Assisted reproductive technology in Europe, 2002. Results generated from European registers by ESHRE

Effectiveness of recombinant human FSH: recombinant human LH combination treatment versus recombinant human FSH alone for assisted reproductive technology in women aged 35-40 years

RESEARCH QUESTION

According to real-world data, is recombinant human FSH (r-hFSH) combined with recombinant human LH (r-hLH) or r-hFSH alone more effective for women of advanced maternal age (AMA) in terms of live birth?

DESIGN

Non-interventional study comparing the effectiveness of r-hFSH and recombinant r-hLH (2:1 ratio) versus r-hFSH alone for ovarian stimulation during ART treatment in women aged 35-40 years, using real-world data from the Deutsches IVF-Register.

RESULTS

Overall clinical pregnancy (29.8%, 95% CI 28.2 to 31.6 versus 27.8%, 95% CI 26.5 to 29.2) and live birth (20.3%, 95% CI 18.7 to 21.8 versus 18.0%, 95% CI 16.6 to 19.4) rates were not significantly different between the combined r-hFSH and r-hLH group and the r-hFSH alone group (P = 0.269 and P = 0.092, respectively). Treatment effect was significantly higher for combined r-hFSH and r-hLH compared with r-hFSH alone for clinical pregnancy (33.1%, 95% CI 31.0 to 35.0 versus 28.5%, 95% CI 26.6 to 30.4; P = 0.001, not adjusted for multiplicity) and live birth (22.5%, 95% CI 20.5 to 24.2 versus 19.4%, 95% CI 17.6 to 20.9; P = 0.014, not adjusted for multiplicity) in a post-hoc analysis of women with five to 14 oocytes retrieved (used as a surrogate for normal ovarian reserve), highlighting the potential benefits of combined r-hFSH and r-hLH for ovarian stimulation in women aged 35-40 years with normal ovarian reserve.

CONCLUSIONS

Women of AMA with normal ovarian response benefit from treatment with combined r-hFSH and r-hLH in a 2:1 ratio versus r-hFSH alone in terms of live birth rate. The effectiveness of treatments is best assessed by RCTs; however, real-world data are valuable for examining the effectiveness of fertility treatment, especially among patient groups that are not well represented in clinical trials.

Comparison of progesterone protocol versus gonadotropin-releasing hormone antagonist protocol in terms of preventing premature LH surge and assisted reproductive technology outcome in infertile women: a randomized controlled trial

INTRODUCTION

Progesterone can be used instead of GnRH agonists and antagonists in order to avert a premature LH surge during controlled ovarian stimulation (COS) protocol. Nonetheless, there is limited knowledge regarding its utilization. Thus, this study compared the effects of progesterone and GnRH antagonists (GnRH-ant) on premature LH surges and assisted reproductive technology (ART) results in infertile women undergoing ART.

MATERIALS AND METHODS

In this clinical trial, the progesterone protocol (study group) and GnRH-ant protocol (control group) were tested in 300 infertile individuals undergoing IVF/ICSI. The main outcome was the number of oocytes retrieved. The secondary outcomes included premature LH rise/surge, the quantity of follicles measuring ≥ 10 and 14 mm, oocyte maturity and fertilization rate, the number of viable embryos, high-quality embryo rate and pregnancy outcomes.

RESULTS

The study group exhibited a statistically significant increase in the number of retrieved oocytes, follicles measuring 14 mm or greater, and viable embryos compared to the control group (P < 0.05). The study group also increased oocyte maturity, chemical pregnancy rate, and clinical pregnancy rate (P < 0.05). Both groups had similar mean serum LH, progesterone, and E2 levels on trigger day. The control group had more premature LH rise than the study group, although this difference was not statistically significant.

CONCLUSION

In conclusion, it can be stated that the progesterone protocol and the GnRH-ant protocol exhibit similar rates of sudden premature LH surge in infertile patients. However, it is important to note that the two regiments differ in their outcomes in ART.

TRIAL REGISTRATION

This study was retrospectively registered in the Iranian website ( www.irct.ir ) for clinical trials registration ( http://www.irct.ir : IRCT-ID: IRCT20201029049183N, 2020-11-27).

Effectiveness of recombinant human follicle-stimulating hormone (r-hFSH): recombinant human luteinizing hormone versus r-hFSH alone in assisted reproductive technology treatment cycles among women aged 35-40 years: A German database study

This non-interventional study compared the effectiveness of recombinant human follicle-stimulating hormone (r-hFSH) and recombinant human luteinizing hormone (r-hLH) (2:1 ratio) versus r-hFSH alone for ovarian stimulation (OS) during assisted reproductive technology treatment in women aged 35-40 years, using real-world data from the Deutsches IVF-Register (D·I·R). Numerically higher clinical pregnancy (29.8% [95% CI 28.2, 31.6] vs. 27.8% [26.5, 29.2]) and live birth (20.3% [18.7, 21.8] vs. 18.0% [16.6, 19.4]) rates were observed with r-hFSH:r-hLH versus r-hFSH alone. The treatment effect was consistently higher for r-hFSH:r-hLH compared with r-hFSH alone in terms of clinical pregnancy (relative risk [RR] 1.16 [1.05, 1.26]) and live birth (RR 1.16 [1.02, 1.31]) in a post-hoc analysis of women with 5-14 oocytes retrieved (used as a surrogate for normal ovarian reserve), highlighting the potential benefits of r-hFSH:r-hLH for OS in women aged 35-40 years with normal ovarian reserve.

The value of treatment for infertility: A systematic literature review of willingness-to-pay thresholds and approaches for determining the cost effectiveness of fertility therapies

Willingness to pay (WTP) for an infertility treatment is the maximum amount of money a patient is willing to pay per treatment, or to achieve a live birth or pregnancy. Such thresholds are important to determine the cost effectiveness of a treatment. A systematic review was conducted to identify and explore the studies that attempt to ascertain WTP for infertility and compare them with the cost-effectiveness studies that claimed to use WTP thresholds. For comparison, all the costs were converted and inflated to 2021 euros. The results demonstrated that there were no standard outcomes or WTP thresholds for an outcome/treatment, and the methodologies used vary. Cost-effectiveness studies either used the incremental cost-effectiveness ratio to imply a WTP threshold, or used thresholds that were previously accepted for a quality-adjusted life year outcome converted, inappropriately, to an infertility outcome. There is a need for further research by health economists to develop a consensus for the meaningful assessment of WTP for ART.

Ovulation induction and intrauterine insemination in women of advanced reproductive age: a systematic review of the literature

PURPOSE

The objective of this review is to define live birth rate (LBR) and clinical pregnancy rate (CPR) for women ≥ 40 undergoing ovulation induction (OI)/intrauterine insemination (IUI).

METHODS

A systematic review was performed in accordance with PRISMA guidelines using PubMed and Google Scholar. The primary and secondary outcomes of interest were LBR and CPR, respectively.

RESULTS

There were 636 studies screened of which 42 were included. In 8 studies which provided LBR for partner sperm, LBR/cycle ranged from 0 to 8.5% with majority being ≤ 4%. Cumulative LBR was 3.6 to 7.1% over 6 cycles with the majority of pregnancies in the first 4. In the four studies providing LBR for donor sperm cycles, LBR/cycle ranged from 3 to 7% with cumulative LBR of 12 to 24% over 6 cycles. The majority of pregnancies occurred in the first 6 cycles. There were three studies with LBR or CPR/cycle ≥ 1% for women ≥ 43. No studies provided data above this range for women ≥ 45. In 4 studies which compared OI/IUI and IVF, the LBR from IVF was 9.2 to 22% per cycle. In 7 studies which compared outcomes by stimulation protocol, no significant differences were seen.

CONCLUSION

For women ≥ 40 using homologous sperm, the highest probability of live birth is via IVF. However, if IVF is not an option, OI/IUI may be considered for up to 4 cycles in those using partner sperm or 6 cycles with donor sperm. For women > 45, OI/IUI is likely futile but a limited trial may be considered for psychological benefit while encouraging consideration of donor oocyte IVF or adoption. Use of gonadotropins does not appear to be more effective than oral agents in this age group.

Obstetric Outcomes and Successful Reduction of Twin Pregnancies Achieved by In Vitro Fertilization

The use of in vitro fertilization methods around the world is constantly increasing. In some developed countries, up to 5% of newborns are as a result of pregnancies after IVF procedures. In vitro fertilization as one of the main and widespread methods for treatment of infertility is the main reason for the high frequency of multiple pregnancies, which, in many countries, is still too high. Most of the multiple pregnancies are in fact twin pregnancies. Twin pregnancies, regardless of how they are achieved, are associated with large number of complications compared with singleton ones. More often these pregnancies can lead to maternal complications and adverse pregnancy outcomes. Maternal complications include development of preeclampsia, gestational diabetes, placenta previa, placental abruption, premature rupture of membranes, antepartum and postpartum hemorrhage, and delivery by cesarean sections. Adverse pregnancy outcomes mostly include preterm birth (PTB), low birth weight (LBW), small for gestational age newborn (SGA), intrauterine growth restriction (IUGR), neonatal respiratory distress syndrome (RDS), and admission to neonatal intensive care unit (NICU). A number of studies have found differences in the course of twin pregnancies according to their mode of occurrence – spontaneous or after IVF. Some of them have found that twin pregnancies after IVF are associated with poorer obstetric and perinatal outcomes, others do not find such a difference, and there are even studies that find a better outcome in IVF twin pregnancies. Twin pregnancy is a common occurrence after IVF procedure, because multiple-embryo transfer is commonly regarded as an effective strategy to improve the likelihood of a successful pregnancy. Understanding the risks of these pregnancies should be a strong motive for the transfer of fewer embryos during IVF procedures. The most effective way to do this is to transfer a single-embryo into the uterus in cases, where this is justified and the chances of getting pregnant are high. An important element in achieving this goal is the use of methods for vitrification of embryos, which leads to a sufficiently high rate of clinical pregnancies after freezing of embryos obtained by IVF and their subsequent transfer after thawing in case of failure of fresh ET.

Recombinant human luteinizing hormone co-treatment in ovarian stimulation for assisted reproductive technology in women of advanced reproductive age: a systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Several studies suggest that luteinizing hormone (LH) could improve IVF outcome in women of advanced reproductive age by optimizing androgen production. In this review, we assessed the role of recombinant-human LH (r-hLH) and recombinant human follicle stimulating hormone (r-hFSH) co-treatment in ovarian stimulation for assisted reproductive technology in women of advanced reproductive age candidates for assisted reproduction.

MATERIAL AND METHODS

Using a preregistered protocol we systematically searched Medline/PubMed, Scopus and the ISI Web of Science databases to identify randomized controlled trials in which r-hFSH monotherapy protocols were compared with r-hFSH/r-hLH co-treatment in women ≥35 years undergoing fresh IVF cycles. We calculated the pooled odds ratio (OR) for dichotomous data and the weight mean difference (WMD) for continuous data with an associated 95% confidence interval (CI). The meta-analyses were conducted using the random-effect model. P values < 0.05 were considered statistically significant. Subgroup analyses of all primary and secondary outcomes were performed only in women aged 35-40 years.

RESULTS

Twelve studies were identified. In women aged between 35 and 40 years, r-hFSH/r-hLH co-treatment was associated with higher clinical pregnancy rates (OR 1.45, CI 95% 1.05-2.00, I² = 0%, P = 0.03) and implantation rates (OR 1.49, CI 95% 1.10-2.01, I² = 13%, P = 0.01) versus r-hFSH monotherapy. Fewer oocytes were retrieved in r-hFSH/r-hLH-treated patients than in r-hFSH-treated patients both in women aged ≥35 years (WMD -0.82 CI 95% -1.40 to - 0.24, I² = 88%, P = 0.005) and in those aged between 35 and 40 years (WMD -1.03, CI - 1.89 to - 0.17, I² = 0%, P = 0.02). The number of metaphase II oocytes, miscarriage rates and live birth rates did not differ between the two groups of women overall or in subgroup analysis.

CONCLUSION

Although more oocytes were retrieved in patients who underwent r-hFSH monotherapy, this meta-analysis suggests that r-hFSH/r-hLH co-treatment improves clinical pregnancy and implantation rates in women between 35 and 40 years of age undergoing ovarian stimulation for assisted reproduction technology. However, more RCTs using narrower age ranges in advanced age women are warranted to corroborate these findings.

Lipid Metabolic Disorders and Ovarian Hyperstimulation Syndrome: A Retrospective Analysis

OBJECTIVES

To evaluate the effect of dyslipidemia on the incidence of moderate and severe Ovarian hyperstimulation syndrome (OHSS) in the duration of assisted reproduction technique (ART).

METHODS

The study included 233 moderate and severe OHSS patients who received hospitalization after in-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) cycles to avoid severe complications. They were divided into dyslipidemia group and normal lipid metabolism group to evaluate whether dyslipidemia contributes to the development of severe OHSS. Subgroup analysis was set to avoid deviation including the freeze-all group and fresh embryo transfer (ET) group according to whether the eligible women chose fresh embryo transfer immediately after their IVF or ICSI cycles. The main outcome measures included the incidence of moderate OHSS and severe OHSS, total gonadotropin dose, number of oocytes retrieved, age and body mass index (BMI). In the ET groups, the rate of pregnancy is also included for analysis.

RESULTS

In the freeze-all group, lipid metabolism was ultimately identified as the factor affecting the morbidity of severe OHSS and the ones with dyslipidemia were more likely to develop to severe OHSS (P < 0.05), while the incidence of severe OHSS among the ET groups had no statistical significance (P > 0.05).

CONCLUSION

The findings of this study suggested that dyslipidemia might contribute to the development of OHSS, especially for those patients who chose the cryopreservation of all embryos. It is essential to consider the risk of OHSS in patients with dyslipidemia although they required cryopreservation of all embryos.

Intra-uterine insemination for unexplained subfertility

BACKGROUND

Intra-uterine insemination (IUI) is a widely-used fertility treatment for couples with unexplained subfertility. Although IUI is less invasive and less expensive than in vitro fertilisation (IVF), the safety of IUI in combination with ovarian hyperstimulation (OH) is debated. The main concern about IUI treatment with OH is the increase in multiple pregnancy rates.

OBJECTIVES

To determine whether, for couples with unexplained subfertility, the live birth rate is improved following IUI treatment with or without OH compared to timed intercourse (TI) or expectant management with or without OH, or following IUI treatment with OH compared to IUI in a natural cycle.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL and two trials registers up to 17 October 2019, together with reference checking and contact with study authors for missing or unpublished data.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing IUI with TI or expectant management, both in stimulated or natural cycles, or IUI in stimulated cycles with IUI in natural cycles in couples with unexplained subfertility.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, quality assessment and data extraction. Primary review outcomes were live birth rate and multiple pregnancy rate.

MAIN RESULTS

We include 15 trials with 2068 women. The evidence was of very low to moderate quality. The main limitation was very serious imprecision. IUI in a natural cycle versus timed intercourse or expectant management in a natural cycle It is uncertain whether treatment with IUI in a natural cycle improves live birth rate compared to treatment with expectant management in a natural cycle (odds ratio (OR) 1.60, 95% confidence interval (CI) 0.92 to 2.78; 1 RCT, 334 women; low-quality evidence). If we assume the chance of a live birth with expectant management in a natural cycle to be 16%, that of IUI in a natural cycle would be between 15% and 34%. It is uncertain whether treatment with IUI in a natural cycle reduces multiple pregnancy rates compared to control (OR 0.50, 95% CI 0.04 to 5.53; 1 RCT, 334 women; low-quality evidence). IUI in a stimulated cycle versus timed intercourse or expectant management in a stimulated cycle It is uncertain whether treatment with IUI in a stimulated cycle improves live birth rates compared to treatment with TI in a stimulated cycle (OR 1.59, 95% CI 0.88 to 2.88; 2 RCTs, 208 women; I² = 72%; low-quality evidence). If we assume the chance of achieving a live birth with TI in a stimulated cycle was 26%, the chance with IUI in a stimulated cycle would be between 23% and 50%. It is uncertain whether treatment with IUI in a stimulated cycle reduces multiple pregnancy rates compared to control (OR 1.46, 95% CI 0.55 to 3.87; 4 RCTs, 316 women; I² = 0%; low-quality evidence). IUI in a stimulated cycle versus timed intercourse or expectant management in a natural cycle In couples with a low prediction score of natural conception, treatment with IUI combined with clomiphene citrate or letrozole probably results in a higher live birth rate compared to treatment with expectant management in a natural cycle (OR 4.48, 95% CI 2.00 to 10.01; 1 RCT; 201 women; moderate-quality evidence). If we assume the chance of a live birth with expectant management in a natural cycle was 9%, the chance of a live birth with IUI in a stimulated cycle would be between 17% and 50%. It is uncertain whether treatment with IUI in a stimulated cycle results in a lower multiple pregnancy rate compared to control (OR 3.01, 95% CI 0.47 to 19.28; 2 RCTs, 454 women; I² = 0%; low-quality evidence). IUI in a natural cycle versus timed intercourse or expectant management in a stimulated cycle Treatment with IUI in a natural cycle probably results in a higher cumulative live birth rate compared to treatment with expectant management in a stimulated cycle (OR 1.95, 95% CI 1.10 to 3.44; 1 RCT, 342 women: moderate-quality evidence). If we assume the chance of a live birth with expectant management in a stimulated cycle was 13%, the chance of a live birth with IUI in a natural cycle would be between 14% and 34%. It is uncertain whether treatment with IUI in a natural cycle results in a lower multiple pregnancy rate compared to control (OR 1.05, 95% CI 0.07 to 16.90; 1 RCT, 342 women; low-quality evidence). IUI in a stimulated cycle versus IUI in a natural cycle Treatment with IUI in a stimulated cycle may result in a higher cumulative live birth rate compared to treatment with IUI in a natural cycle (OR 2.07, 95% CI 1.22 to 3.50; 4 RCTs, 396 women; I² = 0%; low-quality evidence). If we assume the chance of a live birth with IUI in a natural cycle was 14%, the chance of a live birth with IUI in a stimulated cycle would be between 17% and 36%. It is uncertain whether treatment with IUI in a stimulated cycle results in a higher multiple pregnancy rate compared to control (OR 3.00, 95% CI 0.11 to 78.27; 2 RCTs, 65 women; low-quality evidence).

AUTHORS' CONCLUSIONS

Due to insufficient data, it is uncertain whether treatment with IUI with or without OH compared to timed intercourse or expectant management with or without OH improves cumulative live birth rates with acceptable multiple pregnancy rates in couples with unexplained subfertility. However, treatment with IUI with OH probably results in a higher cumulative live birth rate compared to expectant management without OH in couples with a low prediction score of natural conception. Similarly, treatment with IUI in a natural cycle probably results in a higher cumulative live birth rate compared to treatment with timed intercourse with OH. Treatment with IUI in a stimulated cycle may result in a higher cumulative live birth rate compared to treatment with IUI in a natural cycle.

Effects of pre-pregnancy body mass index on pregnancy and perinatal outcomes in women with PCOS undergoing frozen embryo transfer

BACKGROUND

Previous studies have shown that among women with polycystic ovary syndrome who have difficulties conceiving, frozen-embryo transfer resulted in increased live birth rates and decreased ovarian hyperstimulation syndrome risk than did fresh-embryo transfer. In the present retrospective analysis, we sought to determine the effect of body mass index (BMI) on pregnancy and perinatal outcomes in women with PCOS undergoing FET.

METHODS

Women with PCOS (n = 1556) undergoing FET were divided into groups based on weight, with those with normal weight having a BMI of 18.5-24.9 kg/m2,those who were overweight having a BMI of 25-29.9 kg/m2, and those who were obese having a BMI ≥30 kg/m2. Both pregnancy and perinatal outcomes were compared among these groups.

RESULTS

The normal-weight, overweight, or obese groups exhibited similar pregnancy outcomes, including clinical pregnancy rate, miscarriage rate, ongoing pregnancy rate and live birth rate. In singletons, birth characteristics regarding newborn gender, gestational age, birthweight and length at birth were comparable between the three groups. For adverse neonatal outcomes, the three groups showed no significant differences on the rates of low birthweight, very low birthweight, preterm birth, and very preterm birth after adjustment. In addition, the obstetric complications and the frequencies of live-birth defects were also comparable between the three groups except that overweight and obese women were more likely than women of normal weight to have delivered via cesarean section.

CONCLUSION

BMI did not affect the pregnancy or perinatal outcomes in women with PCOS undergoing FET.

What makes people ready to conceive? Findings from the International Fertility Decision-Making Study

This study investigated fertility decision-making in people currently trying to conceive, and examined whether factors that make people ready to conceive differ by gender and country. The study used data from the International Fertility Decision-Making Study, a cross-sectional study of 10,045 participants (1690 men and 8355 women) from 79 countries. Respondents were aged 18-50 years (mean 31.8 years), partnered and had been trying to conceive for > 6 months (mean 2.8 years). Respondents indicated their need for parenthood; their own/partner's desire for a child; and the influence of certain preconditions, motivational forces and subjective norms in relation to readiness to conceive. Factor analysis of preconditions and motivational forces revealed four decisional factors: social status of parents, economic preconditions, personal and relational readiness, and physical health and child costs. Significant gender differences were found for desire for a child, decisional factors and subjective norms. Compared with men, women had higher personal desire for a child, and rated economic and personal and relational readiness as more influential. Men were more likely to rate subjective norms and social status of parents as more influential. Country comparisons found significant differences in personal desire for a child, partner's desire for a child, need for parenthood, preconditions, motivational forces and subjective norms. The results demonstrate that some decisional factors have a universal association with starting families (e.g. desire for a child), whilst the influence of others (e.g. personal and relational readiness) is dependent on contextual factors. These findings support the need for contemporary, prospective and international research on reproductive decision-making, and emphasize the need for effective fertility policies to take contextual factors into account.

Trends over 15 years in ART in Europe: an analysis of 6 million cycles

STUDY QUESTION

Was the European IVF Monitoring (EIM) Consortium, established in 1999 by ESHRE, able to monitor the trend over time of ART in Europe?

SUMMARY ANSWER

The initial aims of the EIM programme (to collect and publish regional European data on census and trends on ART utilization, effectiveness, safety and quality) have been achieved.

WHAT IS ALREADY KNOWN

ART data in Europe have been collected and reported annually in Human Reproduction.

STUDY DESIGN SIZE DURATION

A retrospective data analysis and summary of the first 15 years of ART activity in Europe (1997-2011) was carried out, using the key figures from the annual ESHRE reports and focusing on how the practice of ART has evolved over the years.

PARTICIPANTS/MATERIALS SETTING METHOD

A total of 5 919 320 ART cycles are reported, including IVF, ICSI, frozen embryo relacment and egg donation, resulting in the birth of more than 1 million infants. A total of 1 548 967 IUIs are also reported, including husband/partner's semen and donor semen cycles. The most relevant and complete data are analysed and discussed.

MAIN RESULTS AND THE ROLE OF CHANCE

With some fluctuations, the number of countries and clinics reporting to EIM increases significantly from 1997 to 2011. A constant increase was also registered in the number of annual cycles reported. Since 2005, the estimation of the EIM coverage on the total European activity was >80%. In countries with 100% of coverage, the mean availability of ART increased from 765 cycles per million inhabitants in 1997 to 1269 cycles per million inhabitants in 2011, and the proportion of ART infants of the total number of infants born in the country increased from 1.3% to 2.4%. The proportion of women aged > 39 years undergoing IVF and ICSI cycles gradually increased. For 12 consecutive years, the proportion of ICSI versus IVF cycles showed a marked increase before reaching a plateau from 2008. The proportion of transfers with three or more embryos decreased constantly and the proportion of SETs increased over the time period. The triplets deliveries were reduced from 3.7% in 1997 to less than 1% since 2005 (0.6% in 2011). The effectiveness (evaluated as clinical pregnancy rate per aspiration and per embryo transfer) increased until 2007, then the figure remained stable. The cumulative percentage of documented pregnancy losses was 17%. No differences have been noted in terms of outcomes in the IUI cycles.

LIMITATIONS REASONS FOR CAUTION

The data presented are accumulated from countries with different collection systems, regulations, insurance coverage and different practices. Each year a number of countries have been unable to provide some of the data.

WIDER IMPLICATIONS OF THE FINDINGS

The first summary of 15 years of the EIM reports offers interesting data on census and trends on ART utilization, safety and quality in Europe. The primary aim of the ESHRE effort in supporting European data collection has been reached. Owing to its importance inside and outside the professional community, European data collection and publication on ART have to be supported and implemented.

STUDY FUNDING/COMPETING INTERESTS

None.

Chapter 3 Current Challenges in Immature Oocyte Cryopreservation

Current freezing technology, especially the vitrification method, has markedly improved oocyte survival rate after warming, and the pregnancy rate is comparable to that achieved with fresh oocytes. However, most groups report using oocytes matured in vivo for vitrification. Although immature oocytes can be vitrified successfully, clinical outcomes do not reach that of vitrification of matured oocytes. The current literature suggests that oocytes should be vitrified at mature metaphase II (M-II) stage following IVM rather than at the immature germinal vesicle (GV) stage, because the potential for oocyte maturation is reduced when vitrification is performed on immature oocytes at the GV stage.

Intra-uterine insemination for unexplained subfertility

BACKGROUND

Intra-uterine insemination (IUI) is a widely used fertility treatment for couples with unexplained subfertility. Although IUI is less invasive and less expensive thAppendixan in vitro fertilisation (IVF), the safety of IUI in combination with ovarian hyperstimulation (OH) is debated. The main concern about IUI treatment with OH is the increase in multiple pregnancy rate. This is an update of a Cochrane review (Veltman-Verhulst 2012) originally published in 2006 and updated in 2012.

OBJECTIVES

To determine whether, for couples with unexplained subfertility, IUI improves the live birth rate compared with timed intercourse (TI), or expectant management, both with and without ovarian hyperstimulation (OH).

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility (formerly Cochrane Menstrual Disorders and Subfertility Group) Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, inception to Issue 11, 2015), Ovid MEDLINE, Ovid EMBASE, PsycINFO and trial registers, all from inception to December 2015 and reference lists of articles. Authors of identified studies were contacted for missing or unpublished data. The evidence is current to December 2015.

SELECTION CRITERIA

Truly randomised controlled trial (RCT) comparisons of IUI versus TI, in natural or stimulated cycles. Only couples with unexplained subfertility were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, quality assessment and data extraction. We extracted outcomes, and pooled data and, where possible, we carried out subgroup and sensitivity analyses.

MAIN RESULTS

We included 14 trials including 1867 women. IUI versus TI or expectant management both in natural cycleLive birth rate (all cycles)There was no evidence of a difference in cumulative live births between the two groups (Odds Ratio (OR) 1.60, 95% confidence interval (CI) 0.92 to 2.78; 1 RCT; n = 334; moderate quality evidence). The evidence suggested that if the chance of a live birth in TI was assumed to be 16%, that of IUI would be between 15% and 34%.Multiple pregnancy rateThere was no evidence of a difference in multiple pregnancy rate between the two treatment groups (OR 0.50, 95% CI 0.04 to 5.53; 1 RCT; n = 334; moderate quality evidence). IUI versus TI or expectant management both in stimulated cycleLive birth rate (all cycles)There was no evidence of a difference between the two treatment groups (OR 1.59, 95% CI 0.88 to 2.88; 2 RCTs; n = 208; I(2) = 72%; moderate quality evidence). The evidence suggested that if the chance of achieving a live birth in TI was assumed to be 26%, the chance of a live birth with IUI would be between 23% and 50%.Multiple pregnancy rateThere was no evidence of a difference in multiple pregnancy rates between the two treatment groups (OR 1.46, 95% CI 0.55 to 3.87; 4 RCTs, n = 316; I(2) = 0%; low quality evidence). IUI in a natural cycle versus IUI in a stimulated cycle Live birth rate (all cycles)An increase in live birth rate was found for women who were treated with IUI in a stimulated cycle compared with those who underwent IUI in natural cycle (OR 0.48, 95% CI 0.29 to 0.82; 4 RCTs, n = 396; I(2) = 0%; moderate quality evidence). The evidence suggested that if the chance of a live birth in IUI in a stimulated cycle was assumed to be 25%, the chance of a live birth in IUI in a natural cycle would be between 9% and 21%.Multiple pregnancy rateThere was no evidence of a difference in multiple pregnancy rate between the two treatment groups (OR 0.33, 95% CI 0.01 to 8.70; 2 RCTs; n = 65; low quality evidence). IUI in a stimulated cycle versus TI or expectant management in a natural cycleLive birth rate (all cycles)There was no evidence of a difference in live birth rate between the two treatment groups (OR 0.82, 95% CI 0.45 to 1.49; 1 RCT; n = 253; moderate quality evidence). The evidence suggested that if the chance of a live birth in TI or expectant management in a natural cycle was assumed to be 24%, the chance of a live birth in IUI in a stimulated cycle would be between 12% and 32%.Multiple pregnancy rateThere was no evidence of a difference in multiple pregnancy rate between the two treatment groups (OR 2.00, 95% CI 0.18 to 22.34; 2 RCTs; n = 304; moderate quality evidence). IUI in natural cycle versus TI or expectant management in stimulated cycle Live birth rate (all cycles)There was evidence of an increase in live births for IUI (OR 1.95, 95% CI 1.10 to 3.44; 1 RCT, n = 342; moderate quality evidence). The evidence suggested that if the chance of a live birth in TI in a stimulated cycle was assumed to be 13%, the chance of a live birth in IUI in a natural cycle would be between 14% and 34%.Multiple pregnancy rateThere was no evidence of a difference in multiple pregnancy rate between the groups (OR 1.05, 95% CI 0.07 to 16.90; 1 RCT; n = 342; moderate quality evidence).The quality of the evidence was assessed using GRADE methods. Quality ranged from low to moderate, the main limitation being imprecision in the findings for both live birth and multiple pregnancy..

AUTHORS' CONCLUSIONS

This systematic review did not find conclusive evidence of a difference in live birth or multiple pregnancy in most of the comparisons for couples with unexplained subfertility treated with intra-uterine insemination (IUI) when compared with timed intercourse (TI), both with and without ovarian hyperstimulation (OH). There were insufficient studies to allow for pooling of data on the important outcome measures for each of the comparisons.

Human Sperm Cryopreservation

As the demand for assisted reproductive techniques in humans increases, so does the demand for the oocytes and sperm that are essential for these techniques. Human sperm banks play a key role in assisted human reproduction, as a reservoir of sperm from the semen of donors and as an option for genetic preservation for some patients. There are different techniques that can be used to store human sperm. This paper will provide an overview of the available techniques of human sperm preservation.

Assisted reproductive technology in Europe, 2011: results generated from European registers by ESHRE

STUDY QUESTION

The 15th European IVF-monitoring (EIM) report presents the results of treatments involving assisted reproductive technology (ART) initiated in Europe during 2011: are there any changes in the trends compared with previous years?

SUMMARY ANSWER

Despite some fluctuations in the number of countries reporting data, while the overall number of ART cycles has continued to increase year by year, the pregnancy rates in 2011 decreased slightly to those reported in 2010, and the number of transfers with multiple embryos (3+) and the multiple delivery rates declined.

WHAT IS KNOWN ALREADY

Since 1997, ART data in Europe have been collected and reported in 14 manuscripts, published in Human Reproduction.

STUDY DESIGN, SIZE, DURATION

Retrospective data collection of European ART data by the EIM Consortium for the European Society of Human Reproduction and Embryology (ESHRE); cycles started between 1 January and 31 December 2011 are collected on a yearly basis. The data are collected by National Registers, when existing, or on a voluntary basis by personal information.

PARTICIPANTS/MATERIALS SETTING, METHODS

From 33 countries (+2 compared with 2010), 1064 clinics reported 609 973 treatment cycles including: IVF 138 592, ICSI 298 918, frozen embryo replacement (FER) 129 693, egg donation (ED) 30 198, in vitro maturation 511, preimplantation genetic diagnosis/screening 6824 and frozen oocyte replacements 5237. European data on intrauterine insemination (IUI) using husband/partner's semen (IUI-H) and donor semen (IUI-D) were reported from 861 IUI laboratories in 24 countries. A total of 174 390 IUI-H and 41 151 IUI-D cycles were included.

MAIN RESULTS AND THE ROLE OF CHANCE

In 17 countries where all clinics reported to the ART register, a total of 361 972 ART cycles were performed in a population of 285 million inhabitants, corresponding to 1269 cycles per million inhabitants. For all IVF cycles, the clinical pregnancy rates per aspiration and per transfer were stable with 29.1 and 33.2%, respectively, and for ICSI, the corresponding rates also were stable with 27.9 and 31.8%, respectively. In FER cycles, the pregnancy rate per thawing increased to 21.3% if compared with previous years. In ED cycles, the pregnancy rate per fresh transfer decreased to 45.8% (47.4% in 2010) and increased to 33.6% (33.3% in 2010) per thawed transfer. The delivery rate after IUI-H decreased to 8.3 (8.9 in 2010), and to 12.2% (13.8% in 2010) after IUI-D. In IVF and ICSI cycles, 1, 2, 3 and 4+ embryos were transferred in 27.5, 56.7, 14.5 and 1.3% of cycles, respectively. The proportions of singleton, twin and triplet deliveries after IVF and ICSI (added together) were 80.8, 18.6 and 0.6%, respectively, resulting in a total multiple delivery rate of 19.2% compared with 20.6% in 2010, 20.2% in 2009, 21.7% in 2008, 22.3% in 2007 and 20.8% in 2006. In FER cycles, the multiple delivery rate was 13.2% (12.8% twins and 0.4% triplets). Twin and triplet delivery rates associated with IUI cycles were 9.7/0.6% and 7.3/0.3%, following IUI-H and IUI-D treatment, respectively.

LIMITATIONS, REASONS FOR CAUTION

The method of reporting varies among countries, and registers from a number of countries have been unable to provide some of the relevant data such as initiated cycles and deliveries. As long as data are incomplete and generated through different methods of collection, results should be interpreted with caution.

WIDER IMPLICATIONS OF THE FINDINGS

The 15th ESHRE report on ART shows a continuing expansion of the number of treatment cycles in Europe, with more than 600 000 cycles reported in 2011. Since 2006, the proportion of IVF to ICSI cycles has reached a plateau after a small decrease in 2009. Pregnancy and delivery rates after IVF remained relatively stable compared with 2010 and 2009. The pregnancy rate per aspiration in ICSI cycles declined for the first time by 0.9%. The multiple delivery rate is lower than ever before.

STUDY FUNDING/COMPETING INTERESTS

The study had no external funding; all costs are covered by ESHRE. There are no competing interests.

Live birth following vitrification of in vitro matured oocytes derived from sibling smaller follicles at follicle selection phase in the context of in vitro fertilization

In ovarian stimulation, a 31-year-old woman with polycystic ovary syndrome was at the risk of developing ovarian hyperstimulation syndrome, follicle aspiration was performed, and eight immature oocytes were collected from follicle fluids. After 28 h in vitro culture, six of them reached MII and were vitrified. The patient failed to conceive in her fresh in vitro fertilization cycle and next two replacement cycles. In the third replacement cycle, a successful pregnancy was obtained by vitrified-thawed oocytes. This case demonstrates that follicular aspiration during follicle selection phase has protective effects against developing ovarian hyperstimulation syndrome, and rescued immature oocytes are viable and could produce promising embryos for live birth.

Demographic relevancy of increased use of assisted reproduction in European countries

BACKGROUND

Delayed childbearing in European countries has resulted in an increase in the number of women having children later in life. Thus more women face the problem of age-related infertility and cannot achieve their desired number of children. Childbearing postponement is one of the main reasons for the increasing use of assisted reproductive technology (ART) and conversely, the latter may be one of the factors contributing to the rise in female childbearing age. The research goal of our article is to evaluate the demographic importance of ART increased use and to examine its impact on both the fertility rate and birth timing.

METHODS

Comparative analysis based on demographic and ART data collected by the European IVF-monitoring (EIM) Consortium for the European Society of Human Reproduction and Embryology (ESHRE).

RESULTS

Most countries with a higher total fertility rate (TFR) also registered a higher number of treatment cycles per 1 million women of reproductive age. Despite the positive relationship between the postponement rate and the demand for ART among women aged 35 and older, the highest share of children born after ART was not found in countries characterized by a "delayed" fertility schedule. Instead, the highest proportion of ART births was found in countries with fertility schedules concentrated on women aged between 25 and 34. Accordingly, the effective use of ART can be expected in populations with a less advanced postponement rate.

CONCLUSIONS

ART can have a demographic relevancy when women take advantage of it earlier rather than later in life. Furthermore it is suggested that the use of ART at a younger age increases women's chance of achieving their reproductive goals and reduces the risk of age-related infertility and failed ART. Based on a demographic approach, reproductive health policy may become an integral part of policies supporting early childbearing: it may keep women from delaying too long having children and increase the chance of diagnosing potential reproductive health problems requiring a timely ART application.

Predictive factors for pregnancy during the first four intrauterine insemination cycles using gonadotropin

PURPOSE

Although a variety of factors have been reported as affecting pregnancy rates after intrauterine insemination (IUI), there have been conflicting results on prognostic factors. This study aimed to determine predictive factors for pregnancy in patients undergoing the first four IUI cycles.

METHODS

A total of 348 IUI cycles using clomiphene citrate or letrozole combined with gonadotropin, or gonadotropin only were analyzed. Baseline clinical characteristics, variables related to ovulation induction and sperm parameters were compared between pregnant (n = 54) and non-pregnant groups (n = 294). Logistic regression analysis was performed to identify factors that could predict a pregnancy.

RESULTS

The overall clinical pregnancy rate was 15.5% (54/348) per cycle and 30.0% (54/180) per couple. During the first four IUI cycles, logistic regression analysis revealed that woman who were 39 years or older (OR: 0.263, 95% CI: 0.076-0.906, p = 0.034), longer duration of infertility (OR: 0.967, 95% CI: 0.942-0.993, p = 0.012), endometriosis (versus unexplained infertility; OR: 0.177, 95% CI: 0.040-0.775, p = 0.022) and endometrial thickness below 7 mm (OR: 0.114, 95% CI: 0.015-0.862, p = 0.035) were unfavorable factors to predict clinical pregnancy.

CONCLUSIONS

Women with old age, longer duration of infertility, the presence of endometriosis or thin endometrium in the preovulatory phase may have unfavorable outcomes during the first four IUI cycles.

Risk disparities in the globalisation of assisted reproductive technology: the case of Asia

This paper analyses the disparities in risks associated with biomedical technology focusing on the results of assisted reproductive technology (ART). ART among biomedical technologies transferred to Asia is a representative case that reveals in its clinical use and related scientific research the global politics of technology. This study notes the global politics at work in the recognition of and reaction to such risks. While many Asian countries aggressively pursue technological development, weak legislative and administrative regulations have created various problems and controversial cases. This study asserts that risks associated with technology are characterised as social facts not natural ones or mere 'side effects', since technological development and risk are closely intertwined.

Interparental conflict, parent psychopathology, hostile parenting, and child antisocial behavior: examining the role of maternal versus paternal influences using a novel genetically sensitive research design

Past research has linked interparental conflict, parent psychopathology, hostile parenting, and externalizing behavior problems in childhood. However, few studies have examined these relationships while simultaneously allowing the contribution of common genetic factors underlying associations between family- and parent-level variables on child psychopathology to be controlled. Using the attributes of a genetically sensitive in vitro fertilization research design, the present study examined associations among interparental conflict, parents' antisocial behavior problems, parents' anxiety symptoms, and hostile parenting on children's antisocial behavior problems among genetically related and genetically unrelated mother-child and father-child groupings. Path analyses revealed that for genetically related mothers, interparental conflict and maternal antisocial behavior indirectly influenced child antisocial behavior through mother-to-child hostility. For genetically unrelated mothers, effects were apparent only for maternal antisocial behavior on child antisocial behavior through mother-to-child hostility. For both genetically related and genetically unrelated fathers and children, interparental conflict and paternal antisocial behavior influenced child antisocial behavior through father-to-child hostility. Effects of parental anxiety symptoms on child antisocial behavior were apparent only for genetically related mothers and children. Results are discussed with respect to the relative role of passive genotype-environment correlation as a possible confounding factor underlying family process influences on childhood psychopathology.

Cabergoline as treatment of ovarian hyperstimulation syndrome: a review

One of the most serious complications of assisted reproduction techniques is ovarian hyperstimulation syndrome (OHSS). OHSS not only increases morbidity and mortality in IFV cycles, but also causes significant other problems, as cancelled in vitro fertilization (IVF) cycles, prolonged hospitalization, causing emotional and sociofinancial consequences. Several treatments for OHSS have been proposed and among these Cabergoline (Cb2). Despite the above-mentioned beneficial effect, Cb2 has not been widely used in everyday's clinical practice. With our study, we try to review all studies with strong evidence examining Cb2 use for OHSS prevention.

New trends in female fertility preservation: in vitro maturation of oocytes

As antineoplastic treatments have become more successful, an increasing number of women with cancer survive to endure the long-term consequences of chemotherapy. One of the most important of these consequences in young females is premature ovarian failure and infertility. Owing to increasing survival rates, many of these young women are seeking methods to preserve their fertility. Currently, embryo/oocyte cryopreservation obtained after controlled ovarian stimulation appears to provide the best fertility preservation option. However, patients may not have enough time to undergo ovarian stimulation prior to chemotherapy and/or have contraindications to exogenous gonadotropin administration owing to estrogen-dependant tumors. In vitro maturation of oocytes is an attractive alternative for fertility preservation in cancer patients because it does not require ovarian stimulation and it can be performed at any time of the menstrual cycle. In addition, this technique can be combined with ovarian tissue cryobanking. In this review, we discuss the position of in vitro maturation of oocytes in the fertility preservation strategy in young women.

Fertility knowledge and beliefs about fertility treatment: findings from the International Fertility Decision-making Study

STUDY QUESTION

How good is fertility knowledge and what are treatment beliefs in an international sample of men and women currently trying to conceive?

SUMMARY ANSWER

The study population had a modest level of fertility knowledge and held positive and negative views of treatment.

WHAT IS KNOWN ALREADY

Few studies have examined general fertility treatment attitudes but studies of specific interventions show that attitudes are related to characteristics of the patient, doctor and context. Further, research shows that fertility knowledge is poor. However, the majority of these studies have examined the prevalence of infertility, the optimal fertile period and/or age-related infertility in women, in university students and/or people from high-resource countries making it difficult to generalize findings.

STUDY DESIGN, SIZE, DURATION

A cross-sectional sample completed the International Fertility Decision-making Study (IFDMS) over a 9-month period, online or via social research panels and in fertility clinics.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were 10 045 people (8355 women, 1690 men) who were on average 31.8 years old, had been trying to conceive for 2.8 years with 53.9% university educated. From a total of 79 countries, sample size was >100 in 18 countries. All 79 countries were assigned to either a very high Human Development Index (VH HDI) or a not very high HDI (NVH HDI). The IFDMS was a 45-min, 64-item English survey translated into 12 languages. The inclusion criteria were the age between 18 and 50 years and currently trying to conceive for at least 6 months. Fertility knowledge was assessed using a 13-item correct/incorrect scale concerned with risk factors, misconceptions and basic fertility facts (range: 0-100% correct). Treatment beliefs were assessed with positive and negative statements about fertility treatment rated on a five-point agree/disagree response scale.

MAIN RESULTS AND THE ROLE OF CHANCE

Average correct score for Fertility Knowledge was 56.9%, with greater knowledge significantly related to female gender, university education, paid employment, VH HDI and prior medical consultation for infertility (all P < 0.001). The mean agreement scores for treatment beliefs showed that agreement for positive items (safety, efficacy) was correlated with agreement for negative items (short/long-term physical/emotional effects) (P > 0.001). People who had given birth/fathered a child, been trying to conceive for less than 12 months, who had never consulted for a fertility problem and who lived in a country with an NVH HDI agreed less with negative beliefs. HDI, duration of trying to conceive and help-seeking were also correlates of higher positive beliefs, alongside younger age, living in an urban area and having stepchildren. Greater fertility knowledge was associated with stronger agreement on negative treatment beliefs items (P < 0.001) but was unrelated to positive treatment beliefs items.

LIMITATIONS, REASONS FOR CAUTION

There was volunteer bias insofar as more women, people of higher education and people with fertility problems (i.e. met criteria for infertility, had consulted a medical doctor, had conceived with fertility treatment) participated and this was true in VH and NVH HDI countries. The bias may mean that people in this sample had better fertility knowledge and less favourable treatment beliefs than is the case in the general population.

WIDER IMPLICATIONS OF THE FINDINGS

Educational interventions should be directed at improving knowledge of fertility health. Future prospective research should be aimed at investigating how fertility knowledge and treatment beliefs affect childbearing and help-seeking decision-making.

Multiple-gestation pregnancies after assisted reproductive technology treatment: population trends and future directions

Assisted reproductive technology (ART) treatments, such as in vitro fertilization, have benefited many couples worldwide. However, ART as currently practiced, with the usual transfer of at least two embryos, poses sizable risks for multiple-gestation pregnancy and accompanying serious maternal and child health sequelae. While limiting the number of embryos transferred would appear a straightforward solution, treatments with single-embryo transfer are rare. Likely reasons for this include patient and provider desires to maximize the chance for success in a single treatment given the high cost and lack of insurance coverage, the (sometimes mistaken) belief that transferring more embryos will increase the chance for pregnancy, and the preference for multiple births among some women undergoing ART. Although recent population-based data in the USA and Europe suggest the number of embryos transferred is decreasing, the ART multiple-birth rate remains high. Comprehensive patient-education efforts and continued research on the efficacy of single-embryo transfer are needed.

Effect of polyvinylpyrrolidone on sperm function and early embryonic development following intracytoplasmic sperm injection in human assisted reproduction

The objective here was to review the effects of polyvinylpyrrolidone (PVP) upon sperm function and embryonic development in humans. PVP has been used successfully in intracytoplasmic sperm injection (ICSI) to facilitate the handling and immobilization of sperm for both domestic animals and humans. In our previous reports, PVP solution exists locally in embryos injected during the early developmental period, and also exerts influence over the developmental capacity of such embryos. In other reports, PVP causes significant damage to sperm membranes that can be detected by transmission electron microscopy, and has been associated with chromosomal abnormalities in pregnancy derived from ICSI embryos. In some Japanese clinics, PVP-free media has been used for sperm immobilization in order to optimise safety. Consequently, it is strongly suggested that the success rate of fertilization and clinical pregnancy could be improved by using PVP-free solution for human ICSI. In conclusion, our interpretation of the available data is to perform ICSI without PVP or select a lower concentration of PVP solution in order to reduce safety for pregnancy and children born via ICSI.

Intra-uterine insemination for unexplained subfertility

BACKGROUND

Intra-uterine insemination (IUI) is a widely used fertility treatment for couples with unexplained subfertility. Although IUI is less invasive and less expensive than in vitro fertilisation (IVF), the safety of IUI in combination with ovarian hyperstimulation (OH) is debated. The main concern about IUI treatment with OH is the increase in multiple pregnancy rate.

OBJECTIVES

To determine whether, for couples with unexplained subfertility, IUI improves the live birth rate compared with timed intercourse (TI), both with and without ovarian hyperstimulation (OH).

SEARCH METHODS

We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched July 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 7), MEDLINE (1966 to July 2011), EMBASE (1980 to July 2011), PsycINFO (1806 to July 2011), SCIsearch and reference lists of articles. Authors of identified studies were contacted for missing or unpublished data.

SELECTION CRITERIA

Truly randomised controlled trials (RCTs) with at least one of the following comparisons were included: IUI versus TI, both in a natural cycle; IUI versus TI, both in a stimulated cycle; IUI in a natural cycle versus IUI in a stimulated cycle; IUI with OH versus TI in a natural cycle; IUI in a natural cycle versus TI with OH. Only couples with unexplained subfertility were included.

DATA COLLECTION AND ANALYSIS

Quality assessment and data extraction were performed independently by two review authors. Outcomes were extracted and the data were pooled. Subgroup and sensitivity analyses were done where possible.

MAIN RESULTS

One trial compared IUI in a natural cycle with expectant management and showed no evidence of increased live births (334 women: odds ratio (OR) 1.60, 95% confidence interval (CI) 0.92 to 2.8). In the six trials where IUI was compared with TI, both in stimulated cycles, there was evidence of an increased chance of pregnancy after IUI (six RCTs, 517 women: OR 1.68, 95% CI 1.13 to 2.50). A significant increase in live birth rate was found for women where IUI with OH was compared with IUI in a natural cycle (four RCTs, 396 women: OR 2.07, 95% CI 1.22 to 3.50). However the trials provided insufficient data to investigate the impact of IUI with or without OH on several important outcomes including live births, multiple pregnancies, miscarriage and risk of ovarian hyperstimulation. There was no evidence of a difference in pregnancy rate for IUI with OH compared with TI in a natural cycle (two RCTs, total 304 women: data not pooled). The final comparison of IUI in natural cycle to TI with OH showed a marginal, significant increase in live births for IUI (one RCT, 342 women: OR 1.95, 95% CI 1.10 to 3.44).

AUTHORS' CONCLUSIONS

There is evidence that IUI with OH increases the live birth rate compared to IUI alone. The likelihood of pregnancy was also increased for treatment with IUI compared to TI in stimulated cycles. One adequately powered multicentre trial showed no evidence of effect of IUI in natural cycles compared with expectant management. There is insufficient data on multiple pregnancies and other adverse events for treatment with OH. Therefore couples should be fully informed about the risks of IUI and OH as well as alternative treatment options.

Assisted reproductive technology in Europe, 2008: results generated from European registers by ESHRE

BACKGROUND

This 12th European IVF-monitoring (EIM) report presents the results of treatments involving assisted reproductive technology (ART) initiated in Europe during 2008.

METHODS

From 36 countries (3 more compared with 2007), 1051 clinics reported 532 260 treatment cycles including: IVF (124 539), ICSI (280 552), frozen embryo replacements (FER, 97 120), egg donation (ED, 13 609), in vitro maturation (IVM, 562), preimplantation genetic diagnosis/screening (PGD/PGS, 2875) and frozen oocyte replacements (FOR, 4080). Overall, this represents a 7.9% increase in the activity since 2007, which is mainly related to an increase in cycles from almost all registers and only partially to the new countries entering EIM (Estonia, Kazakhstan, Moldova and Romania, 5480 cycles in total). European data on intrauterine insemination using husband/partner's (IUI-H) and donor (IUI-D) semen were reported from 27 and 21 countries, respectively. A total of 144 509 IUI-H (+1.5%) and 24 960 IUI-D (-4.3%) cycles were included.

RESULTS

In 19 countries where all clinics reported to the ART register, a total of 350 143 ART cycles were performed in a population of 369.8 million, corresponding to 947 cycles per million inhabitants. For IVF, the clinical pregnancy rates per aspiration and per transfer were 28.5 and 32.5%, respectively, and for ICSI the corresponding rates were 28.7 and 31.9%. In FER cycles, the pregnancy rate per thawing was 19.3%. The delivery rate after IUI was 9.1% for IUI-H and 13.8% for IUI-D. In IVF and ICSI cycles, one, two, three and four or more embryos were transferred in 22.4, 53.2, 22.3 and 2.1%, respectively. The proportions of singleton, twin and triplet deliveries after IVF and ICSI (combined) were 78.3, 20.7 and 1.0%, respectively, resulting in a total multiple delivery rate of 21.7%, compared with 22.3% in 2007, 20.8% in 2006 and 21.8% in 2005. In FER cycles, the multiple delivery rate was 13.7% (13.4% twins and 0.3% triplets). In women undergoing IUI, twin and triplet deliveries occurred in 10.6% and 0.7% with IUI-H and in 9.4 and 0.3% with IUI-D, respectively.

CONCLUSIONS

In comparison with previous years, there was an increase in the reported number of ART cycles in Europe. For the first time in 5 years, the pregnancy rates failed to show a year-on-year increase. Compared with 2007, the number of transfers of multiple embryos (3+) and a multiple delivery rate showed a marginal decline.

Assisted reproductive technology in Europe, 2007: results generated from European registers by ESHRE

BACKGROUND

This 11th European IVF-monitoring report presents the results of assisted reproductive technology (ART) treatments initiated in Europe during 2007.

METHODS

From 33 countries, 1029 clinics reported 493 184 treatment cycles: IVF (120 761), ICSI (256 642), frozen embryo replacement (91 145), egg donation (15 731), preimplantation genetic diagnosis/preimplantation genetic screening (4638), in vitro maturation (660) and frozen oocytes replacements (3607). Overall, this represents a 7.6% increase since 2006, mostly related to an increase in all registers. IUI using husband/partner's (IUI-H) and donor (IUI-D) semen was reported from 23 countries: 142 609 IUI-H (+6.2%) and 26 088 IUI-D (+7.2%).

RESULTS

In 18 countries where all clinics reported, 376 971 ART cycles were performed in a population of 425.6 million (886 cycles per million). The clinical pregnancy rates per aspiration and per transfer were 29.1 and 32.8% for IVF, and 28.6 and 33.0% for ICSI. Delivery rate after IUI-H was 10.2% in women aged < 40 years. In IVF/ICSI cycles, 1, 2, 3 and ≥4 embryos were transferred in 21.4, 53.4, 22.7 and 2.5% of cycles, with no decline in the number of embryos per transfer since 2006. The proportion of multiple deliveries (22.3: 21.3% twin and 1.0% triplet), did not decrease compared with 2006 (20.8%) and 2005 (21.8%). In women < 40 years undergoing IUI-H, twin deliveries occurred in 11.7% and triplets in 0.5%.

CONCLUSIONS

In comparison with previous years, the reported number of ART cycles in Europe increased in 2007; pregnancy rates increased marginally, but the earlier decline in the number of embryos transferred and multiple births did not continue.

Reproductive health options among HIV-infected persons in the low-income Niger Delta of Nigeria

Background

With the advent and widespread use of highly active antiretroviral therapy for the treatment of human immunodeficiency virus (HIV), persons living with HIV/acquired immune deficiency syndrome (AIDS) are living good quality, longer, and healthier lives. Many couples affected by HIV, both serodiscordant and seroconcordant, are beginning to consider options for safer reproduction. The aim of this study was to assess the reproductive health concerns among persons living with HIV/AIDS in the Niger Delta of Nigeria.

Methods and results

The subjects were aged 18–58 (mean 41.25 ± 11.50) years, with 88 males (45.1%) and 107 females (54.9). Of the 195 subjects studied, 111 (56.9%) indicated a desire to have children. The main reasons for wanting to procreate included ensuring lineage continuity and posterity (52.3%), securing relationships (27.0%), and pressure from relatives to reproduce (20.7%). Single subjects were more inclined to have children (76.3%) compared with married (51.5%), widowed (18.2%), and separated/divorced subjects (11.1%, P = 0.03). Of the 111 subjects who indicated their desire to have children, women were more inclined to have children (64.5%) than men (47.7%). The major concern among the 84 (43.1%) subjects not desiring more children were the fear of infecting a serodiscordant partner and baby (57.1%), fear of dying and leaving behind orphans (28.6%), and fear that they may become too ill and unable to support the child financially (14.3%). Persons with no formal education were more likely to have children irrespective of their positive HIV status (66.7%) than persons educated to tertiary education level (37.0%, P = 0.01). Of 111 subjects who desired to have children, only 58% had attended reproductive health counseling with HIV counselors. Reasons for not seeking advice were anticipated negative reactions and discrimination from counselors. A significant number of subjects were only aware of some of the reproductive health options available to reduce the risk of infecting their partners and/or baby, such as artificial vaginal insemination, intrauterine insemination, cesarean section, avoidance of breast feeding, and offering prenatal pre-exposure prophylaxis to the fetus. They were unaware of other options, such as sperm washing, in vitro fertilization, and intracytoplasmic sperm injection. Of the 43.1% not anticipating more children, 36.9% were anticipating adoption.

Conclusion

Our study has shown that a significant number of HIV-infected persons in the Niger Delta of Nigeria desire to have children irrespective of their positive serostatus. There is the need to support the sexual and reproductive rights of HIV-infected individuals. Additional training needs to be offered to HIV counselors on evidence-based best and affordable practices regarding reproductive health issues among persons living with HIV. Policies that support availability and accessibility to relevant reproductive and sexual health services, including contraception and procreation, need to be developed. Public enlightenment programs on HIV are needed to reduce the stigmatization that HIV-infected persons face from family members and their communities.

Birth defects in singleton versus multiple ART births in Japan (2004-2008)

The purpose of the present study was to evaluate the relative risk (RR) of multiple births for birth defects after assisted reproductive technology (ART) using Japanese nationwide data from 2004 to 2008 with singletons as the reference group. In multiples compared to singletons, the percentage of birth defects per pregnancy were significantly higher (RR = 1.88, 95% confidence interval (CI) 1.60–2.13), the percentage of birth defects per live birth was not significantly higher (RR = 0.90, 95% CI 0.78–1.05 or RR = 0.94, 95% CI 0.81–1.10), and the early neonatal mortality rate was significantly higher (RR = 2.68, 95% CI 1.52–4.70 or RR = 2.80, 95% CI 1.60–4.92). The early neonatal mortality per 10,000 live births was slightly higher in ART (5.09) than in the general population (3.86). We concluded that the impact of birth defects after ART would be larger in families with multiples compared to families with singletons, since the mean number of children would be larger in the former.

Comparison of chromosomal abnormality rates in ICSI for non-male factor and spontaneous conception

OBJECTIVE

To compare cytogenetic data of first-trimester missed abortions in intracytoplasmic sperm injection (ICSI) for non-male factor-mediated and spontaneous pregnancies.

METHODS

Using karyotype analysis, we conducted a retrospective cohort trial of missed abortions following ICSI for non-male factor and spontaneous pregnancies. Patients experienced missed abortions during the first 12 weeks of pregnancy. Dilation and curettage procedure was performed followed by cytogenetic evaluations. Two patient groups were created: ICSI (n = 71) and spontaneous pregnancies (n = 81). At least 20 GTG-banded metaphases were analyzed in each case for cytogenetic analyses. Statistical analyses were performed using NCSS 2007 Statistical Program software. The significance level and confidence interval for all analyses were set to p < 0.05 and a 95% confidence interval, respectively.

RESULTS

A total of 49.3% (75/152) of the miscarriages were cytogenetically abnormal among the patients. We detected cytogenetically abnormalities in 47.9% (34/71) of the ICSI group and 50.6% (41/81) of the control group, which were not statistically significant differences (p=NS). The sex chromosome abnormalities were similar between the ICSI and control groups (p=NS). The most prevalent abnormalities that were observed in the ICSI and control groups with first-trimester pregnancy loss were trisomy (n = 42; 27.6%), Turner syndrome (45, X0, n = 13; 8.6%), triploidy (n = 13; 8.6%), 48 chromosomes (n = 5; 3.3%), and mixed chromosomal abnormalities (n = 3; 1.2%). In addition, the karyotypes were similar between the ICSI and control groups (p=NS). We observed increases in fetal aneuploidy rates with increased maternal age (<30 years = 23.9% vs. 31-34 years = 37.0% vs. 35-39 years = 82.9% vs. >39 years = 90.9%). However, the observed increases in fetal aneuploidy rates were not statistically significant (p=NS).

CONCLUSION

The aneuploidy rates and sex chromosome anomalies following ICSI for non-male factor were similar to those following natural conception.

Effect of maternal age and fertility treatment on the increase in multiple births in Japan: vital statistics, 1974-2009

Background

The present study used vital-statistics data to estimate the effect of maternal age and fertility treatment on the number and rate of multiple live births in Japan from 1974 through 2009.

Methods

Japanese vital statistics published by the Ministry of Health, Labour and Welfare from 1974 to 2009 were gathered and reanalyzed with regard to maternal age class and plurality of live births. The numbers of spontaneous and iatrogenic multiple births during 1977–2009 were estimated, with the assumption that spontaneous multiple-birth rates according to maternal age class would be constant and equal to those of baseline values, ie, the means between 1974 and 1976.

Results

During the 25-year period, multiple-birth rates according to maternal age class increased after the late 1980s. This tendency was obvious in women aged 35 to 39 years. The estimated numbers of iatrogenic multiple births remained nearly constant in women aged 20 to 24 years and greatly increased in women aged 30 to 34 and 35 to 39 years. The rate (per 1000 live births) of iatrogenic multiple births gradually increased from 0.7 (1977) to 1.3 (1986), then rapidly and markedly increased from 1.3 (1986) to 11.4 (2005), and finally decreased to 8.1 (2009). The estimated maximum percentage of iatrogenic multiple births was 50.0%, in 2004 and 2005.

Conclusions

The rapid increases in Japan in the number and rate of multiples born to women older than 30 years are likely due to iatrogenic rather than spontaneous multiple births.

Successful pregnancy after rituximab in a women with recurrent in vitro fertilisation failures and anti-phospholipid antibody positive

We report a case of successful pregnancy after rituximab in a patient with a history of in vitro fertilisation (IVF) failures and positive anti-cardiolipin antibody (ACA). Following a course of rituximab, her ACA became negative and she successfully conceived with IVF treatment. This is the first case in literature describing the use of rituximab therapy in this clinical scenario.

Familial transmission of depression and antisocial behavior symptoms: disentangling the contribution of inherited and environmental factors and testing the mediating role of parenting

BACKGROUND

Genetic and environmental influences on child psychopathology have been studied extensively through twin and adoption designs. We offer a novel methodology to examine genetic and environmental influences on the intergenerational transmission of psychopathology using a sample of parents and children conceived through in vitro fertilization (IVF).

METHOD

The sample included families with children born through IVF methods, who varied as to whether the child was genetically related or unrelated to the rearing mother and father (mother genetically related, n=434; mother genetically unrelated, n=127; father genetically related, n=403; father genetically unrelated, n=156). Using standardized questionnaires, mothers and fathers respectively reported on their own psychopathology (depression, aggression), their parenting behavior toward their child (warmth, hostility) and their child's psychopathology (depression, aggression). A cross-rater approach was used, where opposite parents reported on child symptoms (i.e. fathers reported on symptoms for the mother-child dyad, and vice versa).

RESULTS

For mother-child dyads, a direct association between mother depression and child depression was observed among genetically unrelated dyads, whereas a fully mediated path was observed among genetically related dyads through mother-to-child hostility and warmth. For father-child dyads, direct and mediated pathways were observed for genetically related father-child dyads. For aggression, the direct association between parent aggression and child aggression was fully mediated by parent-to-child hostility for both groups, indicating the role of parent-to-child hostility as a risk mechanism for transmission.

CONCLUSIONS

A differential pattern of genetic and environmental mediation underlying the intergenerational transmission of psychopathology was observed among genetically related and genetically unrelated father-child and mother-child dyads.

The effect of anandamide on uterine nitric oxide synthase activity depends on the presence of the blastocyst

Nitric oxide production, catalyzed by nitric oxide synthase (NOS), should be strictly regulated to allow embryo implantation. Thus, our first aim was to study NOS activity during peri-implantation in the rat uterus. Day 6 inter-implantation sites showed lower NOS activity (0.19±0.01 pmoles L-citrulline mg prot⁻¹ h⁻¹) compared to days 4 (0.34±0.03) and 5 (0.35±0.02) of pregnancy and to day 6 implantation sites (0.33±0.01). This regulation was not observed in pseudopregnancy. Both dormant and active blastocysts maintained NOS activity at similar levels. Anandamide (AEA), an endocannabinoid, binds to cannabinoid receptors type 1 (CB1) and type 2 (CB2), and high concentrations are toxic for implantation and embryo development. Previously, we observed that AEA synthesis presents an inverted pattern compared to NOS activity described here. We adopted a pharmacological approach using AEA, URB-597 (a selective inhibitor of fatty acid amide hydrolase, the enzyme that degrades AEA) and receptor selective antagonists to investigate the effect of AEA on uterine NOS activity in vitro in rat models of implantation. While AEA (0.70±0.02 vs 0.40±0.04) and URB-597 (1.08±0.09 vs 0.83±0.06) inhibited NOS activity in the absence of a blastocyst (pseudopregnancy) through CB2 receptors, AEA did not modulate NOS on day 5 pregnant uterus. Once implantation begins, URB-597 decreased NOS activity on day 6 implantation sites via CB1 receptors (0.25±0.04 vs 0.40±0.05). While a CB1 antagonist augmented NOS activity on day 6 inter-implantation sites (0.17±0.02 vs 0.27±0.02), a CB2 antagonist decreased it (0.17±0.02 vs 0.12±0.01). Finally, we described the expression and localization of cannabinoid receptors during implantation. In conclusion, AEA levels close to and at implantation sites seems to modulate NOS activity and thus nitric oxide production, fundamental for implantation, via cannabinoid receptors. This modulation depends on the presence of the blastocyst. These data establish cannabinoid receptors as an interesting target for the treatment of implantation deficiencies.

Sperm stories: Policies and practices of sperm banking in Denmark and Sweden

In Denmark and Sweden sperm donation is the most debated and contested of the reproductive technologies that are currently in use. Although the two countries are neighbouring welfare states with public healthcare in common, policies and practices of sperm banking and sperm donation differ strongly. Drawing on ethnographic fieldwork, this article explores how the sperm used for donor insemination is narrated, chosen, produced and consumed at sperm banks in Denmark and Sweden.The analysis illustrates that marginalization and stigmatization of infertile men, donors, single women, lesbians and donor children not only takes place in the media and during debates in the Danish and Swedish parliaments where the technology has historically been contested, but also at the sperm banks and fertility clinics. This article therefore calls for more inclusive stories on sperm donation to be narrated.

Multiple births conceived by assisted reproductive technology in Korea

PURPOSE

The recent trends of multiple births (MBs) conceived by assisted reproductive technology (ART) in Korea were analyzed as well as the relationship with maternal age, especially advanced maternal age.

METHODS

Data were obtained from the Korean Statistical Information Service and annual ART reports from the ART committee of the Korean Society of Obstetrics and Gynecology.

RESULTS

MBs increased from the early 1990s; there was a 275% increase by 2008. The number of total live births was 448,153 and MBs accounted for 10,767; the MB rate was 24.0% in 2006. Among 2,326 deliveries conceived by ART, multiple deliveries accounted for 786 (33.8%). The total number of live births with ART was 3,125 and 1,585 (50.7%) of them were MBs. During 2006, 14.7% of the entire MBs in Korea were associated with ART. The proportion of women of advanced maternal age was much higher in the ART group than in the total live birth group.

CONCLUSION

MBs in women of advanced maternal age have been increasing in Korea with the use of ART. The results of this study showed that ART was a significant factor associated with the increase in MBs in Korea.

The effect of an increase in the rate of multiple births on low-birth-weight and preterm deliveries during 1975-2008

BACKGROUND

Despite the rapid increase in the rate of multiple births due to the growth of reproductive medicine, there have been no epidemiologic studies of the secular trends in the impact of multiple births on the rates of low-birth-weight and preterm deliveries in Japan.

METHODS

Japanese vital statistics for multiple live births were obtained from the Ministry of Health, Labour and Welfare and reanalyzed. With singletons as the reference group, an analysis was performed of secular trends in relative risk and population attributable risk percent of low-birth-weight (<2500 grams), very-low-birth-weight (<1500 grams), and extremely-low-birth-weight (<1000 grams) deliveries, using 1975-2008 vital statistics, and of preterm deliveries (ie, before 37, 32, and 28 weeks), using 1979-2008 vital statistics.

RESULTS

The rate of multiple births doubled during the past 2 decades, and about 2% of all neonates are now multiples. The population attributable risk percent tended to increase during the same period for all variables, and was approximately 20% in 2008.

CONCLUSIONS

The public health impact of the rapid increase in multiple births remains high in Japan.