESULTS AND THE ROLE OF CHANCE A total of 554 (42%) couples started fertility treatment within 2 years of their first fertility consultation. The natural conception leading to live birth rate was 0.24 natural conceptions per couple per year. Active treatment had a higher chance of conception compared to those who remained under expectant management. This association ranged from weak with clomiphene to strong with IVF [clomiphene, hazard ratio (HR) = 1.42 (95% confidence interval, 1.05 to 1.91); IUI + SO, HR = 2.90 (2.06 to 4.08); IVF, HR = 5.09 (4.04 to 6.40)]. Female age and duration of subfertility were significant predictors, without clear interaction with the relative effect of treatment. LIMITATIONS, REASONS FOR CAUTION We were unable to adjust for other potentially important predictors, e.g. measures of ovarian reserve, which were not available in the linked Grampian dataset that may have made predictions more specific. This study was conducted using single centre data meaning that it may not be generalizable to other centres. However, the model performed as well as previous models in reproductive medicine when externally validated using the Dutch cohort. WIDER IMPLICATIONS OF THE FINDINGS For the first time, it is possible to estimate the chances of conception following expectant management and different fertility treatments over time in couples with unexplained subfertility. This information will help inform couples and their clinicians of their likely chances of success, which may help manage expectations, not only at diagnostic workup completion but also throughout their fertility journey. STUDY FUNDING/COMPETING INTEREST(S) This work was supported by a Chief Scientist Office postdoctoral training fellowship in health services research and health of the public research (ref PDF/12/06). B.W.M. is supported by an NHMRC Practitioner Fellowship (GNT1082548). B.W.M. reports consultancy for ObsEva, Merck, and Guerbet. None of the other authors declare any conflicts of interest.
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Affiliation(s)
- D J McLernon
- Medical Statistics Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - A J Lee
- Medical Statistics Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - A Maheshwari
- Aberdeen Centre for Reproductive Medicine, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - R van Eekelen
- Centre for Reproductive Medicine, Academic Medical Centre, AZ Amsterdam, The Netherlands.,Department of Biostatistics and Research Support, University Medical Centre Utrecht-Julius Centre, GA Utrecht, The Netherlands
| | - N van Geloven
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, RC Leiden, The Netherlands
| | - H Putter
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, RC Leiden, The Netherlands
| | - M J Eijkemans
- Department of Biostatistics and Research Support, University Medical Centre Utrecht-Julius Centre, GA Utrecht, The Netherlands
| | - J W van der Steeg
- Department for Obstetrics and Gynaecology, Jeroen Bosch Ziekenhuis, GZ 's-Hertogenbosch, The Netherlands
| | - F van der Veen
- Centre for Reproductive Medicine, Academic Medical Centre, AZ Amsterdam, The Netherlands
| | - E W Steyerberg
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, RC Leiden, The Netherlands.,Department of Public Health, Erasmus MC-University Medical Centre Rotterdam, CN Rotterdam, The Netherlands
| | - B W Mol
- The Robinson Institute-School of Medicine, University of Adelaide, Adelaide, Australia
| | - S Bhattacharya
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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van Rijswijk J, van Welie N, Dreyer K, Pham CT, Verhoeve HR, Hoek A, de Bruin JP, Nap AW, van Hooff MHA, Goddijn M, Hooker AB, Bourdrez P, van Dongen AJCM, van Rooij IAJ, van Rijnsaardt-Lukassen HGM, van Golde RJT, van Heteren CF, Pelinck MJ, Duijn AEJ, Kaplan M, Lambalk CB, Mijatovic V, Mol BWJ. Tubal flushing with oil-based or water-based contrast at hysterosalpingography for infertility: long-term reproductive outcomes of a randomized trial. Fertil Steril 2020; 114:155-162. [PMID: 32553471 DOI: 10.1016/j.fertnstert.2020.03.022] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 03/02/2020] [Accepted: 03/17/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To determine the impact of oil-based versus water-based contrast on pregnancy and live birth rates ≤5 years after hysterosalpingography (HSG) in infertile women. DESIGN A 5-year follow-up study of a multicenter randomized trial. SETTING Hospitals. PATIENT(S) Infertile women with an ovulatory cycle, 18-39 years of age, and having a low risk of tubal pathology. INTERVENTION(S) Use of oil-based versus water-based contrast during HSG. MAIN OUTCOME MEASURE(S) Ongoing pregnancy, live births, time to ongoing pregnancy, second ongoing pregnancy. RESULT(S) A total of 1,119 women were randomly assigned to HSG with oil-based contrast (n = 557) or water-based contrast (n = 562). After 5 years, 444 of 555 women in the oil group (80.0%) and 419 of 559 women in the water group (75.0%) had an ongoing pregnancy (relative risk [RR] 1.07; 95% confidence interval [CI] 1.00-1.14), and 415 of 555 women in the oil group (74.8%) and 376 of 559 women in the water group (67.3%) had live births (RR 1.11; 95% CI 1.03-1.20). In the oil group, 228 pregnancies (41.1%) were conceived naturally versus 194 (34.7%) pregnancies in the water group (RR 1.18; 95% CI 1.02-1.38). The time to ongoing pregnancy was significantly shorter in the oil group versus the water group (10.0 vs. 13.7 months; hazard ratio, 1.25; 95% CI 1.09-1.43). No difference was found in the occurrence of a second ongoing pregnancy. CONCLUSION(S) During a 5-year time frame, ongoing pregnancy and live birth rates are higher after tubal flushing with oil-based contrast during HSG compared with water-based contrast. More pregnancies are naturally conceived and time to ongoing pregnancy is shorter after HSG with oil-based contrast. CLINICAL TRIAL REGISTRATION NUMBER Netherlands Trial Register (NTR) 3270 and NTR6577(www.trialregister.nl).
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Affiliation(s)
- Joukje van Rijswijk
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
| | - Nienke van Welie
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Kim Dreyer
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Clarabelle T Pham
- College of Medicine and Public Health, Flinders University, Adelaide, Victoria, Australia
| | - Harold R Verhoeve
- Department of Obstetrics and Gynaecology, Onze Lieve Vrouwe Gasthuis, Amsterdam; the Netherlands
| | - Annemieke Hoek
- Department of Reproductive Medicine and Gynaecology, University of Groningen, University Medical Centre Groningen, Hanzeplein, the Netherlands
| | - Jan Peter de Bruin
- Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, Hertogenbosch, the Netherlands
| | - Annemiek W Nap
- Department of Obstetrics and Gynaecology, Rijnstate Hospital, Arnhem, the Netherlands
| | - Machiel H A van Hooff
- Department of Obstetrics and Gynaecology, Franciscus Hospital, Rotterdam, the Netherlands
| | - Mariëtte Goddijn
- Centre for Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Angelo B Hooker
- Department of Obstetrics and Gynaecology, Zaans Medical Centre, Zaandam, the Netherlands
| | - Petra Bourdrez
- Department of Obstetrics and Gynaecology, VieCuri Medical Centre, Venlo, the Netherlands
| | | | - Ilse A J van Rooij
- Department of Obstetrics and Gynaecology, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | | | - Ron J T van Golde
- Department of Obstetrics and Gynaecology, Maastricht UMC, Maastricht, the Netherlands
| | - Cathelijne F van Heteren
- Department of Obstetrics and Gynaecology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Marie J Pelinck
- Department of Obstetrics and Gynaecology, Scheper Hospital, Emmen, the Netherlands
| | | | - Mesrure Kaplan
- Department of Obstetrics and Gynaecology, Röpcke-Zweers Hospital, Hardenberg, the Netherlands
| | - Cornelis B Lambalk
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Velja Mijatovic
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ben W J Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
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Burks HR, Hansen KR. Oil or water-based contrast for hysterosalpingography? Fertil Steril 2020; 114:75-76. [PMID: 32532493 DOI: 10.1016/j.fertnstert.2020.04.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/15/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Heather R Burks
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Karl R Hansen
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
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Wang R, Danhof NA, Tjon‐Kon‐Fat RI, Eijkemans MJC, Bossuyt PMM, Mochtar MH, van der Veen F, Bhattacharya S, Mol BWJ, van Wely M. Interventions for unexplained infertility: a systematic review and network meta-analysis. Cochrane Database Syst Rev 2019; 9:CD012692. [PMID: 31486548 PMCID: PMC6727181 DOI: 10.1002/14651858.cd012692.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Clinical management for unexplained infertility includes expectant management as well as active treatments, including ovarian stimulation (OS), intrauterine insemination (IUI), OS-IUI, and in vitro fertilisation (IVF) with or without intracytoplasmic sperm injection (ICSI).Existing systematic reviews have conducted head-to-head comparisons of these interventions using pairwise meta-analyses. As this approach allows only the comparison of two interventions at a time and is contingent on the availability of appropriate primary evaluative studies, it is difficult to identify the best intervention in terms of effectiveness and safety. Network meta-analysis compares multiple treatments simultaneously by using both direct and indirect evidence and provides a hierarchy of these treatments, which can potentially better inform clinical decision-making. OBJECTIVES To evaluate the effectiveness and safety of different approaches to clinical management (expectant management, OS, IUI, OS-IUI, and IVF/ICSI) in couples with unexplained infertility. SEARCH METHODS We performed a systematic review and network meta-analysis of relevant randomised controlled trials (RCTs). We searched electronic databases including the Cochrane Gynaecology and Fertility Group Specialised Register of Controlled Trials, the Cochrane Central Register of Studies Online, MEDLINE, Embase, PsycINFO and CINAHL, up to 6 September 2018, as well as reference lists, to identify eligible studies. We also searched trial registers for ongoing trials. SELECTION CRITERIA We included RCTs comparing at least two of the following clinical management options in couples with unexplained infertility: expectant management, OS, IUI, OS-IUI, and IVF (or combined with ICSI). DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts identified by the search strategy. We obtained the full texts of potentially eligible studies to assess eligibility and extracted data using standardised forms. The primary effectiveness outcome was a composite of cumulative live birth or ongoing pregnancy, and the primary safety outcome was multiple pregnancy. We performed a network meta-analysis within a random-effects multi-variate meta-analysis model. We presented treatment effects by using odds ratios (ORs) and 95% confidence intervals (CIs). For the network meta-analysis, we used Confidence in Network Meta-analysis (CINeMA) to evaluate the overall certainty of evidence. MAIN RESULTS We included 27 RCTs (4349 couples) in this systematic review and 24 RCTs (3983 couples) in a subsequent network meta-analysis. Overall, the certainty of evidence was low to moderate: the main limitations were imprecision and/or heterogeneity.Ten RCTs including 2725 couples reported on live birth. Evidence of differences between OS, IUI, OS-IUI, or IVF/ICSI versus expectant management was insufficient (OR 1.01, 95% CI 0.51 to 1.98; low-certainty evidence; OR 1.21, 95% CI 0.61 to 2.43; low-certainty evidence; OR 1.61, 95% CI 0.88 to 2.94; low-certainty evidence; OR 1.88, 95 CI 0.81 to 4.38; low-certainty evidence). This suggests that if the chance of live birth following expectant management is assumed to be 17%, the chance following OS, IUI, OS-IUI, and IVF would be 9% to 28%, 11% to 33%, 15% to 37%, and 14% to 47%, respectively. When only including couples with poor prognosis of natural conception (3 trials, 725 couples) we found OS-IUI and IVF/ICSI increased live birth rate compared to expectant management (OR 4.48, 95% CI 2.00 to 10.1; moderate-certainty evidence; OR 4.99, 95 CI 2.07 to 12.04; moderate-certainty evidence), while there was insufficient evidence of a difference between IVF/ICSI and OS-IUI (OR 1.11, 95% CI 0.78 to 1.60; low-certainty evidence).Eleven RCTs including 2564 couples reported on multiple pregnancy. Compared to expectant management/IUI, OS (OR 3.07, 95% CI 1.00 to 9.41; low-certainty evidence) and OS-IUI (OR 3.34 95% CI 1.09 to 10.29; moderate-certainty evidence) increased the odds of multiple pregnancy, and there was insufficient evidence of a difference between IVF/ICSI and expectant management/IUI (OR 2.66, 95% CI 0.68 to 10.43; low-certainty evidence). These findings suggest that if the chance of multiple pregnancy following expectant management or IUI is assumed to be 0.6%, the chance following OS, OS-IUI, and IVF/ICSI would be 0.6% to 5.0%, 0.6% to 5.4%, and 0.4% to 5.5%, respectively.Trial results show insufficient evidence of a difference between IVF/ICSI and OS-IUI for moderate/severe ovarian hyperstimulation syndrome (OHSS) (OR 2.50, 95% CI 0.92 to 6.76; 5 studies; 985 women; moderate-certainty evidence). This suggests that if the chance of moderate/severe OHSS following OS-IUI is assumed to be 1.1%, the chance following IVF/ICSI would be between 1.0% and 7.2%. AUTHORS' CONCLUSIONS There is insufficient evidence of differences in live birth between expectant management and the other four interventions (OS, IUI, OS-IUI, and IVF/ICSI). Compared to expectant management/IUI, OS may increase the odds of multiple pregnancy, and OS-IUI probably increases the odds of multiple pregnancy. Evidence on differences between IVF/ICSI and expectant management for multiple pregnancy is insufficient, as is evidence of a difference for moderate or severe OHSS between IVF/ICSI and OS-IUI.
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Affiliation(s)
- Rui Wang
- Monash UniversityDepartment of Obstetrics and GynaecologyClaytonVICAustralia3168
- The University of AdelaideRobinson Research Institute and Adelaide Medical SchoolAdelaideSAAustralia5005
| | - Nora A Danhof
- Academic Medical Center, University of AmsterdamCenter for Reproductive MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Raissa I Tjon‐Kon‐Fat
- Academic Medical Center, University of AmsterdamCenter for Reproductive MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Marinus JC Eijkemans
- UMC UtrechtDepartment of Biostatistics and Research Support, Julius CenterPO Box 85500UtrechtNetherlands3508GA
| | - Patrick MM Bossuyt
- Academic Medical Center, University of AmsterdamDepartment of Clinical Epidemiology, Biostatistics and BioinformaticsRoom J1b‐217, PO Box 22700AmsterdamNetherlands1100 DE
| | - Monique H Mochtar
- Academic Medical Center, University of AmsterdamCenter for Reproductive MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Fulco van der Veen
- Amsterdan UMC, University of AmsterdamCenter for Reproductive MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
| | | | - Ben Willem J Mol
- Monash UniversityDepartment of Obstetrics and GynaecologyClaytonVICAustralia3168
| | - Madelon van Wely
- Amsterdam UMC, University of AmsterdamCenter for Reproductive MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
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van Rijswijk J, van Welie N, Dreyer K, Tajik P, Lambalk CB, Hompes P, Mijatovic V, Mol BWJ, Zafarmand MH. Tubal flushing with oil- or water-based contrast medium: can we identify markers that indicate treatment benefit? Hum Reprod Open 2019; 2019:hoz015. [PMID: 31334364 PMCID: PMC6638263 DOI: 10.1093/hropen/hoz015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 04/23/2019] [Indexed: 02/01/2023] Open
Abstract
STUDY QUESTION Can we identify patient characteristics that distinguish which ovulatory infertile women undergoing hysterosalpingography (HSG) benefit more or less from flushing with oil-based contrast medium compared to water-based contrast medium? SUMMARY ANSWER In ovulatory infertile women, HSG with oil-based contrast medium resulted in higher 6-month ongoing pregnancy and live birth rates as compared to HSG with water-based contrast medium and this treatment effect was independent of characteristics of the couple. WHAT IS KNOWN ALREADY We recently showed that in infertile women undergoing HSG, flushing with oil-based contrast medium resulted in more ongoing pregnancies than flushing with water-based contrast medium. STUDY DESIGN, SIZE, DURATION We used data from our randomized clinical trial (RCT) in which 1,119 ovulatory infertile women undergoing HSG during fertility work-up were randomized for use of oil-based (N = 557) or water-based (N = 562) contrast medium. PARTICIPANTS/MATERIALS, SETTING, METHODS We built logistic regression models to predict ongoing pregnancy and live birth (secondary outcome) as a function of the specific contrast, the specific marker, and marker-by-contrast-interaction. Markers considered were female age, maternal ethnicity, female smoking, body mass index (BMI), duration of infertility, infertility being primary or secondary, sperm quality, and previous appendectomy. MAIN RESULTS AND THE ROLE OF CHANCE The 6-month ongoing pregnancy rates in the overall population were 39.7% after use of oil-based contrast versus 29.1% after use of water-based contrast medium [relative risk (RR), 1.37; 95% confidence interval (CI), 1.16–1.61; P < 0.001]. Among the studied baseline characteristics, BMI (P = 0.002) and semen volume (P = 0.02) were statistically significant prognosticators. The treatment effect of oil-based contrast was stronger in women with a BMI ≤30 kg/m2 [RR, 1.54; 95% CI, 1.23–1.92; P = 0.002], and in women whose partner had a semen volume >3 ml [RR, 1.77; 95% CI, 1.28–2.46; P = 0.02]. Also, in women who smoked, the treatment effect of flushing with oil was stronger, but this interaction did not reach statistical significance (P = 0.066). We found no positive effect of oil-based contrast in obese women. We found similar but weaker associations for live birth, which was probably due to lower number of events resulting in less power. LIMITATIONS, REASONS FOR CAUTION The RCT was restricted to infertile ovulatory women younger than 39 years of age without endocrinological disorders and at low risk for tubal pathology. Our results should not be generalized to infertile women who do not share these features. WIDER IMPLICATIONS OF THE FINDINGS All infertile, ovulatory women younger than 39 years with a low risk for tubal pathology will benefit from an HSG with oil-based contrast; therefore, this should be offered to them after fertility work-up. STUDY FUNDING/COMPETING INTEREST(S) The original H2Oil RCT was an investigator-initiated study that was funded by the two academic institutions (AMC and VUmc) of the Amsterdam UMC. The study displayed in this paper was funded by an unconditional research grant from Guerbet. B.W.M. is supported by an NHMRC Practitioner Fellowship (GNT1082548). K.D. reports consultancy for Guerbet, during the conduct of the study, and also reports research grants from Guerbet. C.B.L. reports grants from Guerbet, during the conduct of the study, and grants from Ferring, grants from Merck, and personal fees from Ferring, outside the submitted work. P.H. reports grants from Guerbet, during the conduct of the study, and grants from Ferring and Merck, outside the submitted work. V.M. reports receiving travel and speakers fee as well as research grants from Guerbet. B.W.M. reports consultancy for ObsEva, Merck, Merck KGaA, and Guerbet, and research grants from Guerbet and Merck. The other authors have no conflict of interest to declare. TRIAL REGISTRATION NUMBER NTR 3270 www.trialregister.nl TRIAL REGISTRATION DATE 1 February 2012. DATE OF FIRST PATIENT’S ENROLMENT 3 February 2012.
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Affiliation(s)
- Joukje van Rijswijk
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Nienke van Welie
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Kim Dreyer
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Parvin Tajik
- Centre for Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Cornelis B Lambalk
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Peter Hompes
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Velja Mijatovic
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ben W J Mol
- Department of Obstetrics and Gynaecology, Monash Medical Centre, Monash Health and Monash University, Melbourne, Australia
| | - Mohammad H Zafarmand
- Centre for Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Punjabi U, Van Mulders H, Goovaerts I, Peeters K, Roelant E, De Neubourg D. DNA fragmentation in concert with the simultaneous assessment of cell viability in a subfertile population: establishing thresholds of normality both before and after density gradient centrifugation. J Assist Reprod Genet 2019; 36:1413-1421. [PMID: 31089933 PMCID: PMC6642232 DOI: 10.1007/s10815-019-01476-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 05/03/2019] [Indexed: 10/26/2022] Open
Abstract
PURPOSE TUNEL assay is the most common, direct test for sperm chromatin integrity assessment. But, lack of standardized protocols makes interlaboratory comparisons impossible. Consequently, clinical thresholds to predict the chance of a clinical pregnancy also vary with the technique adopted. This prospective study was undertaken to assess the incidence of sperm DNA fragmentation in a subfertile population and to establish threshold values of normality as compared to a fertile cohort, both before and after density gradient centrifugation in the total and vital fractions. METHOD Men presenting at a university hospital setup for infertility treatment. DNA damage via TUNEL assay was validated on fresh semen samples, as conventional semen parameters, to reduce variability of results. RESULTS Total DNA fragmentation in the neat semen was significantly higher in the subfertile group, but the vital fraction was not significantly different between the two cohorts. After gradient centrifugation, DNA fragmentation increased significantly in the total fraction of the subfertile group but decreased significantly in the vital fraction. In the fertile cohort, there was a non-significant increase in total fragmentation and in the vital fraction the trend was unclear. CONCLUSIONS Estimating total and vital sperm DNA fragmentation, after density gradient centrifugation, increased both the sensitivity and the specificity, thereby lowering the number of false negatives and false positives encountered. These findings provide opportunities to investigate the significance of the total and the vital fractions after different assisted reproductive technologies.
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Affiliation(s)
- U Punjabi
- Centre for Reproductive Medicine, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium.
- University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium.
| | - H Van Mulders
- Centre for Reproductive Medicine, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium
| | - I Goovaerts
- Centre for Reproductive Medicine, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium
| | - K Peeters
- Centre for Reproductive Medicine, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium
| | - E Roelant
- Clinical Trial Center (CTC), CRC Antwerp, Antwerp University Hospital, University of Antwerp, Wilrijkstraat 10, 2650, Edegem, Belgium
| | - D De Neubourg
- Centre for Reproductive Medicine, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium
- University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium
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18
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Cohlen B, Bijkerk A, Van der Poel S, Ombelet W. IUI: review and systematic assessment of the evidence that supports global recommendations. Hum Reprod Update 2018; 24:300-319. [PMID: 29452361 DOI: 10.1093/humupd/dmx041] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 12/19/2017] [Indexed: 01/12/2023] Open
Abstract
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.
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Affiliation(s)
- Ben Cohlen
- Isala Fertility Center, Isala, Dr van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Aartjan Bijkerk
- Isala Fertility Center, Isala, Dr van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Sheryl Van der Poel
- WHO/HRP (the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction), Avenue Appia 20, 1202 Geneva, Switzerland
| | - Willem Ombelet
- Genk Institute for Fertility Technology, Department of Obstetrics and Gynaecology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600 Genk, Belgium.,Department of Physiology, Hasselt University, Martelarenlaan 42, 3500 Hasselt, Belgium
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19
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van Rijswijk J, Pham CT, Dreyer K, Verhoeve HR, Hoek A, de Bruin JP, Nap AW, Wang R, Lambalk CB, Hompes PG, Mijatovic V, Karnon JD, Mol BW. Oil-based or water-based contrast for hysterosalpingography in infertile women: a cost-effective analysis of a randomized controlled trial. Fertil Steril 2018; 110:754-760. [DOI: 10.1016/j.fertnstert.2018.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 04/13/2018] [Accepted: 05/02/2018] [Indexed: 10/28/2022]
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20
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van Rijswijk J, van Welie N, Dreyer K, van Hooff MHA, de Bruin JP, Verhoeve HR, Mol F, Kleiman-Broeze KA, Traas MAF, Muijsers GJJM, Manger AP, Gianotten J, de Koning CH, Koning AMH, Bayram N, van der Ham DP, Vrouenraets FPJM, Kalafusova M, van de Laar BIG, Kaijser J, van Oostwaard MF, Meijer WJ, Broekmans FJM, Valkenburg O, van der Voet LF, van Disseldorp J, Lambers MJ, Peters HE, Lier MCI, Lambalk CB, van Wely M, Bossuyt PMM, Stoker J, van der Veen F, Mol BWJ, Mijatovic V. The FOAM study: is Hysterosalpingo foam sonography (HyFoSy) a cost-effective alternative for hysterosalpingography (HSG) in assessing tubal patency in subfertile women? Study protocol for a randomized controlled trial. BMC WOMENS HEALTH 2018; 18:64. [PMID: 29743106 PMCID: PMC5941607 DOI: 10.1186/s12905-018-0556-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 04/26/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND Tubal pathology is a causative factor in 20% of subfertile couples. Traditionally, tubal testing during fertility work-up is performed by hysterosalpingography (HSG). Hysterosalpingo-foam sonography (HyFoSy) is a new technique that is thought to have comparable accuracy as HSG, while it is less expensive and more patient friendly. HyFoSy would be an acceptable alternative for HSG, provided it has similar effectiveness in terms of patient outcomes. METHODS/DESIGN We aim to compare the effectiveness and costs of management guided by HyFoSy or by HSG. Consenting women will undergo tubal testing by both HyFoSy and HSG in a randomized order during fertility work-up. The study group will consist of 1163 subfertile women between 18 and 41 years old who are scheduled for tubal patency testing during their fertility work-up. Women with anovulatory cycles not responding to ovulation induction, endometriosis, severe male subfertility or a known contrast (iodine) allergy will be excluded. We anticipate that 7 % (N = 82) of the participants will have discordant test results for HyFoSy and HSG. These participants will be randomly allocated to either a management strategy based on HyFoSy or a management strategy based on HSG, resulting in either a diagnostic laparoscopy with chromopertubation or a strategy that assumes tubal patency (intrauterine insemination or expectant management). The primary outcome is ongoing pregnancy leading to live birth within 12 months after randomization. Secondary outcomes are patient pain scores, time to pregnancy, clinical pregnancy, miscarriage rate, multiple pregnancy rate, preterm birth rate and number of additional treatments. Costs will be estimated by counting resource use and calculating unit prices. DISCUSSION This trial will compare the effectiveness and costs of HyFoSy versus HSG in assessing tubal patency in subfertile women. TRIAL REGISTRATION Dutch Trial Register (NTR 4746, http://www.trialregister.nl ). Date of registration: 19 August 2014.
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Affiliation(s)
- Joukje van Rijswijk
- Department of Reproductive Medicine, VU University Medical Centre, Postal code, 7057 1007, MB, Amsterdam, The Netherlands.
| | - Nienke van Welie
- Department of Reproductive Medicine, VU University Medical Centre, Postal code, 7057 1007, MB, Amsterdam, The Netherlands
| | - Kim Dreyer
- Department of Reproductive Medicine, VU University Medical Centre, Postal code, 7057 1007, MB, Amsterdam, The Netherlands
| | - Machiel H A van Hooff
- Department of Obstetrics and Gynaecology, Sint Franciscus Hospital, Kleiweg 500, 3045PM, Rotterdam, The Netherlands
| | - Jan Peter de Bruin
- Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, Henri Dunantstraat 1, 5223, GZ, Den Bosch, The Netherlands
| | - Harold R Verhoeve
- Department of Obstetrics and Gynaecology, OLVG Oost, Oosterpark 9, 1091, AC, Amsterdam, The Netherlands
| | - Femke Mol
- Centre for Reproductive Medicine, Department of Obstetrics and Gynaecology, Academic Medical Centre, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands
| | - Kimiko A Kleiman-Broeze
- Department of Obstetrics and Gynaecology, Flevo Hospital, Hospitaalweg 1, 1315, RA, Almere, The Netherlands
| | - Maaike A F Traas
- Department of Obstetrics and Gynaecology, Gelre Hospital, Albert Schweitzerlaan, 31 7334, DZ, Apeldoorn, The Netherlands
| | - Guido J J M Muijsers
- Department of Obstetrics and Gynaecology, Rivierenland Hospital, President Kennedylaan 1, 4002, WP, Tiel, The Netherlands
| | - Arentje P Manger
- Department of Obstetrics and Gynaecology, Diakonessenhuis, Bosboomstraat 1, 3582, KE, Utrecht, The Netherlands
| | - Judith Gianotten
- Department of Obstetrics and Gynaecology, Spaarne Gasthuis, Boerhaavelaan 22, 2035RC, Haarlem, The Netherlands
| | - Cornelia H de Koning
- Department of Obstetrics and Gynaecology, Tergooi Hospital, Rijksstraatweg 1 1261 AN, Blaricum, The Netherlands
| | - Aafke M H Koning
- Department of Obstetrics and Gynaecology, Amstelland Hospital, Laan van de Helende Meesters 8, 1186, AM, Amstelveen, The Netherlands
| | - Neriman Bayram
- Department of Obstetrics and Gynaecology, Zaans Medical Centre, Kon, Julianaplein 58, 1502 DV Zaandam, Zaandam, The Netherlands
| | - David P van der Ham
- Department of Obstetrics and Gynaecology, Martini Hospital Groningen, Van Swietenplein 1, 9700, Groningen, RB, Netherlands
| | - Francisca P J M Vrouenraets
- Department of Obstetrics and Gynecology, Zuyderland Medical Center, Henri Dunantstraat 5, 6419, PC, Heerlen, The Netherlands
| | - Michaela Kalafusova
- Department of Obstetrics and Gynaecology, Refaja Hospital, Boerhaavestraat 1, 9501, HE, Stadskanaal, The Netherlands
| | - Bob I G van de Laar
- Department of Obstetrics and Gynaecology, OLVG West, Jan Tooropstraat, 164 1061AE, Amsterdam, The Netherlands
| | - Jeroen Kaijser
- JDepartment of Obstetrics and Gynaecology, Ikazia medical center, Montessoriweg 1, 3083, AN, Rotterdam, The Netherlands
| | - Miriam F van Oostwaard
- Department of Obstetrics and Gynaecology, IJsselland hospital, Prins Constantijnweg 2, 2906, ZC, Capelle a/d Ijssel, The Netherlands
| | - Wouter J Meijer
- Department of Obstetrics and Gynaecology, Gelre Hospital, Den Elterweg 77, 7207AE, Zutphen, The Netherlands
| | - Frank J M Broekmans
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands
| | - Olivier Valkenburg
- Department of Reproductive Medicine, Maastricht University Medical Centre, P. debeylaan, 25 6229HX, Maastricht, The Netherlands
| | - Lucy F van der Voet
- Department of Obstetrics and Gynaecology, Deventer Hospital, Nico Bolkesteinlaan 75, 7416, SE, Deventer, The Netherlands
| | - Jeroen van Disseldorp
- Department of Obstetrics and Gynaecology, Sint Antonius Hospital, Koekoekslaan 1, 3435, CM, Nieuwegein, The Netherlands
| | - Marieke J Lambers
- Department of Obstetrics and Gynaecology, Westfriesgasthuis, Maelsonstraat 3, 1624, NP, Hoorn, The Netherlands
| | - Henrike E Peters
- Department of Reproductive Medicine, VU University Medical Centre, Postal code, 7057 1007, MB, Amsterdam, The Netherlands
| | - Marit C I Lier
- Department of Reproductive Medicine, VU University Medical Centre, Postal code, 7057 1007, MB, Amsterdam, The Netherlands
| | - Cornelis B Lambalk
- Department of Reproductive Medicine, VU University Medical Centre, Postal code, 7057 1007, MB, Amsterdam, The Netherlands
| | - Madelon van Wely
- Department of Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Patrick M M Bossuyt
- Department of Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Academic Medical Centre, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Fulco van der Veen
- Centre for Reproductive Medicine, Department of Obstetrics and Gynaecology, Academic Medical Centre, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands
| | - Ben W J Mol
- School of Paediatrics and Reproductive Health, The Robinson Research Institute and The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Velja Mijatovic
- Department of Reproductive Medicine, VU University Medical Centre, Postal code, 7057 1007, MB, Amsterdam, The Netherlands
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Fauser BC. Patient-tailored ovarian stimulation for in vitro fertilization. Fertil Steril 2017; 108:585-591. [DOI: 10.1016/j.fertnstert.2017.08.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 08/10/2017] [Indexed: 11/29/2022]
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Tjon-Kon-Fat RI, Wang R, Eijkemans MJC, Bossuyt PMM, Mol BWJ, Van der Veen F, Bhattacharya S, van Wely M. Interventions for unexplained subfertility: a systematic review and network meta-analysis. Hippokratia 2017. [DOI: 10.1002/14651858.cd012692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Raissa I Tjon-Kon-Fat
- Academic Medical Center, University of Amsterdam; Center for Reproductive Medicine; Meibergdreef 9 Amsterdam Netherlands 1105 AZ
| | - Rui Wang
- The University of Adelaide; Discipline of Obstetrics and Gynaecology, School of Medicine, Robinson Research Institute; Norwich Centre Ground Floor, 55 King William Road Adelaide SA Australia 5006
| | - Marinus JC Eijkemans
- UMC Utrecht; Department of Biostatistics and Research Support, Julius Center; PO Box 85500 Utrecht Netherlands 3508GA
| | - Patrick MM Bossuyt
- Academic Medical Center, University of Amsterdam; Department of Clinical Epidemiology, Biostatistics and Bioinformatics; Room J1b-217, PO Box 22700 Amsterdam Netherlands 1100 DE
| | - Ben Willem J Mol
- The University of Adelaide; Discipline of Obstetrics and Gynaecology, School of Medicine, Robinson Research Institute; Norwich Centre Ground Floor, 55 King William Road Adelaide SA Australia 5006
| | - Fulco Van der Veen
- Academic Medical Center, University of Amsterdam; Center for Reproductive Medicine; Meibergdreef 9 Amsterdam Netherlands 1105 AZ
| | - Siladitya Bhattacharya
- Aberdeen Maternity Hospital; Obstetrics and Gynaecology; Foresterhill Aberdeen UK AB9 2ZD
| | - Madelon van Wely
- Academic Medical Center, University of Amsterdam; Center for Reproductive Medicine; Meibergdreef 9 Amsterdam Netherlands 1105 AZ
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Malić Vončina S, Golob B, Ihan A, Kopitar AN, Kolbezen M, Zorn B. Sperm DNA fragmentation and mitochondrial membrane potential combined are better for predicting natural conception than standard sperm parameters. Fertil Steril 2015; 105:637-644.e1. [PMID: 26696300 DOI: 10.1016/j.fertnstert.2015.11.037] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 11/18/2015] [Accepted: 11/19/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate whether DNA fragmentation and/or mitochondrial membrane potential (MMP) predict natural conception better than standard sperm parameters. DESIGN Prospective cross-sectional study. SETTING University medical center. PATIENT(S) Eighty-five infertile and 51 fertile men. INTERVENTION(S) Assessment of sperm DNA fragmentation, MMP, and standard semen parameters over a 6- to 12-month observation period. MAIN OUTCOME MEASURE(S) Comparison between the results of DNA fragmentation, MMP, and standard sperm parameters alone or combined and achievement of natural conception. RESULT(S) Twenty-six of the 85 (31%) men from infertile couples conceived naturally. The median values of DNA fragmentation and MMP in the men who conceived within the observation period were similar to those in the fertile controls. Optimal threshold values of DNA fragmentation and MMP were 25% as determined by receiver operating characteristic analysis (area under the curve [AUC], 0.70; 95% confidence interval (CI) 0.58-0.82) and 62.5% (AUC, 0.68, 95% CI 0.56-0.80), respectively. The men in the infertile group with values of DNA fragmentation ≤25% and with MMP values ≥62.5% had significantly higher odds for conception (odds ratio [OR], 5.22; 95% CI 1.82-14.93] and OR, 4.67; 95% CI 1.74-12.5, respectively). Normal semen analysis alone had no predictive value for natural conception (OR, 1.84; 95% CI 0.67-5.07]). Both sperm function tests combined had significant odds for natural conception (OR, 8.24; 95% CI 2.91-23.33]), with a probability of 0.607 (60.7%) for both normal values and 0.158 (15.8%) for abnormal values. CONCLUSION(S) Sperm DNA fragmentation and MMP combined may be superior to standard semen parameters for the prediction of natural conception.
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Affiliation(s)
- Slađana Malić Vončina
- Andrology Unit, Reproductive Unit, Department of Obstetrics and Gynecology, University Medical Center, Ljubljana, Slovenia
| | - Barbara Golob
- Andrology Unit, Reproductive Unit, Department of Obstetrics and Gynecology, University Medical Center, Ljubljana, Slovenia
| | - Alojz Ihan
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Andreja Nataša Kopitar
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Mojca Kolbezen
- Andrology Unit, Reproductive Unit, Department of Obstetrics and Gynecology, University Medical Center, Ljubljana, Slovenia
| | - Branko Zorn
- Andrology Unit, Reproductive Unit, Department of Obstetrics and Gynecology, University Medical Center, Ljubljana, Slovenia.
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McLernon DJ, te Velde ER, Steyerberg EW, Mol BWJ, Bhattacharya S. Clinical prediction models to inform individualized decision-making in subfertile couples: a stratified medicine approach. Hum Reprod 2014; 29:1851-8. [DOI: 10.1093/humrep/deu173] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Hessel M, Brandes M, de Bruin JP, Bots RSGM, Kremer JAM, Nelen WLDM, Hamilton CJCM. Long-term ongoing pregnancy rate and mode of conception after a positive and negative post-coital test. Acta Obstet Gynecol Scand 2014; 93:913-20. [PMID: 24946691 DOI: 10.1111/aogs.12442] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 06/08/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Many fertility clinics have decided to abolish the post-coital test. Yet, it is a significant factor in prognostic models that predict the spontaneous pregnancy rate within one year. The aim of this study was to evaluate (1) the long-term outcome of infertile couples with a positive or a negative post-coital test during their fertility work-up and (2) the contribution of the different modes of conception. DESIGN Retrospective cohort study. SETTING Three fertility clinics in the Netherlands, of which two are secondary care training hospitals and is a one tertiary care academic training hospital. POPULATION 2476 newly referred infertile couples, where a post-coital test was performed in 1624 couples. METHODS After basic fertility work-up, couples were treated according to the national treatment protocols. MAIN OUTCOME MEASURES Spontaneous and overall ongoing pregnancy rate. RESULTS The spontaneous and overall ongoing pregnancy rates after three years were 37.7 and 77.5% after a positive post-coital test compared with 26.9 and 68.8% after a negative test (p < 0.001). Even in couples with severe male factor infertility (total motile sperm count <3) (p = 0.005) and mild male factor infertility (total motile sperm count 3-20) (p < 0.001), there was a significantly higher spontaneous ongoing pregnancy rate, justifying expectant management. CONCLUSION After a follow-up of three years a positive post-coital test is still associated with a higher spontaneous and a higher overall ongoing pregnancy rate, even in couples with severe male factor infertility.
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Affiliation(s)
- Marloes Hessel
- Department of Obstetrics and Gynecology, Jeroen Bosch Hospital, s-Hertogenbosch, the Netherlands; Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, the Netherlands
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Kamath MS, Bhattacharya S. Demographics of infertility and management of unexplained infertility. Best Pract Res Clin Obstet Gynaecol 2012; 26:729-38. [DOI: 10.1016/j.bpobgyn.2012.08.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Accepted: 08/08/2012] [Indexed: 11/30/2022]
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27
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Tollner TL, Venners SA, Hollox EJ, Yudin AI, Liu X, Tang G, Xing H, Kays RJ, Lau T, Overstreet JW, Xu X, Bevins CL, Cherr GN. A common mutation in the defensin DEFB126 causes impaired sperm function and subfertility. Sci Transl Med 2012; 3:92ra65. [PMID: 21775668 DOI: 10.1126/scitranslmed.3002289] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
A glycosylated polypeptide, β-defensin 126 (DEFB126), derived from the epididymis and adsorbed onto the sperm surface, has been implicated in immunoprotection and efficient movement of sperm in mucosal fluids of the female reproductive tract. Here, we report a sequence variant in DEFB126 that has a two-nucleotide deletion in the open reading frame, which generates an abnormal mRNA. The allele frequency of this variant sequence was high in both a European (0.47) and a Chinese (0.45) population cohort. Binding of the Agaricus bisporus lectin to the sperm surface glycocalyx was significantly lower in men with the homozygous variant (del/del) genotype than in those with either a del/wt or a wt/wt genotype, suggesting an altered sperm glycocalyx with fewer O-linked oligosaccharides in del/del men. Moreover, sperm from del/del carriers exhibited an 84% reduction in the rate of penetration of a hyaluronic acid gel, a surrogate for cervical mucus, compared to the other genotypes. This reduction in sperm performance in hyaluronic acid gels was not a result of decreased progressive motility (average curvilinear velocity) or morphological deficits. Nevertheless, DEFB126 genotype and lectin binding were correlated with sperm performance in the penetration assays. In a prospective cohort study of newly married couples who were trying to conceive by natural means, couples were less likely to become pregnant and took longer to achieve a live birth if the male partner was homozygous for the variant sequence. This common sequence variation in DEFB126, and its apparent effect of impaired reproductive function, will allow a better understanding, clinical evaluation, and possibly treatment of human infertility.
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Affiliation(s)
- Theodore L Tollner
- Department of Obstetrics and Gynecology, School of Medicine, University of California, Davis, CA 95817, USA
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Custers IM, König TE, Broekmans FJ, Hompes PG, Kaaijk E, Oosterhuis J, Mochtar MH, Repping S, van Wely M, Steures P, van der Veen F, Mol BW. Couples with unexplained subfertility and unfavorable prognosis: a randomized pilot trial comparing the effectiveness of in vitro fertilization with elective single embryo transfer versus intrauterine insemination with controlled ovarian stimulation. Fertil Steril 2011; 96:1107-11.e1. [DOI: 10.1016/j.fertnstert.2011.08.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Revised: 08/01/2011] [Accepted: 08/03/2011] [Indexed: 11/30/2022]
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Gurunath S, Pandian Z, Anderson RA, Bhattacharya S. Defining infertility--a systematic review of prevalence studies. Hum Reprod Update 2011; 17:575-88. [PMID: 21493634 DOI: 10.1093/humupd/dmr015] [Citation(s) in RCA: 192] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Existing definitions of infertility lack uniformity, rendering comparisons in prevalence between countries or over time problematic. The absence of an agreed definition also compromises clinical management and undermines the impact of research findings. The aim of this study was to perform a systematic review of the literature to determine how infertility has been defined in prevalence studies and to come up with suggestions for a feasible and clinically relevant definition. METHODS MEDLINE, EMBASE, CINAHL and Cochrane Database of Systematic Reviews were searched for relevant population-based prevalence studies published between 1975 and 2010. RESULTS A total of 39 articles were included in the current review. The results highlight the heterogeneity of criteria used to define infertility and critical differences between demographic and epidemiological definitions. Demographers tend to define infertility as childlessness in a population of women of reproductive age, while the epidemiological definition is based on 'trying for' or 'time to' a pregnancy, generally in a population of women exposed to the risk of conception. There is considerable variation in terms of the duration of 'trying for pregnancy', the age of women sampled and their marital or cohabitation status. This leads to inconsistencies in determining the numerator and denominator used to calculate the prevalence of infertility. CONCLUSIONS There is a need for an agreed definition for infertility. We suggest a clinically relevant definition based on the duration of trying for pregnancy coupled with female age.
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Affiliation(s)
- S Gurunath
- Obstetrics and Gynaecology, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK
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Freour T, Delvigne A, Barrière P. L’exploration de l’homme du couple infécond. ACTA ACUST UNITED AC 2010; 39:S45-52. [DOI: 10.1016/s0368-2315(10)70030-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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The LIFESTYLE study: costs and effects of a structured lifestyle program in overweight and obese subfertile women to reduce the need for fertility treatment and improve reproductive outcome. A randomised controlled trial. BMC WOMENS HEALTH 2010; 10:22. [PMID: 20579357 PMCID: PMC2907305 DOI: 10.1186/1472-6874-10-22] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Accepted: 06/25/2010] [Indexed: 11/16/2022]
Abstract
Background In the Netherlands, 30% of subfertile women are overweight or obese, and at present there is no agreement on fertility care for them. Data from observational and small intervention studies suggest that reduction of weight will increase the chances of conception, decrease pregnancy complications and improve perinatal outcome, but this has not been confirmed in randomised controlled trials. This study will assess the cost and effects of a six-months structured lifestyle program aiming at weight reduction followed by conventional fertility care (intervention group) as compared to conventional fertility care only (control group) in overweight and obese subfertile women. We hypothesize that the intervention will decrease the need for fertility treatment, diminish overweight-related pregnancy complications, and will improve perinatal outcome. Methods/Design Multicenter randomised controlled trial in subfertile women (age 18-39 year) with a body mass index between 29 and 40 kg/m2. Exclusion criteria are azoospermia, use of donor semen, severe endometriosis, premature ovarian failure, endocrinopathies or pre-existent hypertensive disorders. In the intervention group the aim is a weight loss of at least 5% to10% in a six-month period, to be achieved by the combination of a diet, increase of physical activity and behavioural modification. After six months, in case no conception has been achieved, these patients will start fertility treatment according to the Dutch fertility guidelines. In the control group treatment will be started according to Dutch fertility guidelines, independently of the patient's weight. Outcome measures and analysis The primary outcome measure is a healthy singleton born after at least 37 weeks of gestation after vaginal delivery. Secondary outcome parameters including pregnancy outcome and complications, percentage of women needing fertility treatment, clinical and ongoing pregnancy rates, body weight, quality of life and costs. Data will be analysed according to the intention to treat principle, and cost-effectiveness analysis will be performed to compare the costs and health effects in the intervention and control group. Discussion The trial will provide evidence for costs and effects of a lifestyle intervention aiming at weight reduction in overweight and obese subfertile women and will offer guidance to clinicians for the treatment of these patients. Trial registration Dutch Trial Register NTR1530
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Boyd JC. Defining laboratory reference values and decision limits: populations, intervals, and interpretations. Asian J Androl 2010; 12:83-90. [PMID: 20111086 PMCID: PMC3739683 DOI: 10.1038/aja.2009.9] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2009] [Revised: 01/15/2009] [Accepted: 01/19/2009] [Indexed: 11/08/2022] Open
Abstract
This article provides a brief overview of various approaches that may be utilized for the analysis of human semen test results. Reference intervals are the most widely used tool for the interpretation of clinical laboratory results. Reference interval development has classically relied on concepts elaborated by the International Federation of Clinical Chemistry Expert Panel on Reference Values during the 1980s. These guidelines involve obtaining and classifying samples from a healthy population of at least 120 individuals and then identifying the outermost 5% of observations to use in defining limits for two-sided or one-sided reference intervals. More recently, decision limits based on epidemiological outcome analysis have also been introduced to aid in test interpretation. The reference population must be carefully defined on the basis of the intended clinical use of the underlying test. To determine appropriate reference intervals for use in male fertility assessment, a reference population of men with documented time to pregnancy of < 12 months would be most suitable. However, for epidemiological assessment of semen testing results, a reference population made up of unselected healthy men would be preferred. Although reference and decision limits derived for individual semen analysis test results will undoubtedly be the interpretational tools of choice in the near future, in the long term, multivariate methods for the interpretation of semen analysis alone or in combination with information from the female partner seem to represent better means for assessing the likelihood of achieving a successful pregnancy in a subfertile couple.
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Affiliation(s)
- James C Boyd
- Department of Pathology, University of Virginia Health System, Charlottesville, 22908-0168, USA.
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Bensdorp AJ, Slappendel E, Koks C, Oosterhuis J, Hoek A, Hompes P, Broekmans F, Verhoeve H, de Bruin JP, van Weert JM, Traas M, Maas J, Beckers N, Repping S, Mol BW, van der Veen F, van Wely M. The INeS study: prevention of multiple pregnancies: a randomised controlled trial comparing IUI COH versus IVF e SET versus MNC IVF in couples with unexplained or mild male subfertility. BMC WOMENS HEALTH 2009; 9:35. [PMID: 20021654 PMCID: PMC2804565 DOI: 10.1186/1472-6874-9-35] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2009] [Accepted: 12/18/2009] [Indexed: 11/10/2022]
Abstract
Background Multiple pregnancies are high risk pregnancies with higher chances of maternal and neonatal mortality and morbidity. In the past decades the number of multiple pregnancies has increased. This trend is partly due to the fact that women start family planning at an increased age, but also due to the increased use of ART. Couples with unexplained or mild male subfertility generally receive intrauterine insemination IUI with controlled hormonal stimulation (IUI COH). The cumulative pregnancy rate is 40%, with a 10% multiple pregnancy rate. This study aims to reveal whether alternative treatments such as IVF elective Single Embryo Transfer (IVF e SET) or Modified Natural Cycle IVF (MNC IVF) can reduce the number of multiple pregnancy rates, but uphold similar pregnancy rates as IUI COH in couples with mild male or unexplained subfertility. Secondly, the aim is to perform a cost effective analyses and assess treatment preference of these couples. Methods/Design We plan a multicentre randomised controlled clinical trial in the Netherlands comparing six cycles of intra-uterine insemination with controlled ovarian hyperstimulation or six cycles of Modified Natural Cycle (MNC) IVF or three cycles with IVF-elective Single Embryo Transfer (eSET) plus cryo-cycles within a time frame of 12 months. Couples with unexplained subfertility or mild male subfertility and a poor prognosis for treatment independent pregnancy will be included. Women with anovulatory cycles, severe endometriosis, double sided tubal pathology or serious endocrine illness will be excluded. Our primary outcome is the birth of a healthy singleton. Secondary outcomes are multiple pregnancy, treatment costs, and patient experiences in each treatment arm. The analysis will be performed according tot the intention to treat principle. We will test for non-inferiority of the three arms with respect to live birth. As we accept a 12.5% loss in pregnancy rate in one of the two IVF arms to prevent multiple pregnancies, we need 200 couples per arm (600 couples in total). Discussion Determining the safest and most cost-effective treatment will ensure optimal chances of pregnancy for subfertile couples with substantially diminished perinatal and maternal complications. Should patients find the most cost-effective treatment acceptable or even preferable, this could imply the need for a world wide shift in the primary treatment. Trial registration Current Controlled Trials ISRCTN 52843371
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Affiliation(s)
- Alexandra J Bensdorp
- Department of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
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Brandes M, Hamilton CJCM, de Bruin JP, Nelen WLDM, Kremer JAM. The relative contribution of IVF to the total ongoing pregnancy rate in a subfertile cohort. Hum Reprod 2009; 25:118-26. [PMID: 19855108 DOI: 10.1093/humrep/dep341] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Although in vitro fertilization (IVF) was introduced more than 30 years ago, its exact role in the spectrum of fertility treatments has never been studied in an unselected population. The aim of this study was to visualize the contribution of IVF to the ongoing pregnancy rates in a cohort of newly referred subfertile couples. MATERIALS All new subfertile couples (n = 1391) that were referred to our fertility clinic by their general practitioner between January 2002 and December 2006 were included. Fertility care was provided according to the national Dutch fertility guidelines. Data on diagnosis, treatment, mode of conception and pregnancy outcome were documented. If follow-up data were missing, couples were contacted. Cumulative pregnancy curves were constructed for the whole cohort and per diagnostic group. RESULTS As per December 2008 the overall ongoing pregnancy rate was 72.0% (n = 1001). Almost half of the pregnancies were conceived spontaneously (45.6%), 19.2% after ovulation induction (OI), 14.0% after intrauterine insemination (IUI) and 21.2% after IVF. A quarter (n = 349) of couples received IVF treatment, which was successful in 60% of cases. IVF had the largest contribution to ongoing pregnancies in patients with 'tubal factor', 'endometriosis' and 'male factor' (45, 45 and 37%, respectively) while in couples with 'unexplained subfertility' and 'ovulation disorders' the contribution to ongoing pregnancies of IVF was limited (13 and 4.5%, respectively). CONCLUSIONS In a cohort of subfertile couples, most pregnancies were conceived spontaneously. The contribution of IVF to ongoing pregnancy rates was comparable to those of OI and IUI. Compared with the pre-IVF era, couples with 'endometriosis', 'tubal factor' and 'male subfertility' have benefited most from its introduction.
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Affiliation(s)
- M Brandes
- Department of Obstetrics and Gynaecology, Jeroen Bosch Ziekenhuis, PO Box 90153, 5200 ME 's-Hertogenbosch, The Netherlands.
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Devroey P, Fauser BCJM, Diedrich K. Approaches to improve the diagnosis and management of infertility. Hum Reprod Update 2009; 15:391-408. [PMID: 19380415 PMCID: PMC2691653 DOI: 10.1093/humupd/dmp012] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2008] [Revised: 02/19/2009] [Accepted: 03/18/2009] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Recent advances in our understanding of the causes of infertility and of assisted reproductive technology (ART) have led to the development of complex diagnostic tools, prognostic models and treatment options. The Third Evian Annual Reproduction (EVAR) Workshop Meeting was held on 26-27 April 2008 to evaluate evidence supporting current approaches to the diagnosis and management of infertility and to identify areas for future research efforts. METHODS Specialist reproductive medicine clinicians and scientists delivered presentations based on published literature and ongoing research on patient work-up, ovarian stimulation and embryo quality assessment during ART. This report is based on the expert presentations and subsequent group discussions and was supplemented with publications from literature searches and the authors' knowledge. RESULTS It was agreed that single embryo transfer (SET) should be used with increasing frequency in cycles of ART. Continued improvements in cryopreservation techniques, which improve pregnancy rates using supernumerary frozen embryos, are expected to augment the global uptake of SET. Adaptation and personalization of fertility therapy may help to optimize efficacy and safety outcomes for individual patients. Prognostic modelling and personalized management strategies based on individual patient characteristics may prove to represent real progress towards improved treatment. However, at present, there is limited good-quality evidence to support the use of these individualized approaches. CONCLUSIONS Greater quality control and standardization of clinical and laboratory evaluations are required to optimize ART practices and improve individual patient outcomes. Well-designed, good-quality studies are required to drive improvements to the diagnosis and management of ART processes.
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Affiliation(s)
- P Devroey
- Center of Reproductive Medicine, Free University Brussels, Laarbeeklaan 101, Brussels 1090, Belgium.
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Leushuis E, van der Steeg JW, Steures P, Bossuyt PMM, Eijkemans MJC, van der Veen F, Mol BWJ, Hompes PGA. Prediction models in reproductive medicine: a critical appraisal. Hum Reprod Update 2009; 15:537-52. [PMID: 19435779 DOI: 10.1093/humupd/dmp013] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Prediction models have been developed in reproductive medicine to help assess the chances of a treatment-(in)dependent pregnancy. Careful evaluation is needed before these models can be implemented in clinical practice. METHODS We systematically searched the literature for papers reporting prediction models in reproductive medicine for three strategies: expectant management, intrauterine insemination (IUI) or in vitro fertilization (IVF). We evaluated which phases of development these models had passed, distinguishing between (i) model derivation, (ii) internal and/or external validation, and (iii) impact analysis. We summarized their performance at external validation in terms of discrimination and calibration. RESULTS We identified 36 papers reporting on 29 prediction models. There were 9 models for the prediction of treatment-independent pregnancy, 3 for the prediction of pregnancy after IUI and 17 for the prediction of pregnancy after IVF. All of the models had completed the phase of model derivation. For six models, the validity of the model was assessed only in the population in which it was developed (internal validation). For eight models, the validity was assessed in populations other than the one in which the model was developed (external validation), and only three of these showed good performance. One model had reached the phase of impact analysis. CONCLUSIONS Currently, there are three models with good predictive performance. These models can be used reliably as a guide for making decisions about fertility treatment, in patients similar to the development population. The effects of using these models in patient care have to be further investigated.
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Affiliation(s)
- Esther Leushuis
- Department of Obstetrics and Gynecology, Vrije Universiteit Medical Center, Amsterdam, The Netherlands.
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Coppus S, van der Veen F, Opmeer B, Mol B, Bossuyt P. Evaluating prediction models in reproductive medicine. Hum Reprod 2009; 24:1774-8. [DOI: 10.1093/humrep/dep109] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Broekmans FJ, Visser JA, Laven JSE, Broer SL, Themmen APN, Fauser BC. Anti-Müllerian hormone and ovarian dysfunction. Trends Endocrinol Metab 2008; 19:340-7. [PMID: 18805020 DOI: 10.1016/j.tem.2008.08.002] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Revised: 08/07/2008] [Accepted: 08/07/2008] [Indexed: 12/18/2022]
Abstract
Anti-Müllerian hormone (AMH) has important roles in postnatal ovarian function. Produced by ovarian granulosa cells, AMH is involved in initial follicle development. In fact, serum AMH level correlates with ovarian follicle number. In patients with polycystic ovary syndrome (PCOS), AMH levels are elevated, which indicates its potential relevance in PCOS diagnosis and management. AMH represents a useful clinical marker for the assessment of ovarian reserve in cases of subfertility caused by advanced age in women. A potential role for AMH in dominant follicle selection has also been suggested. Future challenges comprise the availability of a well-standardized assay and the development of AMH agonists and antagonists as possible tools to manipulate ovarian function for contraception or ovarian longevity.
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Affiliation(s)
- Frank J Broekmans
- Department for Reproductive Medicine and Gynecology, University Medical Center, PO Box 85500, 3508 6A, Utrecht, The Netherlands.
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Abstract
Various predictors of fertility have been described, suggesting that none are ideal. The literature on tests of ovarian reserve is largely limited to women undergoing in vitro fertilization, and is reliant on the use of surrogate markers, such as cycle cancellation and number of oocytes retrieved, as reference standards. Currently available prediction models are far from ideal; most are applicable only to subfertile women seeking assisted reproduction, and lack external validation. Systematic reviews and meta-analyses of predictors of fertility are limited by their heterogeneity in terms of the population sampled, predictors tested and reference standards used. There is an urgent need for consensus in the design of these studies, definition of abnormal tests, and, above all, a need to use robust outcomes such as live birth as the reference standard. There are no reliable predictors of fertility that can guide women as to how long childbearing can be deferred.
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Affiliation(s)
- Abha Maheshwari
- Assisted Conception Unit, Department of Obstetrics & Gynaecology, University of Aberdeen, Aberdeen Maternity Hospital, Aberdeen, UK
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Tollner TL, Yudin AI, Treece CA, Overstreet JW, Cherr GN. Macaque sperm coating protein DEFB126 facilitates sperm penetration of cervical mucus. Hum Reprod 2008; 23:2523-34. [PMID: 18658160 DOI: 10.1093/humrep/den276] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Sperm coating protein beta-defensin 126 (DEFB126) is adsorbed onto the entire surface of macaque sperm in the caudal epididymis and is retained on viable sperm collected from the cervix and the uterine lumen of mated female macaques. We investigated the role of sperm coating protein DEFB126 in cervical mucus penetration (CMP). METHODS Cervical mucus (CM) was collected from peri-ovulatory female macaques and loaded into CMP chambers. Sperm were introduced to CMP chambers following treatment with either polyclonal antibodies raised to DEFB126 or seminal plasma proteins (SPPs), 1 mM caffeine+1 mM dibutyryl cyclic adenosine monophosphate (dbcAMP) (induces release of DEFB126 from sperm surface), neuraminidase (NMase) or poly-L-lysine (PLP). Following removal of DEFB126 or SPPs from the sperm surface, sperm were treated with concentrated DEFB126 or concentrated SPPs prior to being introduced to CMP chambers. The numbers of sperm that penetrated and traversed CM were scored over 6 min. RESULTS Treatment of sperm with anti-DEFB126 antibodies, 1 mM caffeine+1 mM dbcAMP, NMase, and PLP resulted in similar and significant levels of inhibition of sperm CMP, whereas addition of anti-SPPs antibodies had no effect. In experiments where DEFB126 and SPPs were removed, CMP capability of sperm was restored by addition of DEFB126 back to the sperm surface, whereas treatment of sperm with concentrated SPPs slightly inhibited sperm penetration. CONCLUSIONS DEFB126 and its high negative charge appears to be critical for the movement of sperm through CM in the macaque, while SPPs adhered to the sperm surface offer no advantage in CMP.
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Affiliation(s)
- Theodore L Tollner
- Center for Health and the Environment, Bodega Marine Laboratory, University of California, Davis 94923, USA
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Haadsma M, Groen H, Fidler V, Bukman A, Roeloffzen E, Groenewoud E, Broekmans F, Heineman M, Hoek A. The predictive value of ovarian reserve tests for spontaneous pregnancy in subfertile ovulatory women. Hum Reprod 2008; 23:1800-7. [DOI: 10.1093/humrep/den234] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Verberg MFG, Macklon NS, Heijnen EMEW, Fauser BCJM. ART: iatrogenic multiple pregnancy? Best Pract Res Clin Obstet Gynaecol 2007; 21:129-43. [PMID: 17074535 DOI: 10.1016/j.bpobgyn.2006.09.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Assisted reproductive technologies (ART) are now widely accepted as effective treatment for most causes of infertility. With improving success rates, attention has turned to the problem of multiple pregnancies, which are associated with a poor perinatal outcome, maternal complications and significant financial consequences. The challenge is to reduce multigestational pregnancies while maintaining good treatment outcomes. Methods to prevent multiple pregnancy include restrictive use of ART in couples with a good chance of spontaneous pregnancy, cautious use of gonadotrophins, and increased use of natural-cycle intra-uterine insemination and elective single embryo transfer in in-vitro fertilization and intracytoplasmic sperm injection. The aim of this article is to review the contribution of fertility treatment to multiple pregnancies and strategies for reducing multiples in ART.
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Affiliation(s)
- M F G Verberg
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands.
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Broekmans FJ, Kwee J, Hendriks DJ, Mol BW, Lambalk CB. A systematic review of tests predicting ovarian reserve and IVF outcome. Hum Reprod Update 2006; 12:685-718. [PMID: 16891297 DOI: 10.1093/humupd/dml034] [Citation(s) in RCA: 751] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The age-related decline of the success in IVF is largely attributable to a progressive decline of ovarian oocyte quality and quantity. Over the past two decades, a number of so-called ovarian reserve tests (ORTs) have been designed to determine oocyte reserve and quality and have been evaluated for their ability to predict the outcome of IVF in terms of oocyte yield and occurrence of pregnancy. Many of these tests have become part of the routine diagnostic procedure for infertility patients who undergo assisted reproductive techniques. The unifying goals are traditionally to find out how a patient will respond to stimulation and what are their chances of pregnancy. Evidence-based medicine has progressively developed as the standard approach for many diagnostic procedures and treatment options in the field of reproductive medicine. We here provide the first comprehensive systematic literature review, including an a priori protocolized information retrieval on all currently available and applied tests, namely early-follicular-phase blood values of FSH, estradiol, inhibin B and anti-Müllerian hormone (AMH), the antral follicle count (AFC), the ovarian volume (OVVOL) and the ovarian blood flow, and furthermore the Clomiphene Citrate Challenge Test (CCCT), the exogenous FSH ORT (EFORT) and the gonadotrophin agonist stimulation test (GAST), all as measures to predict ovarian response and chance of pregnancy. We provide, where possible, an integrated receiver operating characteristic (ROC) analysis and curve of all individual evaluated published papers of each test, as well as a formal judgement upon the clinical value. Our analysis shows that the ORTs known to date have only modest-to-poor predictive properties and are therefore far from suitable for relevant clinical use. Accuracy of testing for the occurrence of poor ovarian response to hyperstimulation appears to be modest. Whether the a priori identification of actual poor responders in the first IVF cycle has any prognostic value for their chances of conception in the course of a series of IVF cycles remains to be established. The accuracy of predicting the occurrence of pregnancy is very limited. If a high threshold is used, to prevent couples from wrongly being refused IVF, a very small minority of IVF-indicated cases (approximately 3%) are identified as having unfavourable prospects in an IVF treatment cycle. Although mostly inexpensive and not very demanding, the use of any ORT for outcome prediction cannot be supported. As poor ovarian response will provide some information on OR status, especially if the stimulation is maximal, entering the first cycle of IVF without any prior testing seems to be the preferable strategy.
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Affiliation(s)
- F J Broekmans
- Department of Reproductive Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
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van der Steeg JW, Steures P, Eijkemans MJC, Habbema JDF, Bossuyt PMM, Hompes PGA, van der Veen F, Mol BWJ. Do clinical prediction models improve concordance of treatment decisions in reproductive medicine? BJOG 2006; 113:825-31. [PMID: 16827767 DOI: 10.1111/j.1471-0528.2006.00992.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess whether the use of clinical prediction models improves concordance between gynaecologists with respect to treatment decisions in reproductive medicine. DESIGN We constructed 16 vignettes of subfertile couples by varying fertility history, postcoital test, sperm motility, follicle-stimulating hormone level and Chlamydia antibody titre. SETTING Thirty-five gynaecologists estimated three probabilities, i.e. the 1-year probability of spontaneous pregnancy, the pregnancy chance after intrauterine insemination (IUI) and the pregnancy chance after in vitro fertilisation (IVF). Subsequently they proposed therapeutic regimens for these 16 fictional couples, i.e. expectant management, IUI or IVF. Three months later, the participant gynaecologists again had to propose therapeutic regimes for the same 16 fictional cases but this time accompanied by pregnancy chances obtained from prediction models: predictions on spontaneous pregnancy, IUI and IVF. POPULATION Thirty-five gynaecologists working in academic and nonacademic hospitals in the Netherlands. METHODS Setting section. Main outcome measures The concordance between gynaecologists of probability estimates, expressed as interclass correlation coefficient (ICC) and the concordance between gynaecologists of treatment decisions, analysed by calculating Cohen's kappa (kappa). RESULTS The gynaecologists differed widely in estimating pregnancy chances (ICC: 0.34). Furthermore, there was a huge variation in the proposed therapeutic regimens (kappa: 0.21). The treatment decisions made by gynaecologists were consistent with the ranking of their probability estimates. When prediction models were used, the concordance (kappa) for treatment decisions increased from 0.21 to 0.38. The number of gynaecologists counselling for expectant management increased from 39 to 51%, whereas counselling for IVF dropped from 23 to 14%. CONCLUSION Gynaecologists differed widely in their estimation of prognosis in 16 fictional cases of subfertile couples. Their therapeutic regimens showed likewise huge variation. After confrontation with prediction models in the same 16 fictional cases, the proposed therapeutic regimens showed only slightly better concordance. Therefore a simple introduction of validated prediction models is insufficient to introduce concordant management between doctors.
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Affiliation(s)
- J W van der Steeg
- Department of Public Health, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands.
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