IVF versus IUI with ovarian stimulation for unexplained infertility: a collaborative individual participant data meta-analysis

BACKGROUND

IVF and IUI with ovarian stimulation (IUI-OS) are widely used in managing unexplained infertility. IUI-OS is generally considered first-line therapy, followed by IVF only if IUI-OS is unsuccessful after several attempts. However, there is a growing interest in using IVF for immediate treatment because it is believed to lead to higher live birth rates and shorter time to pregnancy.

OBJECTIVE AND RATIONALE

Randomized controlled trials (RCTs) comparing IVF versus IUI-OS had varied study designs and findings. Some RCTs used complex algorithms to combine IVF and IUI-OS, while others had unequal follow-up time between arms or compared treatments on a per-cycle basis, which introduced biases. Comparing cumulative live birth rates of IVF and IUI-OS within a consistent time frame is necessary for a fair head-to-head comparison. Previous meta-analyses of RCTs did not consider the time it takes to achieve pregnancy, which is not possible using aggregate data. Individual participant data meta-analysis (IPD-MA) allows standardization of follow-up time in different trials and time-to-event analysis methods. We performed this IPD-MA to investigate if IVF increases cumulative live birth rate considering the time leading to pregnancy and reduces multiple pregnancy rate compared to IUI-OS in couples with unexplained infertility.

SEARCH METHODS

We searched MEDLINE, EMBASE, CENTRAL, PsycINFO, CINAHL, and the Cochrane Gynaecology and Fertility Group Specialised Register to identify RCTs that completed data collection before June 2021. A search update was carried out in January 2023. RCTs that compared IVF/ICSI to IUI-OS in couples with unexplained infertility were eligible. We invited author groups of eligible studies to join the IPD-MA and share the deidentified IPD of their RCTs. IPD were checked and standardized before synthesis. The quality of evidence was assessed using the Risk of Bias 2 tool.

OUTCOMES

Of eight potentially eligible RCTs, two were considered awaiting classification. In the other six trials, four shared IPD of 934 women, of which 550 were allocated to IVF and 383 to IUI-OS. Because the interventions were unable to blind, two RCTs had a high risk of bias, one had some concerns, and one had a low risk of bias. Considering the time to pregnancy leading to live birth, the cumulative live birth rate was not significantly higher in IVF compared to that in IUI-OS (4 RCTs, 908 women, 50.3% versus 43.2%, hazard ratio 1.19, 95% CI 0.81-1.74, I2 = 42.4%). For the safety primary outcome, the rate of multiple pregnancy was not significantly lower in IVF than IUI-OS (3 RCTs, 890 women, 3.8% versus 5.2% of all couples randomized, odds ratio 0.78, 95% CI 0.41-1.50, I2 = 0.0%).

WIDER IMPLICATIONS

There is no robust evidence that in couples with unexplained infertility IVF achieves pregnancy leading to live birth faster than IUI-OS. IVF and IUI-OS are both viable options in terms of effectiveness and safety for managing unexplained infertility. The associated costs of interventions and the preference of couples need to be weighed in clinical decision-making.

Assisted reproductive technology in Japan: A summary report for 2021 by the Ethics Committee of the Japan Society of Obstetrics and Gynecology

Purpose

The Japan Society of Obstetrics and Gynecology (JSOG) registry gathers comprehensive data from registered assisted reproductive technology (ART) facilities in Japan. Herein, we report 2021 ART cycle characteristics and outcomes.

Methods

Descriptive statistics were used to summarize and analyze 2021 data.

Results

In 2021, 625 ART facilities participated in the registry; 27 facilities did not conduct ART cycles and 598 registered treatment cycles. In total, 498 140 cycles were registered, and there were 69 797 neonates (increases of 10.7% and 15.5%, respectively, from the previous year). The number of freeze-all in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) cycles decreased in 2021; the number of neonates born was 2268 for IVF-embryo transfer (ET) cycles and 2850 for ICSI cycles. Frozen-thawed ET (FET) cycles increased markedly from 2020 (11.2% increase). In 2021, 239 428 FET cycles were conducted, resulting in 87 174 pregnancies and 64 679 neonates. For fresh transfers, the total single ET, singleton pregnancy rate, and singleton live birth rates were 82.7%, 97.0%, and 97.3%; for FET, these rates were 84.9%, 96.9%, and 97.1%.

Conclusions

The 2021 Japanese ART registry analysis showed marked increases in both total treatment cycles and live births from the previous year.

The social determinants of mental health disorders among women with infertility: a systematic review

INTRODUCTION

Infertility is associated with mental health disorders in women, even if a successful pregnancy resolves infertility. However, the link between social determinants of health (SDoH) and mental health in women with infertility is not well understood. We aimed to investigate the determinants thoroughly so that mental health screening and services can be tailored to suit women with infertility who are vulnerable to mental health disorders.

METHODOLOGY

All observational studies that included women participants of reproductive age with infertility and assessed social determinants associated with mental health disorders were searched using a combination of keywords from MEDLINE, EMBASE, CINAHL, PsycINFO, Scopus, and Web of Science databases and published in English. Two reviewers conducted screening, data extraction, quality assessment and risk of bias. The protocol was registered on PROSPERO (number CRD42022343962).

RESULTS

The systematic review included 32 studies out of 3405 screened articles from January 1st 2010 to 16th October 2023. Compared to women without infertility, the prevalence of mental health disorders, including anxiety, depression, psychological distress, and stress, is high among women with infertility, with the severity being influenced by social determinants-those with higher education, employment, higher personal or family income, private health insurance, higher social support, stronger religious beliefs, and higher spiritual well-being reported better mental health outcomes.

CONCLUSION

The study highlights the need for early detection, tailored interventions, and integrated and comprehensive support systems to address the mental health needs of women with infertility and improve their well-being.

Socioeconomic inequality and contributors in accepting attitudes toward people living with HIV among adults in Ethiopia from 2005 to 2016: a population-based cross-sectional study

INTRODUCTION

The public's accepting attitude toward people living with HIV is crucial in reducing HIV-related stigma and discrimination, increasing people's access to HIV service. This study examines the inequalities in accepting attitudes toward people living with HIV in Ethiopia from 2005 to 2016.

METHODS

This cross-sectional study was based on the 2005, 2011 and 2016 Ethiopian Demographic Health Surveys. A total of 17 075, 28 478 and 25 542 adults were included in the 2005, 2011 and 2016 surveys, respectively. Socioeconomic inequality was investigated using the concentration curve and Erreygers' concentration index (ECI), which is scaled from -1 (pro-poor) to +1 (pro-rich). The ECI was decomposed to identify the contributors to socioeconomic inequality using generalised linear regression with the logit link function.

RESULTS

Accepting attitude toward people living with HIV was 17.9% (95% CI: 16.6%, 19.3%) in 2005, which increased to 33.5% (95% CI: 31.8%, 35.3%) in 2011 and 39.6% (95% CI: 37.6%, 41.9%) in 2016. ECI was 0.342 (p<0.001), 0.436 (p<0.001) and 0.388 (p<0.001), respectively, for 2005, 2011 and 2016. The trend line illustrates socioeconomic inequality seems diverging over time, with an increasing ECI of 0.005 every year (r=0.53; p=0.642; slope=0.005).

CONCLUSIONS

The current study found that there was pro-rich inequality from 2005 to 2016. People with higher socioeconomic status had a better attitude toward people living with HIV. Comprehensive knowledge about HIV/AIDS, education status, residence, and access to electronic and paper-based media, as well as HIV testing, contribute to a better accepting attitude toward people living with HIV. It is of utmost importance for the country to enhance accepting attitude toward people living with HIV to reduce stigma and discrimination. This requires whole-system response according to the primary healthcare approach toward ending the epidemic of HIV/AIDS in the country.

Strong social disparities in access to IVF/ICSI despite free cost of treatment: a French population-based nationwide cohort study

BACKGROUND

Access to IVF/ICSI is facilitated when the financial barrier is removed. In a national context where in vitro fertilisation (IVF)/intracytoplasmic sperm Injection (ICSI) treatment is cost-free, how many women do not access IVF/ICSI and what are the factors associated with non-access?

METHODS

Using French national health insurance databases, the cohort included 20,240 women aged 18-43 years living in France who underwent unsuccessful treatment (no pregnancy) with clomiphene citrate (CC) and/or gonadotropins with treatment started between January and August 2016. The outcome measure was non-access to IVF/ICSI during the 24-month following start of infertility care. Factors associated with non-access to IVF/ICSI were explored using mixed effects logistic regression.

RESULTS

In the cohort, 65.4% of women did not access IVF/ICSI. In multivariable analysis, non-access to IVF/ICSI was higher in younger women (18-25 years: (OR 2.17, 95% CI: 1.85-2.54) and in older women (40-43 years: (OR=3.60, 95% CI: 3.25-3.98)). Non-access was higher among women below the poverty line (OR=3.76, 95% CI: 3.34-4.23) and showed a significant upward trend with increasing deprivation of place of residence. Distance to the nearest fertility centre was not significantly associated with non-access to IVF/ICSI.

CONCLUSIONS

In a national context of cost-free ART treatment, a large proportion of women did not access treatment, with a strong social gradient that raises important issues. We need to understand the underlying social mechanisms to develop an efficient and equitable health policy regarding infertility care.

The search for the principle of justice for infertile couples: characterization of the brazilian population and bioethical discussion

BACKGROUND

Infertility is an increasingly prevalent disease in society and is considered by the World Health Organization to be a public health problem. An important ethical issue arises from the clarification of reproductive rights in a fair and equal way. The objective of this study was to deepen and update the knowledge and discussion about the difficulty of accessing infertility treatments in Brazil.

METHODS

A cross-sectional observational study was carried out through the application of an online questionnaire that collected the socioeconomic characteristics of couples and identify how barriers to infertility care affect the most vulnerable populations. We included couples who sought medical assistance to achieve pregnancy at two clinics in the states of São Paulo and Minas Gerais.

RESULTS

A total of 201 questionnaires were analyzed. Most couples self-declared as white and the average age of wives was 36 years and husbands 38 years. 65% (65%) of couples would proceed with the treatment in a different city to which they lived, 37% evaluated as having easy access to a medical specialist only after indication, and more than half of the participating have thought about giving up the treatment due to some difficulty in accessing it. 39% of participants sought more than one medical service to find better reception, 42% of couples sought more than one medical service to define where it would be better financially, and 67.2% referred to the high cost of treatments, that is, financial issues, as a great difficulty in accessing medical services and/or treatment. Although 72.6% of couples considered having a good quality of life, 54.2% admitted that infertility and the search for treatment generated anxiety/stress in the couple's life.

CONCLUSION

There is a need for public education on reproductive health and for policymakers to raise awareness of the importance of the difficulty that many couples face in seeking treatment to become pregnant, especially in countries with less financial resources. Indeed, it is commonly accepted that there is a universal human right to access healthcare of appropriate quality as a matter of justice. Discussion of access to reproductive technologies should be considered taking into account the longstanding ethical debate regarding fertility, fecundity, and infertility, as well as reproductive care.

Main topics in assisted reproductive market: A scoping review

BACKGROUND

Infertility affects around 12% of couples, and this proportion has been gradually increasing. In this context, the global assisted reproductive technologies (ART) market shows significant expansion, hovering around USD 26 billion in 2019 and is expected to reach USD 45 billion by 2025.

OBJECTIVES

We realized a scoping review of the ART market from academic publications, market reports, and specialized media news, to identify the main terms and characterize them into the main topics in the area.

DESIGN

We apply an LDA topic modeling process to identify the main terms, and clustered them into semantic synonymous topics. We extracted the patterns and information to these topics and purposed a factor/consequence correlation to them.

RESULTS

We found 2,232 academic papers and selected 632 to include in the automatic term detection. We also included 34 market reports and seven notices produced by specialized enterprises. Were identified 121 most relevant cited terms covering 7,806 citations. These terms were manually aggregated into 10 topics based on semantic similarity: neutral terms (37.2%), economic aspects (17.6%), in vitro fertilization (IVF) commodities & cross-border reproductive care (CBRC) (10.6%), geographic distribution (9.5%), social aspects (7%), regulation (6%), trends & concerns (3.9%), accessibility (3.4%), internet influence (2.9%), and fertility preservation for non-medical reasons (2%).

DISCUSSION

The analysis indicates a market with expressive complexity. Most terms were associated with more than one topic, indicating the synergism of this market's behavior. Only seven terms related to economic aspects, surrogacy and donation represent around 50% of the citations. Except for the topic formed by generic terms, the topic of the economic aspects was the most represented, reflecting macro perspectives such as a-la-carte standard of treatments, many clinics operating on a small/medium scale, and the recent formation of conglomerates. The IVF commodities & CBRC topic brings an overview of gametes pricing and transnational surrogacy, and its regulation. The topic of geographic distribution indicates that that the Asia-Pacific (APAC) market has the most significant growth potential in all fields. Despite the increase in supply and demand for infertility treatments and technological advances in recent decades, the success rate of IVF cycles remains at around 30%. Terms referring to research and development or technical improvement were not identified in a significant way in this review.

CONCLUSIONS

The formation of topics by semantic similarity proved to be an initial path for the elaboration of in-depth studies on the dynamics between several factors, for this, we present the panel classifying main terms into factors (demand, pent-up demand, or distributive) or ART market consequences. Through this approach, it was possible to observe that most of the works addresses economic aspects, regulation and geographic aspects and that topics related to research and improvement have not been addressed. In this way, we highlight the need to deepen the analysis of market elements that may be related to increased efficiency of IVF in the technical field.

The distribution and accessibility of assisted reproductive technology clinics in mainland China from 2006 to 2018: a population-based retrospective study

Infertility is a global health problem that carries a high social and economic burden. Assisted reproductive technology (ART) has been developed in mainland China for over 30 years. We aimed to evaluate the accessibility and equity of distribution of ART facilities in mainland China from 2006 to 2018 and quantify the population with reduced geographic access to ART services. A retrospective study was conducted to describe the trend and analyse the equity of distribution of ART clinics in 2006, 2012, and 2018. The accessibility of ART clinics in mainland China increased significantly in the 12 years to 2018 (p ˂ 0.05). Eastern China had the most extensive coverage, followed by the central region, while the western region had the least coverage (p ˂ 0.05). The Gini coefficient for the distribution of ART clinics in 2018 was 0.213, indicating that the equity of distribution of ART clinics was relatively balanced over the country. However, at the end of 2018, there were still 354.9 million people (25.4% of the population) living in 148 cities without access to any ART clinics, which has spurred more targeted policies and cost-effective measures to improve the accessibility and availability of ART services in such areas.

Social disparities in the use of ART treatment: a national register-based cross-sectional study among women in Denmark

STUDY QUESTION

How are educational level, labor market attachment and income associated with receiving a first ART treatment in either the public or private healthcare sector among women in Denmark?

SUMMARY ANSWER

Higher educational level and income as well as labor market attachment were associated with higher probability of initiating ART treatment at public and private fertility clinics among women in Denmark.

WHAT IS KNOWN ALREADY

Infertility is common in populations worldwide, and the approach to this issue differs between societies and healthcare systems. In the public Danish healthcare system, ART treatment is free of charge, and the direct cost for patients is therefore low. In the private healthcare sector in Denmark, ART treatment is self-financed. There is limited knowledge about the association between socioeconomic factors and seeking ART treatment, although previous studies have indicated that higher socioeconomic status is associated with seeking ART treatment.

STUDY DESIGN, SIZE, DURATION

Women undergoing ART treatment during 1994-2016 registered in the Danish IVF register were individually linked with data from sociodemographic population registers using the Danish Personal Identification number. The study population consisted of 69 018 women treated with ART and 670 713 age-matched comparison women from the background population with no previous history of ART treatment.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The women included in the analyses were aged 18-45 years. The associations between attained educational level, labor market attachment and income and receiving a first ART treatment attempt were investigated for women either initiating treatment in the public sector or in the private sector, respectively. Information on age and origin was included as potential confounders, and odds ratios (ORs) were estimated in logistic regression models. In addition, analyses were stratified by age group to investigate potential differences across the age span.

MAIN RESULTS AND THE ROLE OF CHANCE

Adjusted results showed increased odds of receiving a first ART treatment in either the public or private sector among women with a higher educational level. Furthermore, women in employment were more likely to receive a first ART treatment in the public or private sector compared to women outside the workforce. The odds of receiving a first ART treatment increased with increasing income level. Surprisingly, income level had a greater impact on the odds of receiving a first ART treatment in the public sector than in the private sector. Women in the highest income group had 10 times higher odds of receiving a first ART treatment in the public sector (OR: 10.53 95% CI: 10.13, 10.95) compared to women in the lowest income group. Sub-analyses in different age groups showed significant associations between ART treatment and income level and labor market attachment in all age groups.

LIMITATIONS, REASONS FOR CAUTION

Our study does not include non-ART treatments, as the national IVF register did not register these types of fertility treatments before 2007.

WIDER IMPLICATIONS OF THE FINDINGS

In Denmark, there is equal access to medically assisted reproduction treatment in the publicly funded healthcare system, and since there is no social inequality in the prevalence of infertility, social inequality in the use of ART treatment would not be expected as such. However, our results show that social inequality is found for a first ART treatment attempt across publicly and privately funded ART treatment across the socioeconomic indicators, educational level, labor market attachment and income.

STUDY FUNDING/COMPETING INTEREST(S)

The funding for the establishment of the Danish National ART-Couple II Cohort (DANAC II Cohort) was obtained from the Rosa Ebba Hansen Foundation. The authors have no conflict of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

What Features of Fertility Treatment do Patients Value? Price Elasticity and Willingness-to-Pay Values from a Discrete Choice Experiment

BACKGROUND

Infertility is a medical condition affecting an estimated 186 million people worldwide. Medically assisted fertility treatments allow many of these individuals to have a baby. Insights about preferences of patients who have experienced fertility treatment should be used to inform funding policies and treatment configurations that best reflect the patients' voice and the value of fertility treatment to patients.

OBJECTIVE

To explore the preferences for fertility treatment attributes of infertile women who had previously undergone or were undergoing fertility treatments-ex post perspective.

METHODS

We used data from a stated-preference discrete choice experiment (DCE) among 376 Australian women who had undergone or were undergoing fertility treatment. Respondents chose their preferred treatment choices in 12 hypothetical treatment choice scenarios described by seven attributes (success rates, side effects, counselling/peer support, treatment journey, continuity of care, availability of experimental treatment and out-of-pocket cost). We estimated random parameter logit (RPL) and latent class (LC) models that accounted for preference heterogeneity. The results were used to derive price elasticities of demand and marginal willingness-to-pay (WTP) values for the treatment attributes explored within the DCE survey.

RESULTS

Income level did not have a significant effect on marginal WTP for fertility treatment attributes. The demand for fertility treatment from an ex post perspective was found to be highly inelastic (treatment cost changes had almost no impact on demand). Success rates and out-of-pocket costs were significant and important predictors of individuals' treatment choices conditional on the attributes and levels included in the study. These were followed by counselling/peer support, side effects, treatment journey, continuity of care, and availability of experimental treatment, in that order. Respondents were willing to pay $383-$524 per one percentage point increase in the treatment success rate and over $2000 and over $3500 to avoid moderate and significant side effects, respectively (values are reported in AU$). Latent class models revealed that the majority of respondents (51%) were risk-averse success-rate seekers.

CONCLUSION

Infertile women who had previously undergone or were undergoing fertility treatment valued fertility treatment highly as reflected by highly price-inelastic demand. Success rate of treatment and out-of-pocket costs were the most important attributes and largely determined patients' WTP for fertility treatment relative to the attributes and levels used in the study. While further research should investigate the price sensitivity of women who have not experienced fertility treatment, these results might explain why women continue fertility treatment once they have commenced despite their financial capacity to pay. Future research should also determine patients' price elasticities for a fertility treatment program with multiple treatment cycles.

Residential proximity to a fertility clinic is independently associated with likelihood of women having ART and IUI treatment

STUDY QUESTION

Is geographic proximity to a fertility clinic associated with the likelihood of women of reproductive age undertaking different forms of medically assisted fertility treatment?

SUMMARY ANSWER

After adjusting for socioeconomic status (SES) and other confounders including a proxy for the need for infertility treatment, women who lived within 15 km of a fertility clinic were 21% more likely to undergo ART treatment and 68% more likely to undergo IUI treatment than those who lived further than 60 km away.

WHAT IS KNOWN ALREADY

In most countries, patients living outside of metropolitan areas are more likely to be more socio-economically disadvantaged and to have less equitable access to healthcare. However, how a woman's residential proximity to fertility clinics predicts utilization of high-cost/high-technology treatment (ART) and low-cost/low-technology treatment (IUI) is limited, and whether socio-economic disadvantage explains much of the hypothesized lower utilization is unknown. Australia's universal insurance scheme provides supportive reimbursement for almost all ART and IUI treatment regardless of age or number of cycles, providing a unique setting to investigate disparities in access to infertility treatment.

STUDY DESIGN, SIZE, DURATION

National population-based observation study of ART and IUI treatment utilization by women across socio-economic gradients and Australian residential locations between August 2015 and December 2017.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Universal insurance claims information on female patients who underwent ART or IUI were provided by Services Australia, comprising 67 670 female patients who accessed 162 795 ART treatments, and 10 211 female patients who accessed 19 615 IUI treatments over a 29-month period. Incidence rates by SES and proximity to fertility clinics were calculated to describe the number of women undergoing at least one ART or IUI treatment cycle per 1000 women of reproductive age (25-44). Treatment frequencies were calculated to describe the average number of ART or IUI treatment cycles per woman of reproductive age who had undergone at least one ART or IUI treatment during the study period. Poisson regression analyses were used to estimate the independent effect on accessibility to infertility treatment by geographic proximity (based on small area locations) to the closest fertility clinic after adjusting for SES, childbearing delay, remoteness area, and marital status.

MAIN RESULTS AND THE ROLE OF CHANCE

On average, 19.1 women per 1000 women of reproductive age underwent at least one fresh or frozen ART cycle, with an average 2.3 ART cycles each, while 3.0 women per 1000 women of reproductive age received at least one IUI cycle, with an average of 1.6 IUI cycles each. After adjusting for SES and other confounders including a proxy for the need for infertility treatment, women who lived within 15 km of a fertility clinic were 21% more likely to undergo ART treatment and 68% more likely to undergo IUI than those who lived over 60 km away. Regardless of geographic location, there was a steady and independent gradient in access to ART treatment based on increasing SES, with women residing in the most advantaged residential quartile having a 37% higher rate of receiving ART treatment compared to those in the most disadvantaged quartile. The negative effect of social disadvantage on ART use became more pronounced as distance from a fertility clinic grew, indicating that the barriers to access to ART care caused by distance were further compounded by the level of socioeconomic advantage of the women's residential location. In contrast, socioeconomic status did not modify the likelihood of using IUI over and above the distance from a fertility clinic. In relation to IUI treatment, differences in utilization by SES disappeared after adjusting for geographic proximity to a fertility clinic, childbearing delay, remoteness area, and marital status.

LIMITATIONS, REASONS FOR CAUTION

Information is aggregated by small geographic areas and it therefore may not reflect individual characteristics. Australia provides partial but comparably supportive reimbursement for both ART and IUI through its universal healthcare system and thus the results may not be fully generalizable to other settings.

WIDER IMPLICATIONS OF THE FINDINGS

Residential proximity to a fertility clinic is a persistent barrier to accessing ART and IUI treatment, regardless of SES, even in countries characterized by supportive public funding, such as Australia. SES is less of a barrier to accessing IUI than ART, presumably driven by the lower cost and fewer clinic visits required with IUI treatment. Safe and effective fertility treatment should be available to all women regardless of where they live.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the Australian National University Research scholarship and by the Higher Degree Research Fee Merit Scholarship. The authors have no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Out-of-pocket payment and patients' treatment choice for assisted reproductive technology by household income: a conjoint analysis using an online social research panel in Japan

BACKGROUND

Economic disparities affect access to assisted reproductive technology (ART) treatment in many countries. At the time of this survey, Japan provided partial reimbursement for ART treatment only for those in low- or middle-income classes due to limited governmental budgets. However, the optimal level of financial support by income class remains unclear.

METHODS

We conducted a conjoint analysis of ART in Japan in January 2020. We recruited 824 women with fertility problems aged 25 to 44 years via an online social research panel. They completed a questionnaire of 16 hypothetical scenarios measuring six relevant ART attributes (i.e., out-of-pocket payment, pregnancy rate, risk of adverse effects, number of visits to outpatient clinics, consultation hours and kindness of staff) and their relations to treatment choice.

RESULTS

Mixed-effect logistic regression models showed that all six attributes significantly influenced treatment preferences, with participants valuing out-of-pocket payment the most, followed by pregnancy rates and kindness of staff. Significant interactions occurred between high household income (≥ 8 million JPY) and high out-of-pocket payment (≥ 500,000 JPY). However, the average marginal probability of the highest-income patients (i.e., ≥ 10 million JPY, ineligible for the subsidy) receiving ART treatment at the average cost of 400,000 JPY was 47%, compared to 56 - 61% of other income participants, who opted to receive ART at an average cost of 100,000 JPY after a 300,000 JPY subsidy.

CONCLUSION

Our results suggest that out-of-pocket payment is the primary determinant in patients' decision to opt for ART treatment. High-income patients were more likely to choose treatment, even at a high cost, but their income-based ineligibility for government financial support might discourage some from receiving treatment.

Investigating the association between infertility and psychological distress using Australian Longitudinal Study on Women's Health (ALSWH)

Infertility affects millions of people globally. Although an estimated 1 in 6 couples in Australia are unable to conceive without medical intervention, little is known about the mental health impacts of infertility. This study investigated how infertility impacts the mental health of women. The study used nationally representative Australian Longitudinal Study on Women's Health (ALSWH) data. We analysed data from survey periods 2-8 conducted every three years between 2000 and 2018 for 6582 women born in 1973-78. We used a Generalised Equation Modelling (GEE) method to investigate the association of primary, secondary and resolved fertility status and psychological distress over time. Multiple measures were used to measure psychological distress: the (1) the mental health index subscale of the 36-item short form survey (SF-36), (2) the Center for Epidemiological Studies Depression Scale (CESD-10), (3) the Goldberg Anxiety and Depression Scale (GADanx) anxiety subscale; and a (4) composite psychological distress variable. About a third (30%) of women reported infertility at any of the survey rounds; a steady increase over 18 years from 1.7% at round 2 to 19.3% at round 8. Half of the women reporting primary or secondary infertility reported psychological distress, with the odds of having psychological distress was higher in women reporting primary (odds ratio (OR) 1.24, 95% confidence interval (CI) 1.06-1.45), secondary (OR 1.27, 95% CI 1.10-1.46) or resolved infertility (OR 1.15, 95% CI 1.05-1.26) compared to women reporting normal fertility status. Women with partners, underweight or higher BMI, smoking, and high-risk alcohol use had higher odds of psychological distress, whereas women in paid work had significantly lower odds of psychological distress (p < 0.001). Diabetes, high blood pressure, asthma, and other chronic physical illness were independently associated with higher odds of psychological distress. Infertility has a significant impact on mental health even after it is resolved. Frequent mental health assessment and a holistic approach to address the lifestyle factors should be undertaken during the treatment of infertility.

Population-wide contribution of medically assisted reproductive technologies to overall births in Australia: temporal trends and parental characteristics

STUDY QUESTION

In a country with supportive funding for medically assisted reproduction (MAR) technologies, what is the proportion of MAR births over-time?

SUMMARY ANSWER

In 2017, 6.7% of births were conceived by MAR (4.8% ART and 1.9% ovulation induction (OI)/IUI) with a 55% increase in ART births and a stable contribution from OI/IUI births over the past decade.

WHAT IS KNOWN ALREADY

There is considerable global variation in utilization rates of ART despite a similar infertility prevalence worldwide. While the overall contribution of ART to national births is known in many countries because of ART registries, very little is known about the contribution of OI/IUI treatment or the socio-demographic characteristics of the parents. Australia provides supportive public funding for all forms of MAR with no restrictions based on male or female age, and thus provides a unique setting to investigate the contribution of MAR to national births as well as the socio-demographic characteristics of parents across the different types of MAR births.

STUDY DESIGN, SIZE, DURATION

This is a novel population-based birth cohort study of 898 084 births using linked ART registry data and administrative data including birth registrations, medical services, pharmaceuticals, hospital admissions and deaths. Birth (a live or still birth of at least one baby of ≥400 g birthweight or ≥20 weeks’ gestation) was the unit of analysis in this study. Multiple births were considered as one birth in our analysis.

PARTICIPANTS/MATERIALS, SETTING, METHODS

This study included a total of 898 084 births (606 488 mothers) in New South Wales and the Australian Capital Territory, Australia 2009–2017. We calculated the prevalence of all categories of MAR-conceived births over the study period. Generalized estimating equations were used to examine the association between parental characteristics (parent’s age, parity, socio-economic status, maternal country of birth, remoteness of mother’s dwelling, pre-existing medical conditions, smoking, etc.) and ART and OI/IUI births relative to naturally conceived births.

MAIN RESULTS AND THE ROLE OF CHANCE

The proportion of MAR births increased from 5.1% of all births in 2009 to 6.7% in 2017, representing a 30% increase over the decade. The proportion of OI/IUI births remained stable at around 2% of all births, representing 32% of all MAR births. Over the study period, ART births conceived by frozen embryo-transfer increased nearly 3-fold. OI/IUI births conceived using clomiphene citrate decreased by 39%, while OI/IUI births conceived using letrozole increased 56-fold. Overall, there was a 55% increase over the study period in the number of ART-conceived births, rising to 56% of births to mothers aged 40 years and older. In 2017, almost one in six births (17.6%) to mothers aged 40 years and over were conceived using ART treatment. Conversely, the proportion of OI/IUI births was similar across different mother’s age groups and remained stable over the study period. ART children, but not OI/IUI children, were more likely to have parents who were socio-economically advantaged compared to naturally conceived children. For example, compared to naturally conceived births, ART births were 16% less likely to be born to mothers who live in the disadvantaged neighbourhoods after accounting for other covariates (adjusted relative risk (aRR): 0.84 [95% CI: 0.81–0.88]). ART- or OI/IUI-conceived children were 25% less likely to be born to immigrant mothers than births after natural conception (aRR: 0.75 [0.74–0.77]).

LIMITATIONS, REASONS FOR CAUTION

The social inequalities that we observed between the parents of children born using ART and naturally conceived children may not directly reflect disparities in accessing fertility care for individuals seeking treatment.

WIDER IMPLICATIONS OF THE FINDINGS

With the ubiquitous decline in fertility rates around the world and the increasing trend to delay childbearing, this population-based study enhances our understanding of the contribution of different types of MARs to population profiles among births in high-income countries. The parental socio-demographic characteristics of MAR-conceived children differ significantly from naturally conceived children and this highlights the importance of accounting for such differences in studies investigating the health and development of MAR-conceived children.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded through Australian National Health and Medical Research Council (NHMRC) grant: APP1127437. G.M.C. is an employee of The University of New South Wales (UNSW) and Director of the National Perinatal Epidemiology and Statistics Unit (NPESU), UNSW. The NPESU manages the Australian and New Zealand Assisted Reproduction Database with funding support from the Fertility Society of Australia and New Zealand. C.V. is an employee of The University of New South Wales (UNSW), Director of Clinical Research of IVFAustralia, Member of the Board of the Fertility Society of Australia and New Zealand, and Member of Research Committee of School of Women’s and Children’s Health, UNSW. C.V. reports grants from Australian National Health and Medical Research Council (NHMRC), and Merck KGaA. C.V. reports consulting fees, and payment or honoraria for lectures, presentations, speakers, bureaus, manuscript, writing or educational events or attending meeting or travel from Merck, Merck Sparpe & Dohme, Ferring, Gedon-Richter and Besins outside this submitted work. C.V. reported stock or stock options from Virtus Health Limited outside this submitted work. R.J.N. is an employee of The University of Adelaide, and Chair DSMC for natural therapies trial of The University of Hong Kong. R.J.N. reports grants from NHMRC. R.J.N. reports lecture fees and support for attending or travelling for lecture from Merck Serono which is outside this submitted work. L.R.J. is an employee of The UNSW and Foundation Director of the Centre for Big Data Research in Health at UNSW Sydney. L.R.J. reports grants from NHMRC. The other co-authors have no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Social capital and use of assisted reproductive technology in young couples: Ecological study using application information for government subsidies in Japan

BACKGROUND

Assisted reproductive technology (ART) is a globally established treatment; however, large disparities exist in ART use among young couples. We investigated regional-level factors associated with ART use in Japan.

METHODS

We calculated the use rate of ART using the number of women aged <35 years who applied for government subsidies in 2017; we divided that figure by the number of women aged 20-35 years in each prefecture. Prefectural-level average household income; social capital indicators including voting rate, volunteer rate, and move-in rate; and Gini coefficients as indicators of income inequality were linked to ART use, adjusting for prefectural size, the mean age of women at first marriage, number of ART facilities, and additional prefectural subsidies.

RESULTS

The rate of ART use (per 10,000 women) varied significantly from 22.0 to 58.8 across Japan's 47 prefectures. Multivariate analysis demonstrated that the use rate increased by 0.048 (95% confidence interval [CI], 0.007 to 0.088) for each 10,000-yen increase in average household income and 1.5 (95% CI, 0.65 to 2.3) for each 1% increase in volunteer rate. Conversely, the use rate decreased by 18.4 (95% CI, -28.6 to -8.1) for each 1% increase in the move-in rate. There was no significant association between ART use and income inequality.

CONCLUSION

Although we cannot infer causal relationships, the findings suggest that improving financial access and enhancing social capital may increase access to ART. Further research, particularly multilevel analysis using individual data, is required to confirm these findings.

A silent burden-prolapse, incontinence, and infertility in Australian Aboriginal and Torres Strait Islander women: A systematic search and narrative review

BACKGROUND

Pelvic organ prolapse (POP), urinary incontinence, and infertility are all prevalent conditions associated with considerable reduction in quality of life. As a group, Aboriginal and Torres Strait Islander women may be at higher risk of these conditions, but studies are scarce.

OBJECTIVE

To review the literature pertaining to the epidemiology, diagnosis, and management of these conditions in Indigenous Australian women.

SEARCH STRATEGY

Medline, Embase, and Scopus were searched for articles published between 1980 and 2021 pertaining to these conditions in Indigenous Australian women.

SELECTION CRITERIA

Studies that did not directly address the epidemiology, diagnosis, and management of these conditions were excluded.

MAIN RESULTS

It was possible to identify only 11 papers dealing with these conditions in Indigenous Australian women. Only one dealt with POP and was a retrospective audit of a health outreach program in the Northern Territory concluding that there was significant underreporting of the condition. Five papers dealt with urinary incontinence and, again, described significant underreporting and poor referral pathways. Five papers reported small studies about infertility, one reporting poor engagement from clinical directors.

CONCLUSION

It was concluded that despite the importance of these conditions, there is almost no body of research and this is an urgent national problem.

Outcomes of Very Preterm Infants Conceived with Assisted Reproductive Technologies

OBJECTIVE

To compare mortality and early respiratory outcomes of very preterm infants conceived via assisted reproductive technology (ART) vs spontaneously.

STUDY DESIGN

We identified inborn infants (July 2014-July 2019) with gestational age <32 weeks (n = 439); 54 cases were ART conceived. Spontaneously conceived controls (n = 103) were matched by multiple gestation status and gestational age. Primary outcome was 1-year mortality. Secondary outcomes were receipt of respiratory support and supplemental oxygen at 7 and 28 days and 36 weeks of postmenstrual age. We evaluated the association between conception method and outcomes by logistic regression, with adjustment for sociodemographic status.

RESULTS

Women who conceived via ART had increased rates of prepregnancy and gestational diabetes, and no differences in rates of hypertensive disorders. Infant 1-year mortality was not different by mode of conception (ART 11.8% vs spontaneous 7.1%, P = .49). Infants conceived by ART were less likely to receive respiratory support or supplemental oxygen at all time points, but this relationship only reached significance for receipt of oxygen at 28 days (ART 20.8% vs spontaneous 39.0%, P = .03); this remained true after adjustment for race/ethnicity and socioeconomic index.

CONCLUSIONS

When controlling for gestational age and multiple gestation status, very preterm infants conceived following ART had similar outcomes as those conceived spontaneously.

Household income and medical help-seeking for fertility problems among a representative population in Japan

BACKGROUND

Fertility treatments help many infertile couples to have children. However, disparities exist in access to fertility tests and treatments. We investigated the association between household income and medical help-seeking for fertility in Japan.

METHODS

We conducted a cross-sectional study using nationally representative data from the National Fertility Survey 2015. Respondents were 6598 married women younger than 50 years old. The primary outcome was medical help-seeking for fertility among those who experienced fertility problems. Multiple logistic regression models were used to assess the association between household income and medical help-seeking, adjusting for age, length of marriage, educational level, employment status, number of children, childbearing desires, living with parents, and region of residence.

RESULTS

Among 2253 (34%) women who experienced fertility problems, 1154 (51%) sought medical help. The proportion of help-seekers increased linearly from 43% in the low-income group (< 4 million Japanese yen [JPY]) to 59% in the high-income group (≥ 8 million JPY) (P for trend < 0.001). Respondents with upper-middle (6-8 million JPY) or high household income were more likely to seek medical help, compared to those with low household income: adjusted odds ratio [aOR] 1.37 (95% confidence interval [CI]: 1.00-1.86) and aOR 1.78 (95% CI: 1.29-2.47), respectively.

CONCLUSIONS

We found that higher household income was associated with a higher probability of seeking medical help among Japanese women who experienced fertility problem. Along with policy discussion about additional financial support, further studies from societal, cultural, or psychological views are required.

Changes in Multiple Birth Rates and Parental Demographic Factors in South Korea During the Last Four Decades: 1981-2019

Over the previous decades, twinning rates worldwide have increased remarkably. This study aimed to describe changes in multiple birth rates and related demographic characteristics, such as maternal age and the level of education of parents in South Korea from 1981 to 2019. This study analyzed birth data obtained from the Korean Statistical Information Service. From 1981 to 2019, the total twinning rate increased from 5 to 22.5 pairs per 1000 births. This rapid increase was due to an increase in dizygotic twin births, which mainly occurred in mothers aged between 30 and 39 years. The average maternal age of multiples increased from 26.06 years in 1981 to 33.98 years in 2019, suggesting that a delay in childbearing contributed to the increase in the twinning rate. The percentage of mothers of multiples who completed a college or higher degree (CHD) increased by 1000% from 1981 to 2019, indicating that a sharp increase in the level of education of females in part explains the delay in childbearing. The percentages of individuals who completed a CHD were higher among parents of multiples than among those of singletons in recent years when public funding arrangements for fertility treatments were available. This result suggested that completion of higher education may be associated with increased use of assisted reproductive technology (ART) independent of the financial status of couples. Taken together, the analysis suggested that increased maternal age, ART and the increased number of females who completed CHD may be responsible for the remarkable increase in the rates of multiple births in South Korea in the last four decades.

Male age interferes with embryo growth in IVF treatment

STUDY QUESTION

Does male age affect embryo growth or quality in couples undergoing IVF treatment?

SUMMARY ANSWER

Advanced paternal age (APA) is negatively associated with the chance of an optimal eight-cell embryo on the third day of development.

WHAT IS KNOWN ALREADY

Literature shows that APA is associated with decreased sperm quality and fecundity. However, the effect of male age on embryo growth in an IVF setting remains inconclusive. Literature concerning male influences on IVF success is scarce and approaches used to analyse embryo outcomes differ by study.

STUDY DESIGN, SIZE, DURATION

This study was part of the longitudinal Epigenetic Legacy of Paternal Obesity (ELPO) study for which fathers and mothers were followed from pre-pregnancy until the birth of their child. Couples were recruited from April 2015 to September 2017. A total of 1057 embryos from 87 couples were studied.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Dutch-speaking couples planning to undergo an IVF treatment were recruited at the Leuven University Fertility Center in Flanders, Belgium. Anthropometrics were documented and compared to the general Flemish population. Semen characteristics, pregnancy rates and the following embryo characteristics were recorded: number of blastomeres, symmetry and percentage fragmentation. Statistical modelling was applied taking into account correlation of within-cycle outcomes and use of multiple cycles per couple.

MAIN RESULTS AND THE ROLE OF CHANCE

We observed a significant inverse association between APA and a key determinant for scoring of embryo quality: older men were less likely to produce an embryo of eight blastomeres at Day 3, compared to younger fathers; odds ratio for the effect of 1 year equals 0.960 (95% CI: 0.930-0.991; P = 0.011). Our finding remained significant after adjusting for female age and male and female BMI. Degree of fragmentation and symmetry were not significantly related to male age.

LIMITATIONS, REASONS FOR CAUTION

Because of the study's small sample size and its monocentric nature, a larger study is warranted to confirm our results. In addition, distribution of BMI and level of education were not representative of the general Flemish population. Although we corrected for BMI status, we do not exclude that obesity may be one of the determinants of infertility in our study population. Furthermore, it is known from other European countries that a higher education eases access to fertility treatment. Hence, caution should be taken when interpreting our findings from a fertility setting to the general population.

WIDER IMPLICATIONS OF THE FINDINGS

We suggest a heightened need for future research into male age and its potential effects on embryo growth, embryo quality and ART outcomes. Clinical decision-making and preventative public health programmes would benefit from a better understanding of the role of men, carried forward by the Paternal Origins of Health and Disease (POHaD) paradigm. We hope the current finding will encourage others to examine the role of the sperm epigenome in embryo development according to paternal age.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by a research grant from KU Leuven University (OT/14/109). The authors declare no competing financial, professional or personal interests.

TRIAL REGISTRATION NUMBER

KU Leuven S57378 (ML11309), B322201523225.

Clinical Outcomes in High-Risk Pregnancies Due to Advanced Maternal Age

Although the influence of advanced maternal age (AMA) and delayed childbearing on adverse maternal and perinatal outcomes has been studied extensively, no universal consensus on the definition of AMA exists. This terminology currently refers to the later years of a woman's reproductive life span and generally applies to women age ≥35 years. AMA increases the risk of pregnancy complications, including ectopic pregnancy, spontaneous abortion, fetal chromosomal abnormalities, congenital anomalies, placenta previa and abruption, gestational diabetes, preeclampsia, and cesarean delivery. Such complications could be the cause of preterm birth and increase the risk of perinatal mortality. For women who have a chronic illness, pregnancy may lead to additional risk that demands increased monitoring or surveillance. The management of pregnant women of AMA requires understanding the relationship between age and preexisting comorbidities. The outcomes from pregnancy in AMA may have a negative impact on women's health as they age because of both the changes from the pregnancy itself and the increased risk of pregnancy-related complications. Postpartum depression affects women of AMA at higher rates. Links between preeclampsia and the risk of future development of cardiovascular disease require follow-up surveillance. The association between hypertensive pregnancy disorders and cognitive and brain functions needs further investigation of sex-specific risk factors across the life span. Educating providers and women of AMA is crucial to facilitate clinical decision making and such education should consider cultural influences, risk perception, and women's health literacy, as well as providers' biases and system issues.

Reflections on autonomy in travel for cross border reproductive care

Travel for reproductive health care has become a widespread global phenomenon. Within the field, the decision to travel to seek third parties to assist with reproduction is widely assumed to be autonomous. However there has been scant research exploring the application of the principle of autonomy to the experience of the cross-border traveller. Seeking to contribute to the growing, but still small, body of sociological bioethics research, this paper maps the application of the ethical principle of autonomy to the lived experience of infertile individuals who cross borders for reproductive care. It examines their choices as patient, consumer and traveller. It suggests that their experience evidences a contradictory autonomy, which offers them both choice and no choice in their final decision to travel. The paper argues that this lack of meaningful autonomy is enabled by a medicalised framework of infertility which prioritises technology as the cure to infertility. This both shapes expectations of infertile individuals and limits their options of family creation. Ultimately, the paper suggests that sociological bioethics research shows that the liberatory credentials of technology should be questioned, and identifies that this field demands greater scholarly attention.

Provision of assisted reproductive technologies (ART) to Aboriginal and Torres Strait Islander peoples: Limited engagement in an online survey of Medical Directors of ART services

Current knowledge about infertility and access to infertility treatment among Aboriginal and Torres Strait Islander peoples is extremely limited. We conducted an online survey of Medical Directors of registered ART providers in Australia (n = 59) to obtain preliminary information on this topic. Six (10%) Directors responded; only two reported routinely collecting the Aboriginal and Torres Strait Islander status of clients. While the low response rate prevents generalising the findings, the poor engagement may indicate gaps in awareness of fertility issues for this group. This warrants further investigation, to understand whether Aboriginal and Torres Strait Islander people are appropriately accessing infertility care.

Status of racial disparities between black and white women undergoing assisted reproductive technology in the US

BACKGROUND

Numerous studies have demonstrated substantial differences in assisted reproductive technology outcomes between black non-Hispanic and white non-Hispanic women. We sought to determine if disparities in assisted reproductive technology outcomes between cycles from black non-Hispanic and white non-Hispanic women have changed and to identify factors that may have influenced change and determine racial differences in cumulative live birth rates.

METHODS

This is a retrospective cohort study of the SARTCORS database outcomes for 2014-2016 compared with those previously reported in 2004-2006 and 1999/2000. Patient demographics, etiology of infertility, and cycle outcomes were compared between black non-hispanic and white non-hispanic patients. Categorical values were compared using Chi-squared testing. Continuous variables were compared using t-test. Multiple logistic regression was used to assess confounders.

RESULTS

We analyzed 122,721 autologous, fresh, non-donor embryo cycles from 2014 to 2016 of which 13,717 cycles from black and 109,004 cycles from white women. The proportion of cycles from black women increased from 6.5 to 8.4%. Cycles from black women were almost 3 times more likely to have tubal and/or uterine factor and body mass index ≥30 kg/m². Multivariate logistic regression demonstrated that black women had a lower live birth rate (OR 0.71;P < 0.001) and a lower cumulative live birth rate for their initial cycle (OR 0.64; P < 0.001) independent of age, parity, body mass index, etiology of infertility, ovarian reserve, cycle cancellation, past spontaneous abortions, use of intra-cytoplasmic sperm injection or number of embryos transferred. A lower proportion of cycles in black women were represented among non-mandated states (P < 0.001) and cycles in black women were associated with higher clinical live birth rates in mandated states (P = 0.006).

CONCLUSIONS

Disparities in assisted reproductive technology outcomes in the US have persisted for black women over the last 15 years. Limited access to state mandated insurance may be contributory. Race has continued to be an independent prognostic factor for live birth and cumulative live birth rate from assisted reproductive technology in the US.

Socioeconomic Status and Successful Delivery after an Infertility Diagnosis: a Nationwide Health Insurance Cohort Study in Korea Conducted from 2005 to 2013

BACKGROUND

The global disease burden of infertility is rising and accessibility to infertility treatments and assisted reproduction is a challenging issue. Therefore, we investigated characteristics of successful delivery after an infertility diagnosis among infertile women.

METHODS

We designed a retrospective cohort study with the main outcome measure of a delivery medical record after the initial diagnosis of infertility. A total of 10,108 women patients who were diagnosed with infertility between 2005 to 2013 in the National Health Insurance Cooperation Cohort Database of Korea were enrolled. The adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for subsequent delivery were estimated by applying a Cox proportional-hazard regression model.

RESULTS

Approximately 55% of infertile women who reported infertility had a delivery eventually. Infertile women who are aged between 30 to 39 (HR, 0.80; 95% CI, 0.75-0.84), in low income level (HR, 0.77; 95% CI, 0.71-0.84), or diagnosed with diabetes (HR, 0.76; 95% CI, 0.60-0.96) were less likely to report a delivery.

CONCLUSION

These findings highlight demographic, socioeconomic, and medical characteristics of reporting a consequent delivery. Although many previous articles reported an association between socioeconomic status and receiving medical evaluation, there were few studies regarding successful delivery after an infertility diagnosis across socioeconomic status. Thus, the maintaining of support for low socioeconomic status infertile women and their family should be considered after the infertility diagnosis in aspects of financial and social approaches.

Infertility Treatment in France, 2008-2017: A Challenge of Growing Treatment Needs at Older Ages

Objectives. To measure trends in infertility treatment use between 2008 and 2017 in France using data from the national health insurance system.Methods. Between 2008 and 2017, we observed a representative national sample of nearly 1% of all women aged 20 to 49 years who were affiliated with the main health insurance scheme in France (more than 100 000 women observed each year). We exhaustively recorded all health care reimbursed to these women.Results. Among women aged 20 to 49 years, 1.25% were treated for infertility each year. Logistic regression analysis showed a significant interaction between age and year of treatment use (P < .001). Over the decade, infertility treatment use increased by 23.9% among women aged 34 years or older, whereas among women younger than 34 years there was a nonsignificant variation.Conclusions. Women aged 34 years or older were increasingly treated for infertility between 2008 and 2017.Public Health Implications. Treatment efficiency decreases strongly with a woman's age, presenting a challenge for medical infertility care.

Global, regional, and national prevalence and disability-adjusted life-years for infertility in 195 countries and territories, 1990-2017: results from a global burden of disease study, 2017

To provide comprehensive estimates of the global, regional, and national burden of infertility from 1990 to 2017, using findings from a 2017 study on the global burden of disease (GBD), we assessed the burden of infertility in 195 countries and territories from 1990 to 2017. DisMod-MR 2.1 is a Bayesian meta-regression method that estimates non-fatal outcomes using sparse and heterogeneous epidemiological data. Globally, the age-standardized prevalence rate of infertility increased by 0.370% per year for females and 0.291% per year for males from 1990 to 2017. Additionally, age-standardized disability-adjusted life-years (DALYs) of infertility increased by 0.396% per year for females and 0.293% per year for males during the observational period. An increasing trend to these burden estimates was observed throughout the all socio-demographic index (SDI) countries. Interestingly, we found that high SDI countries had the lowest level of prevalence and DALYs in both genders. However, the largest increasing trend was observed in high-SDI countries for females. By contrast, low-SDI countries had the largest increasing trend in males. Negative associations were observed between these burden estimates and the SDI level. The global disease burden of infertility has been increasing throughout the period from 1990 to 2017.

Assisted reproductive technology use in the United States: a population assessment

OBJECTIVE

To study social and demographic differentiation of assisted reproduction technology (ART) use at the population level in the United States.

DESIGN

Population-based study.

SETTING

Not applicable.

PATIENT(S)

Women 15-49 years old in the American Community Survey and National Vital Statistics Birth Certificate data from 2010-2017.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Birth rate after ART by major sociodemographic categories and likelihood of having an ART birth.

RESULT(S)

Net of education, age, period, and marital status, the incidence rates of ART births are lower for black women (0.57 times; 95% CI, 0.52-0.62) and Hispanic women (0.67 times; 95% CI, 0.57-0.62) relative to white women's rates; for Asian women, the incidence rates are 1.21 times that of white women's rates. Further, the incidence rates of ART births are higher for women with more than a 4-year degree (2.08 times; 95% CI, 1.90-2.27) relative to women with a 4-year degree, and are lower for women with less education. Women who are married have an incidence rate of ART that is 5.72 times (95% CI, 5.37-6.09) that of unmarried women. The incidence rates for 2013-2016 are statistically significantly higher than for 2010 by a factor of 1.16 (95% CI, 1.02-1.31), 1.16 (95% CI, 1.03-1.31), 1.27 (95% CI, 1.12-1.43), and 1.51 (95% CI, 1.43-1.82), respectively. The educational differences in ART exist across all age groups from 20 to 49, but are the largest among the 35-39 and 40-44 age groups.

CONCLUSION(S)

Large differences in the risk of an ART birth and the proportion of births and the total fertility rate due to ART exist across period, age, race, education, and marital status groups in the United States. Current measures of ART births may disguise an unmet need for ART.

Infertility management in women and men attending primary care—patient characteristics, management actions and referrals

STUDY QUESTION

How did general practitioners (GPs) (family physicians) manage infertility in females and males in primary care between 2000 and 2016?

SUMMARY ANSWER

The number of GP infertility consultations for females increased 1.6 folds during the study period, with 42.9% of consultations resulting in a referral to a fertility clinic or specialist, compared to a 3-fold increase in the number of consultations for men, with 21.5% of consultations resulting in a referral.

WHAT IS KNOWN ALREADY

Infertility affects one in six couples and is expected to increase with the trend to later childbearing and reports of declining sperm counts. Despite GPs often being the first contact for infertile people, very limited information is available on the management of infertility in primary care.

STUDY DESIGN, SIZE, DURATION

Data from the Bettering the Evaluation and Care of Health programme were used, which is a national study of Australian primary care (general practice) clinical activity based on 1000 ever-changing, randomly selected GPs involved in 100 000 GP–patient consultations per year between 2000 and 2016.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Females and males aged 18–49 years attending GPs for the management of infertility were included in the study. Details recorded by GPs included patient characteristics, problems managed and management actions (including counselling/education, imaging, pathology, medications and referrals to specialists and fertility clinics). Analyses included trends in the rates of infertility consultations by sex of patient, descriptive and univariate analyses of patient characteristics and management actions and multivariate logistic regression to determine which patient and GP characteristics were independently associated with increased rates of infertility management and referrals.

MAIN RESULTS AND THE ROLE OF CHANCE

The rate of infertility consultations per capita increased 1.6 folds for women (17.7–28.3 per 1000 women aged 18–49 years) and 3 folds for men over the time period (3.4–10.2 per 1000 men aged 18–49 years). Referral to a fertility clinic or relevant specialist occurred in 42.9% of female infertility consultations and 21.5% of male infertility consultations. After controlling for age and other patient characteristics, being aged in their 30s, not having income assistance, attending primary care in later years of the study and coming from a non-English-speaking background, were associated with an increased likelihood of infertility being managed in primary care. In female patients, holding a Commonwealth concession card (indicating low income), living in a remote area and having a female GP all indicated a lower adjusted odds of referral to a fertility clinic or specialist.

LIMITATIONS, REASONS FOR CAUTION

Data are lacking for the period of infertility and infertility diagnosis, which would provide a more complete picture of the epidemiology of treatment-seeking behaviour for infertility. Australia’s universal insurance scheme provides residents with access to a GP, and therefore these findings may not be generalizable to other settings.

WIDER IMPLICATIONS OF THE FINDINGS

This study informs public policy on how infertility is managed in primary care in different patient groups. Whether the management actions taken and rates of secondary referral to a fertility clinic or specialist are appropriate warrants further investigation. The development of clinical practice guidelines for the management of infertility would provide a standardized approach to advice, investigations, treatment and referral pathways in primary care.

STUDY FUNDING/COMPETING INTEREST(S)

This paper is part of a study being funded by an Australian National Health and Medical Research Council project grant APP1104543. G.C. reports that she is an employee of The University of New South Wales (UNSW) and Director of the National Perinatal Epidemiology and Statistics Unit (NPESU), UNSW. The NPESU manages the Australian and New Zealand Assisted Reproductive Technology Database on behalf of the Fertility Society of Australia. W.L. reports being a part-time paid employee and minor shareholder of Virtus Health, a fertility company. R.N. reports being a small unitholder in a fertility company, receiving grants for research from Merck and Ferring and speaker travel grants from Merck.

TRIAL REGISTRATION NUMBER

NA

Comparison of neonatal outcomes of very low birth weight infants by mode of conception: in vitro fertilization versus natural pregnancy

OBJECTIVE

To compare the neonatal outcomes of very low birth weight (VLBW) infants born after IVF with those of VLBW infants born after natural pregnancy (NP).

DESIGN

Prospective cohort study.

SETTING

Not applicable.

PATIENT(S)

A total of 6,871 VLBW infants born from January 2014 to December 2016.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Neonatal mortality and morbidities.

RESULT(S)

Of the 6,871 VLBW infants enrolled, 4,438 infants were born as singletons (IVF = 271; NP = 4,167), and 2,433 infants were born as multiplets (IVF = 1,301; NP = 1,132). After adjustment for maternal and neonatal baseline characteristics, infants born as singletons earlier than 28 weeks after IVF more frequently had high-stage retinopathy of prematurity than those born after NP, whereas infants born as multiplets between 28 and 31 weeks after IVF had fewer major congenital anomalies, high-grade intraventricular hemorrhage, and periventricular leukomalacia than those born after NP. Otherwise, no differences in mortality and neonatal outcomes were found.

CONCLUSION(S)

Very low birth weight infants born as singletons after IVF had comparable neonatal outcomes to those born after NP, except for an increased risk of high-stage retinopathy of prematurity. Very low birth weight infants born as multiplets after IVF had fewer neurologic morbidities than those born after NP.

Neurocognitive function of 10-year-old multiples born less than 28 weeks of gestational age

INTRODUCTION

Few studies have examined the relationship between birth plurality and neurocognitive function among children born extremely preterm.

STUDY DESIGN

We compared rates of Z-scores ≤-2 on 18 tests of neurocognitive function and academic achievement at age 10 years in 245 children arising from twin pregnancies, 55 from triplet pregnancies, and 6 from a septuplet pregnancy to that of 568 singletons, all of whom were born before the 28th week of gestation.

RESULTS

In total, 874 children were evaluated at the age of 10 years. After adjusting for confounders, children of multifetal pregnancies performed significantly better on one of six subtests of executive function than their singleton peers. Performance was similar on all other assessments of intelligence, language, academic achievement, processing speed, visual perception, and fine motor skills.

CONCLUSION

We found no evidence that children born of multifetal pregnancies had worse scores than their singleton peers on assessments of neurocognitive and academic function.

Access to Infertility Consultations “What Women Tell Us About it”?

Background:

Infertility has been considered as a serious public health problem. Nevertheless, it is still very difficult to assess the epidemiology of this individual and public health problem. On the other hand, promotion of access to infertility treatments must be treated as a priority to national and regional policies.

Objective:

The aim was to evaluate the perception of women concerning the barriers and access to infertility consultations.

Methods:

Socio cultural and economic access to infertility consultations is detached and three municipalities of the northwest of Portugal were chosen as an example of a peripheral country. A quantitative/qualitative study was done with 60 women.

Results:

Three dimensions were evaluated: geographic and structural and functional access, economic access and sociocultural access. The main barriers were mainly identified in the last two dimensions. The economic access was less well evaluated by women bearing the cost of treatment (medication, and concentration of costs in a short period) which is difficult to bear.

Conclusion:

This can justify a greater involvement of the Portuguese Government, by developing policies for the reimbursement of part of the costs. Also, some changes in structural and functional access must be done with special regard to the separation of the infertility consultations from the reproductive medicine section. The setting of the teams, with a follow-up by the same team of health professionals is also needed.

Risk of endometrial cancer in women treated with ovary-stimulating drugs for subfertility

BACKGROUND

Medical treatment for subfertility principally involves the use of ovary-stimulating agents, including selective oestrogen receptor modulators (SERMs), such as clomiphene citrate, gonadotropins, gonadotropin-releasing hormone (GnRH) agonists and antagonists, as well as human chorionic gonadotropin. Ovary-stimulating drugs may act directly or indirectly upon the endometrium (lining of the womb). Nulliparity and some causes of subfertility are recognized as risk factors for endometrial cancer.

OBJECTIVES

To evaluate the association between the use of ovary-stimulating drugs for the treatment of subfertility and the risk of endometrial cancer.

SEARCH METHODS

A search was performed in CENTRAL, MEDLINE (Ovid) and Embase (Ovid) databases up to July 2016, using a predefined search algorithm. A search in OpenGrey, ProQuest, ClinicalTrials.gov, ZETOC and reports of major conferences was also performed. We did not impose language and publication status restrictions.

SELECTION CRITERIA

Cohort and case-control studies reporting on the association between endometrial cancer and exposure to ovary-stimulating drugs for subfertility in adult women were deemed eligible.

DATA COLLECTION AND ANALYSIS

Study characteristics and findings were extracted by review authors independently working in pairs. Inconsistency between studies was quantified by estimating I2. Random-effects (RE) models were used to calculate pooled effect estimates. Separate analyses were performed, comparing treated subfertile women versus general population and/or unexposed subfertile women, to address the superimposition of subfertility as an independent risk factor for endometrial cancer.

MAIN RESULTS

Nineteen studies were eligible for inclusion (1,937,880 participants). Overall, the quality of evidence was very low, due to serious risk of bias and indirectness (non-randomised studies (NRS), which was reflected on the GRADE assessment.Six eligible studies, including subfertile women, without a general population control group, found that exposure to any ovary-stimulating drug was not associated with an increased risk of endometrial cancer (RR 0.96, 95% CI 0.67 to 1.37; 156,774 participants; very low quality evidence). Fifteen eligible studies, using a general population as the control group, found an increased risk after exposure to any ovary-stimulating drug (RR 1.75, 95% CI 1.18 to 2.61; 1,762,829 participants; very low quality evidence).Five eligible studies, confined to subfertile women (92,849 participants), reported on exposure to clomiphene citrate; the pooled studies indicated a positive association ( RR 1.32; 95% CI 1.01 to 1.71; 88,618 participants; very low quality evidence), although only at high dosage (RR 1.69, 95% CI 1.07 to 2.68; two studies; 12,073 participants) and at a high number of cycles (RR 1.69, 95% CI 1.16 to 2.47; three studies; 13,757 participants). Four studies found an increased risk of endometrial cancer in subfertile women who required clomiphene citrate compared to a general population control group (RR 1.87, 95% CI 1.00 to 3.48; four studies, 19,614 participants; very low quality evidence). These data do not tell us whether the association is due to the underlying conditions requiring clomiphene or the treatment itself.Using unexposed subfertile women as controls, exposure to gonadotropins was associated with an increased risk of endometrial cancer (RR 1.55, 95% CI 1.03 to 2.34; four studies; 17,769 participants; very low quality evidence). The respective analysis of two studies (1595 participants) versus the general population found no difference in risk (RR 2.12, 95% CI 0.79 to 5.64: very low quality evidence).Exposure to a combination of clomiphene citrate and gonadotropins, compared to unexposed subfertile women, produced no difference in risk of endometrial cancer (RR 1.18, 95% CI 0.57 to 2.44; two studies; 6345 participants; very low quality evidence). However, when compared to the general population, an increased risk was found , suggesting that the key factor might be subfertility, rather than treatment (RR 2.99, 95% CI 1.53 to 5.86; three studies; 7789 participants; very low quality evidence).

AUTHORS' CONCLUSIONS

The synthesis of the currently available evidence does not allow us to draw robust conclusions, due to the very low quality of evidence. It seems that exposure to clomiphene citrate as an ovary-stimulating drug in subfertile women is associated with increased risk of endometrial cancer, especially at doses greater than 2000 mg and high (more than 7) number of cycles. This may largely be due to underlying risk factors in women who need treatment with clomiphene citrate, such as polycystic ovary syndrome, rather than exposure to the drug itself. The evidence regarding exposure to gonadotropins was inconclusive.

Regional Variation in Rates of IVF Treatment across Australia: A Population-based Study

Background: There is variation in uptake of in vitro fertilisation (IVF) between countries, and Australia has high incidence rates of IVF due to universal public funding. However, it remains unclear whether there is regional variation and, if present, what might cause this. Objectives: We sought to determine whether regional variations in treatment rates existed and what might influence these. Methods: The number of cycles of fresh IVF and intrauterine insemination (IUI) for women were obtained for the period 2011 until 2014 in two age groups (25 to 34 years and 35 to 44 years) to calculate incidence rates. Proxy indicators that might influence treatment affordability were: unemployment rates; average weekly total earnings; coverage of private health insurance; and, percentage of women in the highest socioeconomic quintile. Measures of accessibility considered were percentage of the population remote from urban areas and average state population density. Linear regressions were performed using log-transformed ratio of IVF and IUI incidence rates. Results: Variations were found in IVF uptake between states with greater differences in older women. There was no significant association between IVF procedures and population density or geographic isolation. Economic factors were not associated with IVF uptake. Conclusion: These findings suggest that factors such as physician preference, clinical practice guidelines, and cryopreservation protocols of ART units might explain the national variation in uptake of IVF.

The current situation of infertility services provision in Europe

Infertility is a global medical problem of the reproductive system which may affect the quality of a woman's life. Whether infertility provision varies between different European countries has not been investigated in the context of a comparative study. There are, however, differences in legislation between different countries, which encourage "infertility tourism". Women cross borders in order to get access to those treatment modalities that are not provided in their own country. Oocyte donation for example and the high cost of the services locally are common reasons for this mobility. Although treatment of infertility is still aetiology based, unexplained cause is most often the underlying reason. The invention of in vitro fertilisation (IVF) has changed the management of infertility globally. In most European countries, treatment is mainly provided by well-organised private IVF centres using highly effective methodologies. Different European scientific organisations, together with European Board and College of Obstetrics and Gynaecology (EBCOG), should provide recommendations to the European Union on the development of common legislation to streamline quality assured clinical care for infertile couples. This will hopefully help to eliminate possible inequalities, providing evidence based services according to patients' needs and also reduce the cross border healthcare demand in European countries.

Hypertension and early menopause after the use of assisted reproductive technologies in women aged 43 years or older: Long-term follow-up study

AIM

The aim of this study was to investigate the long-term consequences to women's health and the onset of menopause in healthy women of advanced reproductive age who conceived by assisted reproductive technologies (ART).

METHODS

Healthy women who conceived by ART (72) and controls (80) were selected among 320 women ≥ 43 years, who delivered between January 2010 and December 2011 in the Department of Gynecological and Obstetrical Sciences and Urological Sciences of "Sapienza" University of Rome. Body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), and presence of hypertension and diabetes were analyzed at three days, six months, and three years after delivery. The onset of menopause was analyzed after three years.

RESULTS

In the ART group, SBP, DBP and hypertension were higher at three days, six months, and three years after delivery. Menopausal age was significantly lower.

CONCLUSION

The impact of ART in healthy women of advanced reproductive age in the years after delivery is not limited to the possible development of cardiovascular risk factors, such as hypertension, but can also influence the age of onset of menopause.

Socio-economic disparities in access to assisted reproductive technologies in Australia

Women from disadvantaged socio-economic groups access assisted reproductive technology treatment less than women from more advantaged groups. However, women from disadvantaged groups tend to start families younger, making them less likely to suffer from age-related subfertility and potentially have less need for fertility treatment. Whether socio-economic disparities in access to assisted reproductive technology treatment persist after controlling for the need for treatment, has not been previously explored. This population based study demonstrates that socio-economic disparities in access to assisted reproductive technology treatment persist after adjusting for several confounding factors, including age at first birth (used as a measure of delayed childbearing, hence a proxy for need for fertility treatment), geographic remoteness and Australian jurisdiction. Assisted reproductive technology access progressively decreased as socio-economic quintiles became more disadvantaged, with a 15.8% decrease in access in the most disadvantaged quintile compared with the most advantaged quintile after controlling for confounding factors. The adjusted rate of access to assisted reproductive technology treatment also decreased by 12.3% for women living in regional and remote areas compared with those in major cities. These findings indicate that financial and sociocultural barriers to assisted reproductive technology treatment remain in disadvantaged groups after adjusting for need.

Prevalence of infertility and help seeking among 15 000 women and men

STUDY QUESTION

What is the prevalence of infertility and of help seeking among women and men in Britain?

SUMMARY ANSWER

One in eight women and one in ten men aged 16–74 years had experienced infertility, defined by unsuccessfully attempting pregnancy for a year or longer, and little more than half of these people sought medical or professional help.

WHAT IS KNOWN ALREADY

Estimates of infertility and help seeking in Britain vary widely and are not easily comparable because of different definitions and study populations.

STUDY DESIGN, SIZE, DURATION

A cross-sectional population survey was conducted between 2010 and 2012 with a sample of 15 162 women and men aged 16–74 years.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants completed the Natsal-3 questionnaire, using computer-assisted personal interviewing (CAPI) and computer-assisted self-interview (CASI).

MAIN RESULTS AND THE ROLE OF CHANCE

The reported prevalence of infertility was 12.5% (CI 95% 11.7–13.3) among women and 10.1% (CI 95% 9.2–11.1) among men. Increased prevalence was associated with later cohabitation with a partner, higher socio-economic status and, for those who had a child, becoming parents at older ages. The reported prevalence of help seeking was 57.3% (CI 95% 53.6–61.0) among women and 53.2% (CI 95% 48.1–58.1) among men. Help seekers were more likely to be better educated and in higher status occupations and, among those who had a child, to have become parents later in life.

LIMITATIONS, REASONS FOR CAUTION

These data are cross-sectional so it is not possible to establish temporality or infer causality. Self-reported data may be subject to recall bias.

WIDER IMPLICATIONS OF THE FINDINGS

The study provides estimates of infertility and help seeking in Britain and the results indicate that the prevalence of infertility is higher among those delaying parenthood. Those with higher educational qualifications and occupational status are more likely to consult with medical professionals for fertility problems than others and these inequalities in help seeking should be considered by clinical practice and public health.

STUDY FUNDING/COMPETING INTEREST(S)

Funding was provided by grants from the Medical Research Council and the Wellcome Trust, with support from the Economic and Social Research Council and the Department of Health. AMJ is a Governor of the Wellcome Trust. Other authors have no competing interests.

Effect of bajijiasu isolated from Morinda officinalis F. C. how on sexual function in male mice and its antioxidant protection of human sperm

ETHNOPHARMACOLOGICAL RELEVANCE

In recent years, the physiological aspects of human fertility have been seriously influenced by the interactions of genetic and environmental factors. Almost one in 20 males has been affected by male infertility, providing a great challenge and an opportunity to use natural compounds as alternatives to chemical drugs with comprehensive adverse effects. However, ample evidences are scanty to support the physiological mechanisms of natural compounds used to treat male infertility. In traditional Chinese medicine, Morinda officinalis F. C. How is widely used as a herb that invigorates the kidneys and supports yang, the original energy in the human body, to resist diseases and in treating male infertility. In this study, we evaluated whether bajijiasu isolated from the roots of M. officinalis F.C. How is a potential agent for the treatment of male infertility.

MATERIALS AND METHOD

In this study, both normal and kidney-yang-deficient mice were administered bajijiasu orally at different concentrations. To determine the pharmacological mechanism of bajijiasu, we observed the sexual behavior and genital organ coefficients, determined their serum hormone levels, analyzed their sperm quality parameters, and examined histopathological sections from them. We also used enzymatic assays to determine the effects of bajijiasu on superoxide dismutase, glutathione peroxidase, and malondialdehyde. Confocal micro-Raman spectroscopy was used to investigate the changes in the DNA of H2O2-damaged human sperm after treatment with bajijiasu in vitro.

RESULTS

Our results showed that bajijiasu enhanced the sexual behavior of both normal and kidney-yang-deficient mice. It also markedly increased the testosterone concentrations, reduced the levels of cortisol, improved the quality of the sperm, and counteracted the histopathological impairment induced by hydroxyurea in the kidney-yang-deficient mice. The enzymatic assay and Raman spectra showed that bajijiasu protects the DNA of sperm from damage by H2O2.

CONCLUSION

Bajijiasu is a potential androgen-like drug that modulates hormone levels to some extent without producing reproductive-organ lesions, enhances the sexual function of male mice, and protects the DNA of human sperm from H2O2 damage. Thus, bajijiasu is an active ingredient of M. officinalis F.C. How that improves the human reproductive capacity.

Motivations and experiences of patients seeking cross-border reproductive care: the Australian and New Zealand context

OBJECTIVE

To explore the motivations, clinical care, counseling, and support experiences of Australian and New Zealand participants considering or having participated in cross-border reproductive care (CBRC).

DESIGN

Questionnaire-based study.

SETTING

Not applicable.

PATIENT(S)

One hundred thirty-seven Australian and New Zealand participants aged 23-53 years.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURES(S)

Quantitative and qualitative responses to an anonymously completed online questionnaire.

RESULT(S)

Quantitative responses from participants indicated that motivations for engaging in CBRC included limited availability of gamete donors in their home state, difficulty in meeting treatment eligibility criteria, and treatment being legally prohibited. Experiences of CBRC were generally rated positively in terms of medical needs (91.2%), safety (89.4%), and costs (85.7%), although rated more conservatively to emotional needs being met (57.9%). Less than half the sample (47.5%) had accessed some form of CBRC-related counseling. Themes identified in qualitative analysis reflected gamete supply and demand issues, the importance of donor information and disclosure, the personal impact of legislation, and ongoing support needs after CBRC treatment.

CONCLUSION(S)

A greater percentage of participants agreed that their CBRC clinic satisfied their overall medical needs and treatment expectations in comparison with overall emotional needs. Participants indicated access to post-treatment support counseling particularly with regard to their emotional well-being and disclosure issues to donor-conceived children would be useful. The implications of our findings for the provision of best-practice psychosocial counseling support and development of counseling guidelines are highlighted.

Low-cost in vitro fertilization: current insights

Despite the development of in vitro fertilization (IVF) more than 30 years ago, the cost of treatment remains high. Furthermore, over the years, more sophisticated technologies and expensive medications have been introduced, making IVF increasingly inaccessible despite the increasing need. Globally, the option to undergo IVF is only available to a privileged few. In recent years, there has been growing interest in exploring strategies to reduce the cost of IVF treatment, which would allow the service to be provided in low-resource settings. In this review, we explore the various ways in which the cost of this treatment can be reduced.

An international survey of assisted reproductive technologies (ARTs) policies and the effects of these policies on costs, utilization, and health outcomes

OBJECTIVES

The purpose of this study was to compare existing policies regarding access to 7 assisted reproductive technologies (ARTs) and to examine the effects of these policies on costs, utilization, and health outcomes in 14 countries and 2 Canadian provinces based on publicly available information.

METHODS

A systematic review of publicly available information from peer-reviewed literature (using biomedical and social science databases) and grey literature (e.g., health ministry websites, health technology assessment agency websites, etc.) was performed.

RESULTS

ARTs services permitted or funded vary across jurisdictions. The goals and eligibility restrictions (e.g., on maternal age, number of embryos transferred, and number of cycles) defined in ARTs policies also vary across jurisdictions. Studies on the impact of such policies have primarily been retrospective and focused on short-term service utilization. Nevertheless, they suggest that the policies have achieved specific outcomes, such as reductions in multiple births and in costs to payers.

CONCLUSIONS

Based on the evidence reviewed, policies aimed at reducing public coverage of ARTs or restricting the number of embryos transferred have achieved these goals. However, their effects on maternal and infant health outcomes have not been well explored.