Fertility Treatment, Use of in Vitro Fertilization, and Time to Live Birth Based on Initial Provider Type

Time to live birth: towards a common agreement

The major purpose of a couple at the first infertility appointment is to get a healthy baby as soon as possible. From diagnosis and decision on which assisted reproduction technique (ART) and controlled ovarian stimulation, to the selection of which embryo to transfer, the dedicated team of physicians and embryologists puts all efforts to shorten the time to pregnancy and live birth. Time seems thus central in assisted reproduction, and we can conveniently use it as a measure of treatment efficiency. How can we measure time to live birth? What timelines do we need to consider to evaluate efficiency? In this paper, we will discuss the importance of "Time" as a fundamental parameter for measuring ART success.

Provision of fertility services to women in same-sex relationships at Catholic and non-Catholic clinics in the United States

INTRODUCTION

This study addressed deficient information on the provision of infertility care in obstetrics and gynecology clinics. We additionally evaluated the availability of these services based on clinic affiliations or stated sexual orientation.

METHODOLOGY

We performed a national cross-sectional "mystery caller" survey of 293 general obstetrics and gynecology clinics in 2017-2018. We matched clinics identified by web-based search engine in a 1:1 ratio by Catholic hospital affiliation, after determining number of clinics based on state-population densities. A standard call script included questions regarding provision of infertility services, ovulation induction methods, and information about the caller's sexual orientation. We performed descriptive frequencies and compared responses based on hospital affiliations.

RESULTS

Of the 293 clinics included, 49% were affiliated with Catholic and 17% with academic hospitals. The majority offered infertility care (85%, 248/293), and of these 97% (240/248) offered ovulation induction. Only 3% (6/240) reported they would not provide to women in same-sex relationships. Most clinics not offering infertility evaluations (43/45, 96%) cited it was outside of their scope of care and of these 33% (15/45) did not provide information for self-referral. Clinics affiliated with academic (aOR 0.23) or Catholic (aOR 0.34) hospitals were less likely to provide evaluations. Those with academic affiliation were more likely to provide information for self-referral (aOR 19.2).

DISCUSSION

Most general obstetrics and gynecology practices offered appointments for infertility evaluation and ovulation induction. Clinics rarely denied services to women reporting a same-sex partnership, regardless of hospital affiliation. These findings provide reassurance to same-sex couples seeking fertility care.

International Natural Procreative Technology Evaluation and Surveillance of Treatment for Subfertility (iNEST): enrollment and methods

STUDY QUESTION

What is the feasibility of a prospective protocol to follow subfertile couples being treated with natural procreative technology for up to 3 years at multiple clinical sites?

SUMMARY ANSWER

Overall, clinical sites had missing data for about one-third of participants, the proportion of participants responding to follow-up questionnaires during time periods when participant compensation was available (about two-thirds) was double that of time periods when participant compensation was not available (about one-third) and follow-up information was most complete for pregnancies and births (obtained from both clinics and participants).

WHAT IS KNOWN ALREADY

Several retrospective single-clinic studies from Canada, Ireland and the USA, with subfertile couples receiving restorative reproductive medicine, mostly natural procreative technology, have reported adjusted cumulative live birth rates ranging from 29% to 66%, for treatment for up to 2 years, with a mean women’s age of about 35 years.

STUDY DESIGN, SIZE, DURATION

The international Natural Procreative Technology Evaluation and Surveillance of Treatment for Subfertility (iNEST) was designed as a multicenter, prospective cohort study, to enroll subfertile couples seeking treatment for live birth, assess baseline characteristics and follow them up for up to 3 years to report diagnoses, treatments and outcomes of pregnancy and live birth. In addition to obtaining data from medical record abstraction, we sent follow-up questionnaires to participants (both women and men) to obtain information about treatments and pregnancy outcomes, including whether they obtained treatment elsewhere. The study was conducted from 2006 to 2016, with a total of 10 clinics participating for at least some of the study period across four countries (Canada, Poland, UK and USA).

PARTICIPANTS/MATERIALS, SETTING, METHODS

The 834 participants were subfertile couples with the woman’s age 18 years or more, not pregnant and seeking a live birth, with at least one clinic visit. Couples with known absolute infertility were excluded (i.e. bilateral tubal blockage, azoospermia). Most women were trained to use a standardized protocol for daily vulvar observation, description and recording of cervical mucus and vaginal bleeding (the Creighton Model FertilityCare System). Couples received medical and sometimes surgical evaluation and treatments aimed to restore and optimize female and male reproductive function, to facilitate in vivo conception.

MAIN RESULTS AND THE ROLE OF CHANCE

The mean age of women starting treatment was 34.0 years; among those with additional demographic data, 382/478 (80%) had 16 or more years of education, and 199/659 (30%) had a prior live birth. Across 10 clinical sites in four countries (mostly private clinical practices) with family physicians or obstetrician–gynecologists, data about clinic visits were submitted for 60% of participants, and diagnostic data for 77%. For data obtained directly from the couple, 59% of couples had at least one follow-up questionnaire, and the proportion of women and men responding to fill out the follow-up questionnaires was 69% and 67%, respectively, when participant financial compensation was available, compared to 38% and 33% when compensation was not available. Among all couples, 57% had at least one pregnancy and 44% at least one live birth during the follow-up time period, based on data obtained from clinic and/or participant questionnaires. All sites reported on female pelvic surgical procedures, and among all participants, 22% of females underwent a pelvic diagnostic and/or therapeutic procedure, predominantly laparoscopy and hysterosalpingography. Among the 643 (77%) of participants with diagnostic information, ovulation-related disorders were diagnosed in 87%, endometriosis in 31%, nutritional disorders in 47% and abnormalities of semen analysis in 24%. The mean number of diagnoses per couple was 4.7.

LIMITATIONS, REASONS FOR CAUTION

The level of missing data was higher than anticipated, which limits both generalizability and the ability to study different components of treatment and prognosis. Loss to follow-up may also be differential and introduce bias for outcomes. Most of the participating clinicians were not surgeons, which limits the opportunity to study the impact of surgical interventions. Participants were geographically dispersed but relatively homogeneous with regard to socioeconomic status, which may limit the generalizability of current and future findings.

WIDER IMPLICATIONS OF THE FINDINGS

Multicenter studies are key to understanding the outcomes of subfertility treatments beyond IVF or IUI in broader populations, and the association of different prognostic factors with outcomes. We anticipate that the iNEST study will provide insight for clinical and treatment factors associated with outcomes of pregnancy and live birth, with appropriate attention to potential biases (including adjustment for potential confounders, multiple imputation for missing data, sensitivity analysis and inverse probability weighting for potential differential loss to follow-up, and assessments for clinical site heterogeneity). Future studies will need to either have: adequate funding to compensate clinics and participants for robust data collection, including targeted randomized trials; or a scaled-down, registry-based approach with targeted data points, similar to the multiple national and regional ART registries.

STUDY FUNDING/COMPETING INTEREST(S)

Funding for the study came from the International Institute for Restorative Reproductive Medicine, the University of Utah, Department of Family and Preventive Medicine, Health Studies Fund, the Primary Children’s Medical Foundation, the Mary Cross Tippmann Foundation, the Atlas Foundation, the St. Augustine Foundation and the Women’s Reproductive Health Foundation. The authors declare no competing interests.

TRIAL REGISTRATION NUMBER

The iNEST study is registered at clinicaltrials.gov, NCT01363596.

Restorative reproductive medicine for infertility in two family medicine clinics in New England, an observational study

BACKGROUND

Restorative reproductive medicine (RRM) seeks to identify and correct underlying causes and factors contributing to infertility and reproductive dysfunction. Many components of RRM are highly suitable for primary care practice. We studied the outcomes amongst couples who received restorative reproductive medicine treatment for infertility in a primary care setting.

METHODS

Two family physicians in Massachusetts trained in a systematic approach to RRM (natural procreative technology, or NaProTechnology) treated couples with infertility. We retrospectively reviewed the characteristics, diagnoses, treatments, and outcomes for all couples treated during the years 1989 to 2014. We compared pregnancy and live birth by clinical characteristics using Kaplan-Meier analysis. We employed the Fleming-Harrington weighted Renyi test or the logrank test to compare the cumulative proportion with pregnancy or with live birth.

RESULTS

Among 370 couples beginning treatment for infertility, the mean age was 34.8 years, the mean prior time trying to conceive was 2.7 years, and 27% had a prior live birth. The mean number of diagnoses per couple was 4.9. Treatment components included fertility tracking with the Creighton Model FertilityCare System (80%); medications to enhance cervical mucus production (81%), to stimulate ovulation (62%), or to support the luteal phase (75%); and referral to female laparoscopy by a surgeon specializing in endometriosis (46%). The cumulative live birth rate at 2 years was 29% overall; this was significantly higher for women under age 35 (34%), and for women with body mass index < 25 (40%). There were 2 sets of twins and no higher-order multiple gestations. Of the 63 births with data available, 58 (92%) occurred at term.

CONCLUSIONS

Family physicians can provide a RRM approach for infertility to identify underlying causes and promote healthy term live births. Younger women and women with body mass index < 25 are more likely to have a live birth.

Time as an outcome measure in fertility-related clinical studies: long-awaited

Time taken to achieve a live birth is an important consideration that is central to managing patient expectations during infertility treatment. However, time-related endpoints are not reported as standard in the majority of fertility-related clinical studies and there is no internationally recognized consensus definition for such endpoints. There is, therefore, a need for meaningful discussions around the selection of appropriate time-related treatment outcome measures for studies evaluating fertility treatments that will be relevant to diverse stakeholders (e.g. patients, healthcare professionals, clinical scientists, authorities and industry). Here, we provide a proposal for the evaluation of time-related outcome measures in fertility-related clinical studies, alongside associated definitions.

Positive Effect of Acupuncture and Cupping in Infertility Treatment

Background: Infertility is clinically defined as the failure to conceive after 12 months of unprotected sexual intercourse. Organic disorders and lifestyle factors are highly associated with infertility. Generally, acupuncture and its related methods can be applied for treating infertility, according to the theory of Traditional Chinese Medicine. Successful cases of acupuncture-treated infertility without concomitant use of any medication are rare. This article presents a case of an infertile woman having a favorable response to acupuncture treatment. Case: A 39-year-old Mexican woman presented with infertility following right-side fallopian-tube obstruction. She had no significant physical feelings of discomfort apart from work-related stress. Her syndrome was first diagnosed as Deficiency of Spleen and Kidney Qi, accompanied by obstruction of channels due to accumulation of Dampness. Acupuncture, accompanied by cupping therapy, was primarily practiced for this patient. Results: After 28 treatment sessions, she was finally able to conceive. Conclusions: Acupuncture could help treat infertility. Further large-scale, randomized clinical trials are needed to verify the efficacy of acupuncture for treating female infertility.