The effect of the 2004 Italian legislation on perinatal outcomes following assisted reproduction technology

Are sperm parameters able to predict the success of assisted reproductive technology? A retrospective analysis of over 22,000 assisted reproductive technology cycles

Background

An explosive increase in couples attending assisted reproductive technology has been recently observed, despite an overall success rate of about 20%–30%. Considering the assisted reproductive technology‐related economic and psycho‐social costs, the improvement of these percentages is extremely relevant. However, in the identification of predictive markers of assisted reproductive technology success, male parameters are largely underestimated so far.

Study design

Retrospective, observational study.

Objectives

To evaluate whether conventional semen parameters could predict assisted reproductive technology success.

Materials and methods

All couples attending a single third‐level fertility center from 1992 to 2020 were retrospectively enrolled, collecting all semen and assisted reproductive technology parameters of fresh cycles. Fertilization rate was the primary end‐point, representing a parameter immediately dependent on male contribution. Pregnancy and live birth rates were considered in relation to semen variables. Statistical analyses were performed using the parameters obtained according to the World Health Organization manual editions used for semen analysis.

Results

Note that, 22,013 in vitro fertilization and intracytoplasmic sperm injection cycles were considered. Overall, fertilization rate was significantly lower in patients with abnormal semen parameters compared to normozoospermic men, irrespective of the World Health Organization manual edition. In the in vitro fertilization setting, both progressive motility (p = 0.012) and motility after capacitation (p = 0.002) significantly predicted the fertilization rate (statistical accuracy = 71.1%). Sperm motilities also predicted pregnancy (p < 0.001) and live birth (p = 0.001) rates. In intracytoplasmic sperm injection cycles, sperm morphology predicted fertilization rate (p = 0.001, statistical accuracy = 90.3%). Sperm morphology significantly predicted both pregnancy (p < 0.001) and live birth (p < 0.001) rates and a cut‐off of 5.5% was identified as a threshold to predict clinical pregnancy (area under the curve = 0.811, p < 0.001).

Discussion

Interestingly, sperm motility plays a role in predicting in vitro fertilization success, while sperm morphology is the relevant parameter in intracytoplasmic sperm injection cycles. These parameters may be considered reliable tools to measure the male role on ART outcomes, potentially impacting the clinical management of infertile couples.

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.

Five years (2004-2009) of a restrictive law-regulating ART in Italy significantly reduced delivery rate: analysis of 10,706 cycles

STUDY QUESTION

Was the delivery rate of ART cycles negatively affected by the enactment of the Law 40/2004 by the Italian Parliament which imposed a long list of restrictions for ART procedures?

SUMMARY ANSWER

This large and extensive comparative analysis of ART outcomes prior to and after the introduction of the Law 40 revealed a significant reduction in pregnancy and delivery rates per cycle, independent of age or other clinical variables, once the law went into effect.

WHAT IS KNOWN ALREADY

Several studies have been published on the effect of Law 40/2004 on ART outcomes, some authors demonstrating a negative impact of the Law in relation to specific etiologies of infertility, other authors showing opposite conclusions.

STUDY DESIGN, SIZE, DURATION

Retrospective clinical study of 3808 patients treated prior to the enactment of the Law, September 1996-March 2004 (Group I) and 6898 treated during the Law, March 2004-May 2009 (Group II).

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 10 706 ART cycles were analysed, 3808 performed before and 6898 after the application of the Law. An intention-to-treat statistical analysis was performed to detect pregnancy and delivery rates (pregnancies ≥ 24 weeks) per started cycle. A P value of <0.05 was considered statistically significant. We analysed different outcomes: differences in fertilization, pregnancy and delivery rate, multiple pregnancies and miscarriage rates between the two time periods.

MAIN RESULTS AND THE ROLE OF CHANCE

The delivery rate for started cycle was 20% before and 16.0% after the introduction of the Law representing a 25% reduction (P < 0.001). The multivariate analysis, corrected by female age of >38 years, duration of infertility, basal FSH level and number of retrieved oocytes, showed a 16% lower delivery rate (odds ratio: 0.84; confidence interval: 0.75-0.94). This statistical approach removed the risk that the observed effects were due to chance and confirmed unequivocally that the Law was an independent factor responsible for the reduced likelihood of a successful outcome.

LIMITATIONS, REASONS FOR CAUTION

This is a retrospective study. A prospective randomized study, with patients treated in the same time period and randomized to restrictions or not, would have minimized potential limitations due to differences in years of treatments.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings based on the analysis of such a large number of cycles proved clearly and unequivocally that imposing restrictions on the practice of ART penalized patients. These data represent a relevant clinical contribution for countries still debating the enactment of restrictive limitations of ART.

The 2004 Italian legislation on the application of assisted reproductive technology: epilogue

OBJECTIVE

To evaluate how the unique Italian fertility regulations (≤3 inseminated oocytes/cycle, transfer of all embryos, prohibition of embryo cryopreservation) affected outcomes of ART.

STUDY DESIGN

Case-control study from the Center of Reproductive Medicine, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy. We compared outcomes of ART patients between five years before (n=1791) and five years after (n=2474) the implementation of the law.

RESULTS

The mean embryo transfer (ET) rate was 3.1±2.1 and 1.7±1.1 before and after the law. Significantly more ICSI procedures were performed in women above 35 years old during the post-law period. The ET rate was higher before (88.6%) than after (80.5%) the law (OR 1.9, 95% CI 1.6, 2.2) especially in women >37 years undergoing ICSI (88.2 vs. 76.1%; OR 2.3, 95% CI 1.3, 4.2). The clinical pregnancy rates were practically unchanged but the proportion of triplet births significantly decreased after the law (10.3 vs. 4.1%, OR 2.7, 95% CI 1.4, 5.0).

CONCLUSION

In contrast to interim analyses, we found that the statutory obligation to transfer all available embryos produced from up to three inseminated oocytes reduced the ET rates, especially in older women, and decreased the triplet births rate.

Detection of follicular fluid and serum antibodies by protein microarrays in women undergoing in vitro fertilization treatment

A protein microarray serological assay was used to assess the antibody profile of 102 women subjected to in vitro fertilization treatment. The studies were conducted on pairs of serum and follicular fluid samples, collected from each woman on the same day at the time of oocyte recovery. The samples, stored as frozen aliquotes, were assessed by both microarray and ELISA. Follicular fluids and sera were screened to detect the presence of specific IgG and IgM antibodies against seven vertically transmitted pathogens. The IgG reactivity of follicular fluids closely mirrored that of serum in all the patients and for all the antigens, with an agreement of more than 85%. IgM antibodies were undetectable in follicular fluids. The antibody patterns were subsequently related to the biological and clinical outcomes of in vitro fertilization cycles. The results showed that varicella zoster virus (VZV) IgG positive women and cytomegalovirus (CMV) IgG negative women had on average a higher number of inseminated, good quality oocytes compared to VZV IgG negative and CMV IgG positive women. In addition, the rate of successful embryo transfers was significantly higher in Toxoplasma gondii IgG negative women than in their positive counterparts. Overall, the microarray was proven to be a suitable tool for detecting analytes in follicular fluids, therefore supporting its application in a wide spectrum of investigations.

Psychosocial support for infertile couples during assisted reproductive technology treatment

OBJECTIVE

To evaluate the psychosocial support perceived by couples during assisted reproductive technology (ART) treatments.

DESIGN

Prospective follow-up of patients undergoing ART.

SETTING

Department of Obstetrics and Gynecology, S. Maria Nuova Hospital, Reggio Emilia, Italy.

PATIENT(S)

Eighty-three women and 83 men admitted for ART.

INTERVENTION(S)

Patients completed a sociodemographic questionnaire and the Multidimensional Scale of Perceived Social Support at the beginning of ovarian stimulation, upon oocyte pick-up, and 1 month after ET.

MAIN OUTCOME MEASURE(S)

Perception of psychosocial support.

RESULT(S)

Men, compared with women, consistently reported poorer perception of psychosocial support, especially from friends and significant others; family support showed no difference. Women showed a decrease in perceived support, especially from friends, in cases of failure. Both reported less support from significant others if they had previously already undergone ART treatments.

CONCLUSION(S)

Men might feel excluded from the treatment because of the greater attention to women, leading to feelings of isolation from friends and partners. Women suffer particularly in cases of failure that reconfirms the trauma of infertility. These psychological risk factors underline the usefulness of psychological support for these couples, especially in cases of prolonged infertility.