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Wang Z, Cantineau AEP, Hoek A, van Eekelen R, Mol BW, Wang R. Live birth is not the only relevant outcome in research assessing assisted reproductive technology. Best Pract Res Clin Obstet Gynaecol 2023; 86:102306. [PMID: 36642691 DOI: 10.1016/j.bpobgyn.2022.102306] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/30/2022] [Accepted: 12/19/2022] [Indexed: 12/28/2022]
Abstract
In assisted reproductive technology (ART) research, live birth has been generally accepted as an important outcome, if not the most important one. However, it has been reported inconsistently in the literature and solely focusing on live birth can lead to misinterpretation of research findings. In this review, we provide an overview on the definitions of live birth, including various denominators and numerators use. We present a series of real clinical examples in ART research to demonstrate the impact of variations in live birth on research findings and the importance of other outcomes, including multiple pregnancy, pregnancy loss, time to pregnancy leading to live birth, other short and long term maternal and offspring health outcomes and cost effectiveness measures. We suggest that outcome choices in ART research should be tailored for the research questions. A holistic outcome assessment beyond live birth would provide a full picture to address research questions in ART in terms of effectiveness and safety, and thus facilitate evidence-based decision making.
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Affiliation(s)
- Zheng Wang
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Astrid E P Cantineau
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Annemieke Hoek
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Rik van Eekelen
- Department of Epidemiology and Data Science, Amsterdam UMC, Amsterdam, the Netherlands
| | - Ben W Mol
- Department of Obstetrics and Gynecology, The Richie Centre, Monash University, Melbourne, Australia; School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Rui Wang
- Department of Obstetrics and Gynecology, The Richie Centre, Monash University, Melbourne, Australia.
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2
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Peng Y, Ma S, Hu L, Wang X, Xiong Y, Yao M, Tan J, Gong F. Effectiveness and Safety of Two Consecutive Cycles of Single Embryo Transfer Compared With One Cycle of Double Embryo Transfer: A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne) 2022; 13:920973. [PMID: 35846284 PMCID: PMC9279578 DOI: 10.3389/fendo.2022.920973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 05/23/2022] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To date, evidence regarding the effectiveness and safety of two consecutive cycles of single embryo transfer (2SETs) compared with one cycle of double embryo transfer (DET) has been inadequate, particularly considering infertile women with different prognostic factors. This study aimed to comprehensively summarize the evidence by comparing 2SETs with DET. METHODS PubMed, Embase, Cochrane Library databases, ClinicalTrails.gov, and the WHO International Clinical Trials Registry Platform were searched up to March 22, 2022. Peer-reviewed, English-language randomized controlled trials (RCTs) and observational studies (OS) comparing the outcomes of 2SETs with DET in infertile women with their own oocytes and embryos were included. Two authors independently conducted study selection, data extraction, and bias assessment. The Mantel-Haenszel random-effects model was used for pooling RCTs, and a Bayesian design-adjusted model was conducted to synthesize the results from both RCTs and OS. MAIN RESULTS Twelve studies were finally included. Compared with the DET, 2SETs were associated with a similar cumulative live birth rate (LBR; 48.24% vs. 48.91%; OR, 0.97; 95% credible interval (CrI), 0.89-1.13, τ2 = 0.1796; four RCTs and six observational studies; 197,968 women) and a notable lower cumulative multiple birth rate (MBR; 0.87% vs. 17.72%; OR, 0.05; 95% CrI, 0.02-0.10, τ2 = 0.1036; four RCTs and five observational studies; 197,804 women). Subgroup analyses revealed a significant increase in cumulative LBR (OR, 1.33; 95% CrI, 1.29-1.38, τ2 = 0) after two consecutive cycles of single blastocyst transfer compared with one cycle of double blastocyst transfer. Moreover, a lower risk of cesarean section, antepartum hemorrhage, preterm birth, low birth weight, and neonatal intensive care unit admission but a higher gestational age at birth and birth weight were found in the 2SETs group. CONCLUSION Compared to the DET strategy, 2SETs result in a similar LBR while simultaneously reducing the MBR and improving maternal and neonatal adverse outcomes. The 2SETs strategy appears to be especially beneficial for women aged ≤35 years and for blastocyst transfers.
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Affiliation(s)
- Yangqin Peng
- Reproductive and Genetic Hospital of CITIC-Xiangya, Clinical Research Center for Reproduction and Genetics in Hunan Province, Changsha City, China
| | - Shujuan Ma
- Reproductive and Genetic Hospital of CITIC-Xiangya, Clinical Research Center for Reproduction and Genetics in Hunan Province, Changsha City, China
| | - Liang Hu
- Reproductive and Genetic Hospital of CITIC-Xiangya, Clinical Research Center for Reproduction and Genetics in Hunan Province, Changsha City, China
| | - Xiaojuan Wang
- Reproductive and Genetic Hospital of CITIC-Xiangya, Clinical Research Center for Reproduction and Genetics in Hunan Province, Changsha City, China
| | - Yiquan Xiong
- Chinese Evidence-Based Medicine Center and CREAT Group, West China Hospital, Sichuan University, Chengdu, China
| | - Minghong Yao
- Chinese Evidence-Based Medicine Center and CREAT Group, West China Hospital, Sichuan University, Chengdu, China
| | - Jing Tan
- Chinese Evidence-Based Medicine Center and CREAT Group, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Jing Tan, ; Fei Gong,
| | - Fei Gong
- Reproductive and Genetic Hospital of CITIC-Xiangya, Clinical Research Center for Reproduction and Genetics in Hunan Province, Changsha City, China
- *Correspondence: Jing Tan, ; Fei Gong,
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Abdulrahim B, Scotland G, Bhattacharya S, Maheshwari A. Assessing couples' preferences for fresh or frozen embryo transfer: a discrete choice experiment. Hum Reprod 2021; 36:2891-2903. [PMID: 34550368 DOI: 10.1093/humrep/deab207] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 08/24/2021] [Indexed: 11/13/2022] Open
Abstract
STUDY QUESTION What are couples' preferences for fresh embryo transfer versus freezing of all embryos followed by frozen embryo transfer and the associated clinical outcomes that may differentiate them? SUMMARY ANSWER Couples' preferences are driven by anticipated chances of live birth, miscarriage, neonatal complications, and costs but not by the differences in the treatment process (including delay of embryo transfer linked to frozen embryo transfer and risk of ovarian hyperstimulation syndrome (OHSS) associated with fresh embryo transfer). WHAT IS KNOWN ALREADY A policy of freezing all embryos followed by transfer of frozen embryos results in livebirth rates which are similar to or higher than those following the transfer of fresh embryos while reducing the risk of OHSS and small for gestational age babies: it can, however, increase the risk of pre-eclampsia and large for gestational age offspring. Hence, the controversy continues over whether to do fresh embryo transfer or freeze all embryos followed by frozen embryo transfer. STUDY DESIGN, SIZE, DURATION We used a discrete choice experiment (DCE) technique to survey infertile couples between August 2018 and January 2019. PARTICIPANTS/MATERIALS, SETTING, METHODS We asked IVF naïve couples attending a tertiary referral centre to independently complete a questionnaire with nine hypothetical choice tasks between fresh and frozen embryo transfer. The alternatives varied across the choice occurrences on several attributes including efficacy (live birth rate), safety (miscarriage rate, neonatal complication rate), and cost of treatment. We assumed that a freeze-all strategy prolonged treatment but reduced the risk of OHSS. An error components mixed logit model was used to estimate the relative value (utility) that couples placed on the alternative treatment approaches and the attributes used to describe them. Willingness to pay and marginal rates of substitution between the non-cost attributes were calculated. A total of 360 individual questionnaires were given to 180 couples who fulfilled the inclusion criteria, of which 212 were completed and returned Our study population included 3 same sex couples (2 females and 1 male) and 101 heterosexual couples. Four questionnaires were filled by one partner only. The response rate was 58.8%. MAIN RESULTS AND THE ROLE OF CHANCE Couples preferred both fresh and frozen embryo transfer (odds ratio 27.93 and 28.06, respectively) compared with no IVF treatment, with no strong preference for fresh over frozen. Couples strongly preferred any IVF technique that offered an increase in live birth rates by 5% (P = 0.006) and 15% (P < 0.0001), reduced miscarriage by 18% (P < 0.0001) and diminished neonatal complications by 10% (P < 0.0001). Respondents were willing to pay an additional £2451 (95% CI 604 - 4299) and £761 (95% CI 5056-9265) for a 5 and 15% increase in the chance of live birth, respectively, regardless of whether this involved fresh or frozen embryos. They required compensation of £5230 (95% CI 3320 - 7141) and £13 245 (95% CI 10 110-16 380) to accept a 10 and 25% increase in the risk of neonatal complications, respectively (P < 0.001). Results indicated that couples would be willing to accept a 1.26% (95% CI 1.001 - 1.706) reduction in the live birth rate for a 1% reduction in the risk of neonatal complications per live birth. Older couples appeared to place less emphasis on the risk of neonatal complications than younger couples. LIMITATIONS, REASONS FOR CAUTION DCEs can elicit intentions which may not reflect actual behaviour. The external validity of this study is limited by the fact that it was conducted in a single centre with generous public funding for IVF. We cannot rule out the potential for selection or responder bias. WIDER IMPLICATIONS OF THE FINDINGS If a strategy of freeze all was to be implemented it would appear to be acceptable to patients, if either success rates can be improved or neonatal complications reduced. Live birth rates, neonatal complication rates, miscarriage rates, and cost are more likely to drive their preferences than a slight delay in the treatment process. The results of this study have important implications for future economic evaluations of IVF, as they suggest that the appropriate balance needs to be struck between success and safety. A holistic approach incorporating patient preferences for expected clinical outcomes and risks should be taken into consideration for individualized care. STUDY FUNDING/COMPETING INTEREST(S) No external funding was sought for this study. A.M. is the chief investigator of the randomized controlled trial 'Freeze all'. S.B. is an Editor in Chief of Human Reproduction Open. The other co-authors have no conflicts of interest to declare. Graham Scotland reports non-financial support from Merck KGaA, Darmstadt, Germany, outside the submitted work. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
| | - Graham Scotland
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Siladitya Bhattacharya
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
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Vlaisavljevic V, Apter S, Capalbo A, D'Angelo A, Gianaroli L, Griesinger G, Kolibianakis EM, Lainas G, Mardesic T, Motrenko T, Pelkonen S, Romualdi D, Vermeulen N, Tilleman K. The Maribor consensus: report of an expert meeting on the development of performance indicators for clinical practice in ART. Hum Reprod Open 2021; 2021:hoab022. [PMID: 34250273 PMCID: PMC8254491 DOI: 10.1093/hropen/hoab022] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 04/28/2021] [Indexed: 12/17/2022] Open
Abstract
STUDY QUESTION Is it possible to define a set of performance indicators (PIs) for clinical work in ART, which can create competency profiles for clinicians and for specific clinical process steps? SUMMARY ANSWER The current paper recommends six PIs to be used for monitoring clinical work in ovarian stimulation for ART, embryo transfer, and pregnancy achievement: cycle cancellation rate (before oocyte pick-up (OPU)) (%CCR), rate of cycles with moderate/severe ovarian hyperstimulation syndrome (OHSS) (%mosOHSS), the proportion of mature (MII) oocytes at ICSI (%MII), complication rate after OPU (%CoOPU), clinical pregnancy rate (%CPR), and multiple pregnancy rate (%MPR). WHAT IS KNOWN ALREADY PIs are objective measures for evaluating critical healthcare domains. In 2017, ART laboratory key PIs (KPIs) were defined. STUDY DESIGN, SIZE, DURATION A list of possible indicators was defined by a working group. The value and limitations of each indicator were confirmed through assessing published data and acceptability was evaluated through an online survey among members of ESHRE, mostly clinicians, of the special interest group Reproductive Endocrinology. PARTICIPANTS/MATERIALS, SETTING, METHODS The online survey was open for 5 weeks and 222 replies were received. Statements (indicators, indicator definitions, or general statements) were considered accepted when ≥70% of the responders agreed (agreed or strongly agreed). There was only one round to seek levels of agreement between the stakeholders. Indicators that were accepted by the survey responders were included in the final list of indicators. Statements reaching less than 70% were not included in the final list but were discussed in the paper. MAIN RESULTS AND THE ROLE OF CHANCE Cycle cancellation rate (before OPU) and the rate of cycles with moderate/severe OHSS, calculated on the number of started cycles, were defined as relevant PIs for monitoring ovarian stimulation. For monitoring ovarian response, trigger and OPU, the proportion of MII oocytes at ICSI and complication rate after OPU were listed as PIs: the latter PI was defined as the number of complications (any) that require an (additional) medical intervention or hospital admission (apart from OHSS) over the number of OPUs performed. Finally, clinical pregnancy rate and multiple pregnancy rate were considered relevant PIs for embryo transfer and pregnancy. The defined PIs should be calculated every 6 months or per 100 cycles, whichever comes first. Clinical pregnancy rate and multiple pregnancy rate should be monitored more frequently (every 3 months or per 50 cycles). Live birth rate (LBR) is a generally accepted and an important parameter for measuring ART success. However, LBR is affected by many factors, even apart from ART, and it cannot be adequately used to monitor clinical practice. In addition to monitoring performance in general, PIs are essential for managing the performance of staff over time, and more specifically the gap between expected performance and actual performance measured. Individual clinics should determine which indicators are key to the success in their organisation based on their patient population, protocols, and procedures, and as such, which are their KPIs. LIMITATIONS, REASONS FOR CAUTION The consensus values are based on data found in the literature and suggestions of experts. When calculated and compared to the competence/benchmark limits, prudent interpretation is necessary taking into account the specific clinical practice of each individual centre. WIDER IMPLICATIONS OF THE FINDINGS The defined PIs complement the earlier defined indicators for the ART laboratory. Together, both sets of indicators aim to enhance the overall quality of the ART practice and are an essential part of the total quality management. PIs are important for education and can be applied during clinical subspecialty. STUDY FUNDING/COMPETING INTEREST(S) This paper was developed and funded by ESHRE, covering expenses associated with meetings, literature searches, and dissemination. The writing group members did not receive payment. Dr G.G. reports personal fees from Merck, MSD, Ferring, Theramex, Finox, Gedeon-Richter, Abbott, Biosilu, ReprodWissen, Obseva, PregLem, and Guerbet, outside the submitted work. Dr A.D. reports personal fees from Cook, outside the submitted work; Dr S.A. reports starting a new employment in May 2020 at Vitrolife. Previously, she has been part of the Nordic Embryology Academic Team, with meetings were sponsored by Gedeon Richter. The other authors have no conflicts of interest to declare. DISCLAIMER This document represents the views of ESHRE, which are the result of consensus between the relevant ESHRE stakeholders and where relevant based on the scientific evidence available at the time of preparation. The recommendations should be used for informational and educational purposes. They should not be interpreted as setting a standard of care, or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. They do not replace the need for application of clinical judgment to each individual presentation, nor variations based on locality and facility type. Furthermore, ESHREs recommendations do not constitute or imply the endorsement, recommendation, or favouring of any of the included technologies by ESHRE.
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Affiliation(s)
| | | | | | - Antonio Capalbo
- Igenomix Italy, Marostica, Italy.,DAHFMO, Unit of Histology and Medical Embryology, Sapienza, University of Rome, Rome, Italy
| | - Arianna D'Angelo
- Wales Fertility Institute, Swansea Bay Health Board, University Hospital of Wales, Cardiff University, Cardiff, UK
| | - Luca Gianaroli
- Societa Italiana Studi di Medicina della Riproduzione, S.I.S.Me.R. Reproductive Medicine Institute, Bologna, Emilia-Romagna, Italy
| | - Georg Griesinger
- Department of Gynecological Endocrinology and Reproductive Medicine, University Hospital Schleswig-Holstein, Lubeck, Germany
| | - Efstratios M Kolibianakis
- Unit for Human Reproduction, 1st Department of ObGyn, Medical School, Aristotle University, Thessaloniki, Greece
| | | | | | | | - Sari Pelkonen
- Department of Obstetrics and Gynecology, Oulu University Hospital, University of Oulu, Medical Research Center, PEDEGO Research Unit, Oulu, Finland
| | - Daniela Romualdi
- Department of Woman and Child Health and Public Health, Woman Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Woman and Child Health, Azienda Ospedaliera Card. Panico, Tricase, Italy
| | | | - Kelly Tilleman
- Department for reproductive medicine, Universitair Ziekenhuis Gent, Gent, Belgium
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5
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Chambers GM, Keller E, Choi S, Khalaf Y, Crawford S, Botha W, Ledger W. Funding and public reporting strategies for reducing multiple pregnancy from fertility treatments. Fertil Steril 2021; 114:715-721. [PMID: 33040980 DOI: 10.1016/j.fertnstert.2020.08.1405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/22/2020] [Accepted: 08/24/2020] [Indexed: 10/23/2022]
Abstract
The health of children born through assisted reproductive technologies (ART) is particularly vulnerable to policy decisions and market forces that play out before they are even conceived. ART treatment is costly, and public and third-party funding varies significantly between and within countries, leading to considerable variation in consumer affordability globally. These relative cost differences affect not only who can afford to access ART treatment, but also how ART is practiced in terms of embryo transfer practices, with less affordable treatment creating a financial incentive to transfer more than one embryo to maximize the pregnancy rates in fewer cycles. One mechanism for reducing the burden of excessive multiple pregnancies is to link insurance coverage to the number of embryos that can be transferred; another is to combine supportive funding with patient and clinician education and public reporting that emphasizes a "complete" ART cycle (all embryo transfers associated with an egg retrieval) and penalizes multiple embryo transfers. Improving funding for fertility services in a way that respects clinician and patient autonomy and allows patients to undertake a sufficient number of cycles to minimize moral hazard improves outcomes for mothers and babies while reducing the long-term economic burden associated with fertility treatments.
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Affiliation(s)
- Georgina M Chambers
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health and School of Women's and Children's Health, University of New South Wales, Sydney, Australia.
| | - Elena Keller
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health and School of Women's and Children's Health, University of New South Wales, Sydney, Australia
| | - Stephanie Choi
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health and School of Women's and Children's Health, University of New South Wales, Sydney, Australia
| | - Yakoub Khalaf
- Reproductive Medicine and Surgery, King's College London, London, United Kingdom
| | - Sara Crawford
- Department of Mathematics, University of Mount Union, Alliance, Ohio
| | - Willings Botha
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health and School of Women's and Children's Health, University of New South Wales, Sydney, Australia; RTI Health Solutions, Health Preferences Assessment, Manchester, United Kingdom
| | - William Ledger
- School of Women's and Children's Health, University of New South Wales, Sydney, Australia
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Trias E, Nijs M, Rugescu IA, Lombardo F, Nikolov G, Provoost V, Tolpe A, Vermeulen N, Veleva Z, Piteira R, Casaroli-Marano R, Tilleman K. Evaluating risk, safety and efficacy of novel reproductive techniques and therapies through the EuroGTP II risk assessment tool. Hum Reprod 2021; 35:1821-1838. [PMID: 32728714 DOI: 10.1093/humrep/deaa146] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 04/14/2020] [Indexed: 01/12/2023] Open
Abstract
STUDY QUESTION Can risks associated with novelties in assisted reproduction technologies (ARTs) be assessed in a systematic and structured way? SUMMARY ANSWER An ART-specific risk assessment tool has been developed to assess the risks associated with the development of novelties in ART (EuroGTP II-ART). WHAT IS KNOWN ALREADY How to implement new technologies in ART is well-described in the literature. The successive steps should include testing in animal models, executing pre-clinical studies using supernumerary gametes or embryos, prospective clinical trials and finally, short- and long-term follow-up studies on the health of the offspring. A framework categorizing treatments from experimental through innovative to established according to the extent of the studies conducted has been devised. However, a systematic and standardized methodology to facilitate risk evaluation before innovations are performed in a clinical setting is lacking. STUDY DESIGN, SIZE, DURATION The EuroGTP II-ART risk assessment tool was developed on the basis of a generic risk assessment algorithm developed for tissue and cell therapies and products (TCTPs) in the context of the project 'Good Practices for demonstrating safety and quality through recipient follow-up European Good Tissue and cells Practices II (EuroGTP II)'. For this purpose, a series of four meetings was held in which eight ART experts participated. In addition, several tests and simulations were undertaken to fine-tune the final tool. PARTICIPANTS/MATERIALS, SETTING, METHODS The three steps comprising the EuroGTP II methodology were evaluated against its usefulness and applicability in ART. Ways to improve and adapt the methodology into ART risk assessment were agreed and implemented. MAIN RESULTS AND THE ROLE OF CHANCE Assessment of the novelty (Step 1), consisting of seven questions, is the same as for other TCTPs. Practical examples were included for better understanding. Identification of potential risks and consequences (Step 2), consisting of a series of risks and risk consequences to consider during risk assessment, was adapted from the generic methodology, adding more potential risks for processes involving gonadic tissues. The algorithm to score risks was also adapted, giving a specific range of highest possible risk scores. A list of strategies for risk reduction and definition of extended studies required to ensure effectiveness and safety (Step 3) was also produced by the ART experts, based on generic EuroGTP II methodology. Several explanations and examples were provided for each of the steps for better understanding within this field. LIMITATIONS, REASONS FOR CAUTION A multidisciplinary team is needed to perform risk assessment, to interpret results and to determine risk mitigation strategies and/or next steps required to ensure the safety in the clinical use of novelties. WIDER IMPLICATIONS OF THE FINDINGS This is a dynamic tool whose value goes beyond assessment of risk before implementing a novel ART in clinical practice, to re-evaluate risks based on information collected during the process. STUDY FUNDING / COMPETING INTEREST(S) This study was called EUROGTP II and was funded by the European Commission (Grant agreement number 709567). The authors declare no competing interests concerning the results of this study.
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Affiliation(s)
- Esteve Trias
- Advanced Therapies Unit, Hospital Clinic Barcelona, Leitat Technological Center, Barcelona, Spain
| | | | - Ioana Adina Rugescu
- Embryolab Academy, Thessaloniki, Greece.,Romanian Embryologists Association and Romanian Competent Authority, Romania
| | - Francesco Lombardo
- Laboratory of Seminology and Bank of Semen 'Loredana Gandini', Department of Experimental Medicine, University of Rome 'Sapienza', Rome, Italy
| | - Gueorgui Nikolov
- Laboratory of Seminology and Bank of Semen 'Loredana Gandini', Department of Experimental Medicine, University of Rome 'Sapienza', Rome, Italy
| | - Veerle Provoost
- Department of Philosophy and Moral Science, Bioethics Institute Ghent (BIG), Ghent University, Ghent, Belgium
| | - Annelies Tolpe
- Department of Reproductive Medicine, Ghent University Hospital, Ghent, Belgium
| | - Nathalie Vermeulen
- European Society of Human Reproduction and Embryology, Grimbergen, Belgium
| | - Zdravka Veleva
- Department of Obstetrics and Gynecology, Helsinki University, Helsinki University Central Hospital, Helsinki, Finland
| | - Rita Piteira
- Banc de Sang i Teixits (BST) - Barcelona Tissue Bank, Barcelona, Spain
| | | | - Kelly Tilleman
- Department of Reproductive Medicine, Ghent University Hospital, Ghent, Belgium
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Theobald R, SenGupta S, Harper J. The status of preimplantation genetic testing in the UK and USA. Hum Reprod 2021; 35:986-998. [PMID: 32329514 PMCID: PMC7192533 DOI: 10.1093/humrep/deaa034] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 10/24/2019] [Indexed: 12/31/2022] Open
Abstract
STUDY QUESTION Has the number of preimplantation genetic testing (PGT) cycles in the UK and USA changed between 2014 and 2016? SUMMARY ANSWER From 2014 to 2016, the number of PGT cycles in the UK has remained the same at just under 2% but in the USA has increased from 13% to 27%. WHAT IS KNOWN ALREADY PGT was introduced as a treatment option for couples at risk of transmitting a known genetic or chromosomal abnormality to their child. This technology has also been applied as an embryo selection tool in the hope of increasing live birth rates per transfer. ART cycles are monitored in the UK by the Human Fertilisation and Embryology Authority (HFEA) and in the USA by the Society for Assisted Reproductive Technology (SART). Globally, data are monitored via the ESHRE PGT Consortium. STUDY DESIGN, SIZE, DURATION This cross-sectional study used the HFEA and SART databases to analyse PGT cycle data and make comparisons with IVF data to examine the success of and changes in patient treatment pathways. Both data sets were analysed from 2014 to 2016. The UK data included 3385 PGT cycles and the USA data included 94 935 PGT cycles. PARTICIPANTS/MATERIALS, SETTING, METHODS Following an extensive review of both databases, filters were applied to analyse the data. An assessment of limitations of each database was also undertaken, taking into account data collection by the ESHRE PGT Consortium. In the UK and USA, the publicly available information from these datasets cannot be separated into different indications. MAIN RESULTS AND THE ROLE OF CHANCE The proportion of PGT cycles as a total of ART procedures has remained the same in the UK but increased annually in the USA from 13% to 27%. Between 2014 and 2016 inclusive, 3385 PGT cycles have been performed in the UK, resulting in 1074 PGT babies being born. In the USA 94 935 PGT cycles have been performed, resulting in 26 822 babies being born. This gave a success rate per egg collection for PGT of 32% for the UK and 28% for the USA. Analysis of the data by maternal age shows very different patient populations between the UK and USA. These differences may be related to the way PGT is funded in the UK and USA and the lack of HFEA support for PGT for aneuploidy. LIMITATIONS, REASONS FOR CAUTION Data reported by the HFEA and SART have different limitations. As undertaken by the ESHRE PGT Consortium, both data sets should separate PGT data by indication. Although the HFEA collects data from all IVF clinics in the UK, SART data only represent 83% of clinics in the USA. WIDER IMPLICATIONS OF THE FINDINGS Worldwide, a consistent reporting scheme is required in which success rates can convey the effectiveness of PGT approaches for all indications. STUDY FUNDING/COMPETING INTEREST(S) No specific funding was obtained and there are no competing interests to declare that are directly related to this project. Joyce Harper is the director of the Embryology and PGD Academy, which offers education in these fields.
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Affiliation(s)
- Rachel Theobald
- Institute for Women's Health, 86-96 Chenies Mews, University College London, London, WC1E 6HX, UK
| | - Sioban SenGupta
- Institute for Women's Health, 86-96 Chenies Mews, University College London, London, WC1E 6HX, UK
| | - Joyce Harper
- Institute for Women's Health, 86-96 Chenies Mews, University College London, London, WC1E 6HX, UK.,Institute for Women's Health, University College London, 86-96 Chenies Mews, London, WC1E 6HX, UK
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Alexopoulou E, Stormlund S, Løssl K, Prætorius L, Sopa N, Bogstad JW, Mikkelsen AL, Forman J, la Cour Freiesleben N, Vikkelsø Jeppesen J, Bergh C, Al Humaidan PSH, Grøndahl ML, Zedeler A, Pinborg AB. Embryo Morphokinetics and Blastocyst Development After GnRH Agonist versus hCG Triggering in Normo-ovulatory Women: a Secondary Analysis of a Multicenter Randomized Controlled Trial. Reprod Sci 2021; 28:2972-2981. [PMID: 33847977 DOI: 10.1007/s43032-021-00564-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/31/2021] [Indexed: 11/25/2022]
Abstract
Gonadotropin-releasing hormone agonist (GnRHa) for final oocyte maturation, along with vitrification of all usable embryos followed by transfer in a subsequent frozen-thawed cycle, is the most effective strategy to avoid ovarian hyperstimulation syndrome (OHSS). However, less is known about the ovulation induction triggers effect on early embryo development and blastocyst formation. This study is a secondary analysis of a multicenter, randomized controlled trial, with the aim to compare embryo development in normo-ovulatory women, randomized to GnRHa or human chorionic gonadotropin (hCG) trigger. In all, 4056 retrieved oocytes were observed, 1998 from the GnRHa group (216 women) and 2058 from the hCG group (218 women). A number of retrieved oocytes, mature and fertilized oocytes, and high-quality embryos and blastocysts were similar between the groups. A sub-analysis in 250 women enrolled at the main trial site including 2073 oocytes was conducted to compare embryo morphokinetics and cleavage patterns with EmbryoScope time-lapse system. In total, 1013 oocytes were retrieved from the GnRHa group (124 women) and 1060 oocytes were retrieved from the hCG group (126 women). Morphokinetic parameters and cleavage patterns were comparable between the groups. However, embryos derived from the GnRHa group were less likely to perform rolling during their development than the embryos from the hCG trigger group (OR = 0.41 (95%CI 0.25; 0.67), p-value 0.0003). The comparable results on embryo development and utilization rates between the GnRHa and hCG triggers is of clinical relevance to professionals and infertile patients, when GnRHa trigger and freeze-all is performed to avoid OHSS development. ClinicalTrials.gov Identifier: NCT02746562.
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Affiliation(s)
- Evaggelia Alexopoulou
- The Fertility Clinic, Department of Obstetrics and Gynecology, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, DK-2650, Hvidovre, Denmark.
| | - Sacha Stormlund
- The Fertility Clinic, Department of Obstetrics and Gynecology, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, DK-2650, Hvidovre, Denmark
| | - Kristine Løssl
- The Fertility Clinic, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen Ø, Denmark
| | - Lisbeth Prætorius
- The Fertility Clinic, Department of Obstetrics and Gynecology, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, DK-2650, Hvidovre, Denmark
| | - Negjyp Sopa
- The Fertility Clinic, Department of Obstetrics and Gynecology, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, DK-2650, Hvidovre, Denmark
| | - Jeanette Wulff Bogstad
- The Fertility Clinic, Department of Obstetrics and Gynecology, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, DK-2650, Hvidovre, Denmark.,The Fertility Clinic, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen Ø, Denmark
| | - Anne Lis Mikkelsen
- The Fertility Clinic, Department of Obstetrics and Gynecology, Sealland University Hospital Køge, Lykkebækvej 1, DK-4600, Køge, Denmark
| | - Julie Forman
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5B, DK-1014, Copenhagen, Denmark
| | - Nina la Cour Freiesleben
- The Fertility Clinic, Department of Obstetrics and Gynecology, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, DK-2650, Hvidovre, Denmark
| | - Janni Vikkelsø Jeppesen
- The Fertility Clinic, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen Ø, Denmark
| | - Christina Bergh
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Reproductive Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Marie Louise Grøndahl
- The Fertility Clinic, Department of Obstetrics and Gynecology, Copenhagen University Hospital Herlev, Borgmester Ib Juuls vej 9, DK-2750, Herlev, Denmark
| | - Anne Zedeler
- The Fertility Clinic, Department of Obstetrics and Gynecology, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, DK-2650, Hvidovre, Denmark
| | - Anja Bisgaard Pinborg
- The Fertility Clinic, Department of Obstetrics and Gynecology, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, DK-2650, Hvidovre, Denmark.,The Fertility Clinic, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen Ø, Denmark
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9
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De Neubourg D, Bogaerts K, Anagnostou E, Autin C, Blockeel C, Coetsier T, Delbaere A, Gillain N, Vandekerckhove F, Wyns C. Evolution of cumulative live birth and dropout rates over six complete IVF/ICSI cycles: a large prospective cohort study. Reprod Biomed Online 2021; 42:717-724. [PMID: 33518469 DOI: 10.1016/j.rbmo.2021.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 12/21/2020] [Accepted: 01/10/2021] [Indexed: 11/18/2022]
Abstract
RESEARCH QUESTION How do cumulative live birth rates (CLBR), cumulative multiple live birth rates (CMLBR) and dropout rates over six IVF and intracytoplasmic sperm injection (ICSI) cycles change over time? DESIGN Prospective longitudinal cohort (n = 16,073 patients; 48,946 cycles) starting a first fresh assisted reproductive technology cycle between 1 January 2014 and 31 December 2016, with follow-up until 31 December 2017. Outcomes between the periods 2014-2017 and 2009-2012 were compared. RESULTS Conservative estimates of CLBR after six complete cycles were significantly higher in women younger than 35 years after every cycle: one to three, adjusted P-value [p adj] < 0.0001; four, p = 0.01; five, p adj = 0.03; six, p adj = 0.04) and after the first cycle in women aged 35-37 years (p adj = 0.04) in 2014-2017 versus 2009-2012. For an optimal estimate, the CLBR was significantly higher after the first three cycles in women younger than 35 years (all p adj < 0.0001) and after the first cycle in women aged 35-37 years (p adj = 0.04). The CMLBR rate decreased from 5.1% ± 0.19 (SE) to 4.1% ± 0.16 for the conservative estimate and from 8.6% ±0.37 (SE) to 6.7% ± 0.30 for the optimal estimate after six complete cycles for the whole cohort. Dropout rates of complete cycles were 26.5% 29.4%, 33.4%, 38.9% and 47.3% after the first to fifth cycle, respectively. Compared with 2009-2012, the dropout rate in the current period was significantly higher for the first (P < 0.0001) and second (P = 0.0124) cycle. CONCLUSION Over six complete IVF/ICSI cycles, CLBR and dropout rates increased and multiple live birth rates decreased when 2014-2017 was compared with 2009-2012.
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Affiliation(s)
- Diane De Neubourg
- Center for Reproductive Medicine, Antwerp University Hospital, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijkstraat 10, Edegem 2650, Belgium.
| | - Kris Bogaerts
- I-BioStat, Katholieke Universiteit Leuven and Universiteit Hasselt, Belgium
| | | | - Candice Autin
- Centre de Procréation Medicalement Assistée, St Pierre, Brussels, Belgium
| | - Christophe Blockeel
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Anne Delbaere
- Clinique de Fertilité, Service de Gynécologie-Obstétrique, Hôpital Erasme, Université libre de Bruxelles, Brussels, Belgium
| | - Nicolas Gillain
- Nutrition, Environment and Health, University of Liège, Liège, Belgium
| | | | - Christine Wyns
- Department of Gynaecology-Andrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
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10
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Alfaidy N, Baron C, Antoine Y, Reynaud D, Traboulsi W, Gueniffey A, Lamotte A, Melloul E, Dunand C, Villaret L, Bessonnat J, Mauroy C, Boueihl T, Coutton C, Martinez G, Hamamah S, Hoffmann P, Hennebicq S, Brouillet S. Prokineticin 1 is a new biomarker of human oocyte competence: expression and hormonal regulation throughout late folliculogenesis. Biol Reprod 2020; 101:832-841. [PMID: 31276578 DOI: 10.1093/biolre/ioz114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 04/08/2019] [Accepted: 07/04/2019] [Indexed: 12/19/2022] Open
Abstract
CONTEXT Prokineticin 1 (PROK1) quantification in global follicular fluid (FF) has been recently reported as a predictive biomarker of in vitro fertilization (IVF) outcome. It is now necessary to evaluate its clinical usefulness in individual follicles. OBJECTIVES To evaluate the clinical value of PROK1 secretion in individual FF to predict oocyte competence. To determine the impact of follicular size, oocyte maturity, and gonadotropin treatments on PROK1 secretion. DESIGN AND SETTING Prospective cohort study from May 2015 to May 2017 at the University Hospital of Grenoble. PATIENTS A total of 69 infertile couples underwent IVF. INTERVENTION(S) Collection of 298 individual FF from 44 women undergoing IVF; 52 individual cumulus cell (CC) samples and 15 CC primary cultures from 25 women undergoing IVF-intracytoplasmic sperm injection (ICSI). MAIN OUTCOME MEASURE(S) Oocyte competence was defined as the ability to sustain embryo development to the blastocyst stage. Follicular size was measured by 2D-sonography. PROK1 concentration was quantified by ELISA assay. RESULTS PROK1 concentration was correlated to follicular size (r = 0.85, P = 2.2 × 10-16). Normalized PROK1 concentration in FF was predictive of subsequent oocyte competence (AUROC curve = 0.76 [95% CI, 0.69-0.83]; P = 1.7 × 10-9), irrespectively of day-2 embryo morphokinetic parameters. The expression and secretion of PROK1 were increased in FF and CC of mature oocytes (P < 0.01). Follicle Stimulating Hormone and hCG up-regulated PROK1 secretion in CC primary cultures (P < 0.01; P < 0.05), probably through the cAMP pathway (P < 0.01). CONCLUSIONS PROK1 quantification in individual FF could constitute a new predictive biomarker of oocyte competence in addition with embryo morphokinetic parameters. TRIAL REGISTRATION NUMBER none.
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Affiliation(s)
- Nadia Alfaidy
- Université Grenoble-Alpes, Inserm, Commissariat à l'énergie atomique et aux énergies alternatives (CEA), Institut de Biosciences et Biotechnologies de Grenoble (BIG), Laboratoire Biologie du Cancer et de l'Infection (BCI), 38000, Grenoble, France
| | - Chloé Baron
- Université Grenoble-Alpes, Inserm, Commissariat à l'énergie atomique et aux énergies alternatives (CEA), Institut de Biosciences et Biotechnologies de Grenoble (BIG), Laboratoire Biologie du Cancer et de l'Infection (BCI), 38000, Grenoble, France
- Centre Hospitalier Universitaire de Grenoble, Hôpital Couple-Enfant, Centre Clinique et Biologique d'Assistance Médicale à la Procréation- Centre d'étude et de conservation des œufs et du sperme humains (CECOS), 38700, La Tronche, France
- INSERM U1203, Equipe "Développement Embryonnaire Précoce Humain et Pluripotence", Institut de Médecine Régénératrice et de Biothérapie, Hôpital Saint-Eloi, Montpellier 34295, France
| | - Yannick Antoine
- INSERM U1203, Equipe "Développement Embryonnaire Précoce Humain et Pluripotence", Institut de Médecine Régénératrice et de Biothérapie, Hôpital Saint-Eloi, Montpellier 34295, France
| | - Déborah Reynaud
- Université Grenoble-Alpes, Inserm, Commissariat à l'énergie atomique et aux énergies alternatives (CEA), Institut de Biosciences et Biotechnologies de Grenoble (BIG), Laboratoire Biologie du Cancer et de l'Infection (BCI), 38000, Grenoble, France
| | - Wael Traboulsi
- Université Grenoble-Alpes, Inserm, Commissariat à l'énergie atomique et aux énergies alternatives (CEA), Institut de Biosciences et Biotechnologies de Grenoble (BIG), Laboratoire Biologie du Cancer et de l'Infection (BCI), 38000, Grenoble, France
| | - Aurore Gueniffey
- Centre Hospitalier Universitaire de Grenoble, Hôpital Couple-Enfant, Centre Clinique et Biologique d'Assistance Médicale à la Procréation- Centre d'étude et de conservation des œufs et du sperme humains (CECOS), 38700, La Tronche, France
| | - Anna Lamotte
- Centre Hospitalier Universitaire de Grenoble, Hôpital Couple-Enfant, Centre Clinique et Biologique d'Assistance Médicale à la Procréation- Centre d'étude et de conservation des œufs et du sperme humains (CECOS), 38700, La Tronche, France
| | - Eve Melloul
- Centre Hospitalier Universitaire de Grenoble, Hôpital Couple-Enfant, Centre Clinique et Biologique d'Assistance Médicale à la Procréation- Centre d'étude et de conservation des œufs et du sperme humains (CECOS), 38700, La Tronche, France
| | - Camille Dunand
- Centre Hospitalier Universitaire de Grenoble, Hôpital Couple-Enfant, Centre Clinique et Biologique d'Assistance Médicale à la Procréation- Centre d'étude et de conservation des œufs et du sperme humains (CECOS), 38700, La Tronche, France
| | - Laure Villaret
- Centre Hospitalier Universitaire de Grenoble, Hôpital Couple-Enfant, Centre Clinique et Biologique d'Assistance Médicale à la Procréation- Centre d'étude et de conservation des œufs et du sperme humains (CECOS), 38700, La Tronche, France
| | - Julien Bessonnat
- Centre Hospitalier Universitaire de Grenoble, Hôpital Couple-Enfant, Centre Clinique et Biologique d'Assistance Médicale à la Procréation- Centre d'étude et de conservation des œufs et du sperme humains (CECOS), 38700, La Tronche, France
| | - Charlotte Mauroy
- Centre Hospitalier Universitaire de Grenoble, Hôpital Couple-Enfant, Centre Clinique et Biologique d'Assistance Médicale à la Procréation- Centre d'étude et de conservation des œufs et du sperme humains (CECOS), 38700, La Tronche, France
| | - Thomas Boueihl
- Centre Hospitalier Universitaire de Grenoble, Hôpital Couple-Enfant, Centre Clinique et Biologique d'Assistance Médicale à la Procréation- Centre d'étude et de conservation des œufs et du sperme humains (CECOS), 38700, La Tronche, France
| | - Charles Coutton
- Université Grenoble-Alpes, Inserm, Institute for Advanced Biosciences (IAB), équipe Génétique Epigénétique et Thérapie de l'Infertilité (GETI), 38000, Grenoble, France
- Centre Hospitalier Universitaire de Grenoble, Hôpital Couple Enfant, Département de Génétique et Procréation, Laboratoire de Génétique Chromosomique, 38700, La Tronche, France
| | - Guillaume Martinez
- Centre Hospitalier Universitaire de Grenoble, Hôpital Couple Enfant, Département de Génétique et Procréation, Laboratoire de Génétique Chromosomique, 38700, La Tronche, France
| | - Samir Hamamah
- INSERM U1203, Equipe "Développement Embryonnaire Précoce Humain et Pluripotence", Institut de Médecine Régénératrice et de Biothérapie, Hôpital Saint-Eloi, Montpellier 34295, France
- CHU Montpellier, ART/PGD Division, Hôpital Arnaud de Villeneuve, Montpellier 34295, France
| | - Pascale Hoffmann
- Université Grenoble-Alpes, Inserm, Commissariat à l'énergie atomique et aux énergies alternatives (CEA), Institut de Biosciences et Biotechnologies de Grenoble (BIG), Laboratoire Biologie du Cancer et de l'Infection (BCI), 38000, Grenoble, France
- Centre Hospitalier Universitaire de Grenoble, Hôpital Couple-Enfant, Centre Clinique et Biologique d'Assistance Médicale à la Procréation- Centre d'étude et de conservation des œufs et du sperme humains (CECOS), 38700, La Tronche, France
| | - Sylviane Hennebicq
- Centre Hospitalier Universitaire de Grenoble, Hôpital Couple-Enfant, Centre Clinique et Biologique d'Assistance Médicale à la Procréation- Centre d'étude et de conservation des œufs et du sperme humains (CECOS), 38700, La Tronche, France
- Université Grenoble-Alpes, Inserm, Institute for Advanced Biosciences (IAB), équipe Génétique Epigénétique et Thérapie de l'Infertilité (GETI), 38000, Grenoble, France
| | - Sophie Brouillet
- Université Grenoble-Alpes, Inserm, Commissariat à l'énergie atomique et aux énergies alternatives (CEA), Institut de Biosciences et Biotechnologies de Grenoble (BIG), Laboratoire Biologie du Cancer et de l'Infection (BCI), 38000, Grenoble, France
- Centre Hospitalier Universitaire de Grenoble, Hôpital Couple-Enfant, Centre Clinique et Biologique d'Assistance Médicale à la Procréation- Centre d'étude et de conservation des œufs et du sperme humains (CECOS), 38700, La Tronche, France
- INSERM U1203, Equipe "Développement Embryonnaire Précoce Humain et Pluripotence", Institut de Médecine Régénératrice et de Biothérapie, Hôpital Saint-Eloi, Montpellier 34295, France
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11
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Brouillet S, Martinez G, Coutton C, Hamamah S. Is cell-free DNA in spent embryo culture medium an alternative to embryo biopsy for preimplantation genetic testing? A systematic review. Reprod Biomed Online 2020; 40:779-796. [PMID: 32417199 DOI: 10.1016/j.rbmo.2020.02.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 01/29/2020] [Accepted: 02/02/2020] [Indexed: 12/17/2022]
Abstract
Preimplantation genetic testing (PGT) is increasingly used worldwide. It currently entails the use of invasive techniques, i.e. polar body, blastomere, trophectoderm biopsy or blastocentesis, to obtain embryonic DNA, with major technical limitations and ethical issues. Evidence suggests that invasive PGT can lead to genetic misdiagnosis in the case of embryo mosaicism, and, consequently, to the selection of affected embryos for implantation or to the destruction of healthy embryos. Recently, spent culture medium (SCM) has been proposed as an alternative source of embryonic DNA. An increasing number of studies have reported the detection of cell-free DNA in SCM and highlighted the diagnostic potential of non-invasive SCM-based PGT for assessing the genetic status of preimplantation human embryos obtained by IVF. The reliability of this approach for clinical applications, however, needs to be determined. In this systematic review, published evidence on non-invasive SCM-based PGT is presented, and its current benefits and limitations compared with invasive PGT. Then, ways of optimizing and standardizing procedures for non-invasive SCM-based PGT to prevent technical biases and to improve performance in future studies are discussed. Finally, clinical perspectives of non-invasive PGT are presented and its future applications in reproductive medicine highlighted.
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Affiliation(s)
- Sophie Brouillet
- Université Grenoble-Alpes, Inserm 1036, Commissariat à l'énergie atomique et aux énergies alternatives (CEA), Institut de Biosciences et Biotechnologies de Grenoble (BIG), Laboratoire Biologie du Cancer et de l'Infection (BCI), Grenoble 38000, France; Centre Hospitalier Universitaire de Grenoble, Hôpital Couple-Enfant, Centre Clinique et Biologique d'Assistance Médicale à la Procréation- Centre d'étude et de conservation des œufs et du sperme humains (CECOS), La Tronche 38700, France; INSERM U1203, Equipe "Développement Embryonnaire Précoce Humain et Pluripotence", Institut de Médecine Régénératrice et de Biothérapie, Hôpital Saint-Eloi, Montpellier 34295, France
| | - Guillaume Martinez
- Université Grenoble-Alpes, Inserm, Institute for Advanced Biosciences (IAB), équipe Génétique Epigénétique et Thérapie de l'Infertilité (GETI), Grenoble 38000, France; Centre Hospitalier Universitaire de Grenoble, Hôpital Couple Enfant, Département de Génétique et Procréation, Laboratoire de Génétique Chromosomique, La Tronche 38700, France
| | - Charles Coutton
- Université Grenoble-Alpes, Inserm, Institute for Advanced Biosciences (IAB), équipe Génétique Epigénétique et Thérapie de l'Infertilité (GETI), Grenoble 38000, France; Centre Hospitalier Universitaire de Grenoble, Hôpital Couple Enfant, Département de Génétique et Procréation, Laboratoire de Génétique Chromosomique, La Tronche 38700, France
| | - Samir Hamamah
- INSERM U1203, Equipe "Développement Embryonnaire Précoce Humain et Pluripotence", Institut de Médecine Régénératrice et de Biothérapie, Hôpital Saint-Eloi, Montpellier 34295, France; CHU Montpellier, ART/PGD Division, Hôpital Arnaud de Villeneuve, Montpellier, Cedex 5, Montpellier 34295, France.
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12
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Duffy JMN, Bhattacharya S, Curtis C, Evers JLH, Farquharson RG, Franik S, Khalaf Y, Legro RS, Lensen S, Mol BW, Niederberger C, Ng EHY, Repping S, Strandell A, Torrance HL, Vail A, van Wely M, Vuong NL, Wang AY, Wang R, Wilkinson J, Youssef MA, Farquhar CM. A protocol developing, disseminating and implementing a core outcome set for infertility. Hum Reprod Open 2018; 2018:hoy007. [PMID: 30895248 PMCID: PMC6276643 DOI: 10.1093/hropen/hoy007] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 04/12/2018] [Indexed: 12/13/2022] Open
Abstract
STUDY QUESTIONS We aim to produce, disseminate and implement a core outcome set for future infertility research. WHAT IS KNOWN ALREADY Randomized controlled trials (RCTs) evaluating infertility treatments have reported many different outcomes, which are often defined and measured in different ways. Such variation contributes to an inability to compare, contrast and combine results of individual RCTs. The development of a core outcome set will ensure outcomes important to key stakeholders are consistently collected and reported across future infertility research. STUDY DESIGN, SIZE, DURATION This is a consensus study using the modified Delphi method. All stakeholders, including healthcare professionals, allied healthcare professionals, researchers and people with lived experience of infertility will be invited to participate. PARTICIPANTS/MATERIALS, SETTING, METHODS An international steering group, including people with lived experience of infertility, healthcare professionals, allied healthcare professionals and researchers, has been formed to guide the development of this core outcome set. Potential core outcomes have been identified through a comprehensive literature review of RCTs evaluating treatments for infertility and will be entered into a modified Delphi method. Participants will be asked to score potential core outcomes on a nine-point Likert scale anchored between one (not important) and nine (critical). Repeated reflection and rescoring should promote convergence towards consensus ‘core’ outcomes. We will establish standardized definitions and recommend high-quality measurement instruments for individual core outcomes. STUDY FUNDING/COMPETING INTEREST(S) This project is funded by the Royal Society of New Zealand Catalyst Fund (3712235). BWM reports consultancy fees from Guerbet, Merck, and ObsEva. R.S.L. reports consultancy fees from Abbvie, Bayer, Fractyl and Ogeda and research sponsorship from Ferring. S.B. is the Editor-in-Chief of Human Reproduction Open. The remaining authors declare no competing interests.
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Affiliation(s)
- J M N Duffy
- Balliol College, University of Oxford, Oxford, UK.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - S Bhattacharya
- Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - C Curtis
- Fertility New Zealand, Auckland, New Zealand.,School of Psychology, University of Waikato, Hamilton, New Zealand
| | - J L H Evers
- Centre for Reproductive Medicine and Biology, University Medical Centre Maastricht, Maastricht, The Netherlands
| | - R G Farquharson
- Department of Obstetrics and Gynaecology, Liverpool Women's NHS Foundation Trust, Liverpool, UK
| | - S Franik
- Department of Obstetrics and Gynaecology, Münster University Hospital, Münster, Germany
| | - Y Khalaf
- Assisted Conception Unit, Guy's Hospital, London, UK
| | - R S Legro
- Department of Obstetrics and Gynaecology, Penn State College of Medicine, PA, USA
| | - S Lensen
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - B W Mol
- Department of Obstetrics and Gynaecology, School of Medicine, Monash University, Melbourne, Australia
| | - C Niederberger
- Department of Urology, University of Illinois at Chicago College of Medicine, Chicago, IL, USA
| | - E H Y Ng
- Department of Obstetrics and Gynaecology, The University of Hong Kong, Hong Kong
| | - S Repping
- Center for Reproductive Medicine, Amsterdam Reproduction and Development Institute, Academic Medical Centre, Amsterdam, The Netherlands
| | - A Strandell
- Sahlgrenska University Hospital, Göteborg, Sweden
| | - H L Torrance
- Department of Reproductive Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - A Vail
- Centre for Biostatistics, University of Manchester, Manchester, UK
| | - M van Wely
- Center for Reproductive Medicine, Amsterdam Reproduction and Development Institute, Academic Medical Centre, Amsterdam, The Netherlands
| | - N L Vuong
- Department of Obstetrics and Gynaecology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - A Y Wang
- Faculty of Health, University of Technology Sydney, Broadway, Australia
| | - R Wang
- Robinson Research Institute and Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - J Wilkinson
- Centre for Biostatistics, University of Manchester, Manchester, UK
| | - M A Youssef
- Department of Obstetrics & Gynaecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - C M Farquhar
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
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13
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Wilkinson J, Roberts SA, Vail A. Developments in IVF warrant the adoption of new performance indicators for ART clinics, but do not justify the abandonment of patient-centred measures. Hum Reprod 2018; 32:1155-1159. [PMID: 28369394 DOI: 10.1093/humrep/dex063] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 03/13/2017] [Indexed: 11/14/2022] Open
Abstract
Recent advances in embryo freezing technology together with growing concerns over multiple births have shifted the paradigm of appropriate IVF. This has led to the adoption of new performance indicators for ART clinics by national reporting schemes, such as those curated by the Society for Assisted Reproductive Technology (SART) and the Human Fertilization and Embryology Authority (HFEA). Using these organizations as case studies, we review several outcome measures from a statistical perspective. We describe several denominators that are used to calculate live birth rates. These include cumulative birth rates calculated from all fresh and frozen transfer procedures arising from a particular egg collection or cycle initiation, and live birth rates calculated per embryo transferred. Using data from both schemes, we argue that all cycles should be included in the denominator, regardless of whether or not egg collection and fertilization were successful. Excluding cancelled cycles reduces the impact of confounding due to patient characteristics but also removes policy and performance differences which we argue represent relevant sources of variation. It may be misleading to present prospective patients with essentially hypothetical measures of performance predicated on parity of ovarian stimulation and transfer policies. Although live birth per embryo has the advantage of encouraging single embryo transfer, we argue that it is prone to misinterpretation. This is because the likelihood of live birth is not proportional to the number of embryos transferred. We conclude that it is not possible to present a single measure that encompasses both effectiveness and safety. Instead, we propose that a set of clear, relevant outcome indicators is necessary to enable subfertile patients to make informed choices regarding whether and where to be treated.
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Affiliation(s)
- J Wilkinson
- Centre for Biostatistics, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC), University of Manchester, Room 1.315, Jean McFarlane Building, University Place, Oxford Road, Manchester, M13 9PL, UK.,Research and Development, Salford Royal NHS Foundation Trust, Summerfield House, Stott Lane, Salford, M6 8HD, UK
| | - S A Roberts
- Centre for Biostatistics, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC), University of Manchester, Room 1.315, Jean McFarlane Building, University Place, Oxford Road, Manchester, M13 9PL, UK
| | - A Vail
- Centre for Biostatistics, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC), University of Manchester, Room 1.315, Jean McFarlane Building, University Place, Oxford Road, Manchester, M13 9PL, UK.,Research and Development, Salford Royal NHS Foundation Trust, Summerfield House, Stott Lane, Salford, M6 8HD, UK
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Arab-Zozani M, Nastri CO. Single versus double intrauterine insemination (IUI) for pregnancy: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2017; 215:75-84. [PMID: 28605667 DOI: 10.1016/j.ejogrb.2017.05.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 05/09/2017] [Accepted: 05/25/2017] [Indexed: 12/27/2022]
Abstract
This study is focused in appraising the current evidence comparing double and single IUI for achieving a pregnancy. The primary outcomes were live birth and ectopic pregnancy per women randomized. Secondary outcomes included clinical pregnancy and miscarriage. The evaluation of the risk of bias within each study was structured using the Cochrane risk of bias and the overall quality of the body of evidence was assessed through the GRADE criteria. Electronic searches were run in 4 databases and resulted in 15 studies included encompassing 3795 women. The subgroup 'mild male infertility' included 1246 women whilst the subgroup 'normal semen quality' included 1188 women. Clinical pregnancy was reported by all studies, and there is no evidence of a difference between single and double IUI (RR 1.22, CI 0.97 to 1.54, 15 RCTs, 3795 women, I2=45%). In the subgroup analysis, we could not identify a particular group that could benefit from the intervention. No conclusion can be drawn regarding live birth, ectopic pregnancy, and miscarriage because they were reported by too few studies and the estimates were too imprecise. Currently, there is no evidence to support the use of double IUI in clinical practice. It requires a second appointment and insemination, thus making the treatment more complex and expensive, without a clear evidence of a benefit. Nevertheless, evidence is still of low quality and our confidence in the effect estimate is limited: the true effect may be substantially different from the hereby demonstrated.
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Affiliation(s)
- Morteza Arab-Zozani
- Iranian Center of Excellence in Health Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
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Martins WP, Nastri CO, Rienzi L, van der Poel SZ, Gracia C, Racowsky C. Blastocyst vs cleavage-stage embryo transfer: systematic review and meta-analysis of reproductive outcomes. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:583-591. [PMID: 27731533 DOI: 10.1002/uog.17327] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 10/04/2016] [Indexed: 05/26/2023]
Abstract
OBJECTIVES Blastocyst transfer in assisted reproduction techniques could be advantageous because the timing of exposure of the embryo to the uterine environment is more analogous to a natural cycle and permits embryo self-selection after activation of the embryonic genome on day 3. Conversely, the in-vitro environment is likely to be inferior to that in vivo, and in-vitro culture beyond embryonic genomic activation could potentially harm the embryo. Our objective was to identify, appraise and summarize the available evidence comparing the effectiveness of blastocyst vs cleavage-stage embryo transfer. METHODS This was a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing the transfer of blastocysts (days 5-6) with the transfer of cleavage-stage embryos (days 2-3) in women undergoing in-vitro fertilization or intracytoplasmic sperm injection. The last electronic searches were run on 1 August 2016. Abstracts and studies with a mean difference between the two study groups of > 0.5 for the number of embryos transferred were excluded. RESULTS We screened 1187 records and assessed 33 potentially eligible studies. Twelve studies were included, comprising a total of 1200 women undergoing blastocyst transfer and 1218 undergoing cleavage-stage embryo transfer. We observed low-quality evidence of no significant difference of blastocyst transfer on live birth/ongoing pregnancy (relative risk (RR), 1.11 (95% CI, 0.92-1.35), 10 RCTs, 1940 women, I2 = 54%), clinical pregnancy (RR, 1.10 (95% CI, 0.93-1.31), 12 RCTs, 2418 women, I2 = 64%), cumulative pregnancy (RR, 0.89 (95% CI, 0.67-1.16), four RCTs, 524 women, I2 = 63%) and miscarriage (RR, 1.08 (95% CI, 0.74-1.56), 10 RCTs, 763 pregnancies, I2 = 0%). There was moderate-quality evidence of a decrease in the number of women with surplus embryos after the blastocyst-stage embryo transfer (RR, 0.78 (95% CI, 0.66-0.91)). Overall, the quality of the evidence was limited by the quality of the included studies and by unexplained inconsistency across studies. CONCLUSIONS Current evidence shows no superiority of blastocyst compared with cleavage-stage embryo transfer in clinical practice. As the quality of the evidence for the primary outcomes is low, additional well-designed RCTs are still needed before robust conclusions can be drawn. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- W P Martins
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
- Department of Obstetrics and Gynecology, Ribeirão Preto Medical School, University of Sao Paulo, Ribeirão Preto, Brazil
| | - C O Nastri
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
| | - L Rienzi
- GENERA Centre for Reproductive Medicine, Clinica Valle Giulia, Rome, Italy
| | - S Z van der Poel
- HRP (the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction), Geneva, Switzerland
- Population Council, Reproductive Health Program, New York, NY, USA
| | - C Gracia
- Division of Reproductive Endocrinology, University of Pennsylvania, Philadelphia, PA, USA
| | - C Racowsky
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Martins WP, Nastri CO, Rienzi L, van der Poel SZ, Gracia CR, Racowsky C. Obstetrical and perinatal outcomes following blastocyst transfer compared to cleavage transfer: a systematic review and meta-analysis. Hum Reprod 2016; 31:2561-2569. [PMID: 27907898 DOI: 10.1093/humrep/dew244] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 08/19/2016] [Accepted: 08/31/2016] [Indexed: 01/11/2023] Open
Abstract
STUDY QUESTION Is blastocyst transfer safe when compared to cleavage stage embryo transfer regarding obstetric and perinatal outcomes? SUMMARY ANSWER The clinical equipoise between blastocyst and cleavage stage embryo transfer remains as the evidence associating blastocyst transfer with some adverse perinatal outcomes is of low/very low quality. WHAT IS KNOWN ALREADY Extended embryo culture to the blastocyst stage provides some theoretical advantages and disadvantages. While it permits embryo self-selection, it also exposes those embryos to possible harm due to the in vitro environment. Both effectiveness and safety should be weighed to permit evidence-based decisions in clinical practice. STUDY DESIGN, SIZE, DURATION This is a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies reporting perinatal outcomes for singletons comparing the deliveries resulting from blastocyst and cleavage stage embryo transfer. Observational studies were included because the primary outcomes, perinatal mortality and birth defects, are rare and require a large number of participants (>50 000) to be properly assessed. The last electronic searches were last run on 11 March 2016. PARTICIPANTS/MATERIALS, SETTING, METHOD There were 12 observational studies encompassing 195 325 singleton pregnancies included in the study. No RCT reported the studied outcomes. The quality of the included studies was evaluated according to the Newcastle-Ottawa Scale and the quality of the evidence was evaluated according to GRADE criteria. MAIN RESULTS AND THE ROLE OF CHANCE Blastocyst stage transfer was associated with increased risks of preterm birth (<37 weeks), very preterm birth (<32 weeks), large for gestational age and perinatal mortality, although the latter was only identified from one study. Conversely, blastocyst stage transfer was associated with a decrease in the risks of small for gestational age and vanishing twins, although the latter was reported by only one study. LIMITATIONS, REASONS FOR CAUTION The observational nature of the included studies and some inconsistency and imprecision in the analysis contributed to decreasing our confidence in the estimates. WIDER IMPLICATIONS OF THE FINDINGS Due to the overall low quality of available evidence, the clinical equipoise between cleavage stage and blastocyst transfer remains. More large well-conducted studies are needed to clarify the potential risks and benefits of blastocyst transfer. As this review was initiated to support global recommendations on best practice, and in light of the challenges in lower resource settings to offer extended culture to blastocyst stage, it is critical to take into consideration these obstetric and neonatal outcomes in order to ensure any recommendation will not result in the overburdening of existing maternal and child health care systems and services. STUDY FUNDING/COMPETING INTERESTS No external funding was either sought or obtained for this study. The authors have no competing interests to declare. PROSPERO REGISTRATION NUMBER CRD42015023910.
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Affiliation(s)
- W P Martins
- Department of Obstetrics and Gynecology, Ribeirao Preto Medical School, University of Sao Paulo, Av. Bandeirantes, 3900 - Monte Alegre, Ribeirao Preto - SP, 14049-900, Brazil
| | - C O Nastri
- SMEAR fertilidade, Reproductive Medicine, Av. Aurea Aparecida Bragheto Machado, 220 - City Ribeirao, Ribeirao Preto - SP, 14021-570, Brazil
| | - L Rienzi
- GENERA Centre for Reproductive Medicine, Clinica Valle Giulia, via de Notaris 2b, Rome, Italy
| | - S Z van der Poel
- HRP (UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction), Avenue Appia 20, 1211 Geneva, Switzerland (at the time of the study); Population Council, Reproductive Health Programme, Center for Biomedical Research, 1230 York Ave, New York, NY 10065, USA
| | - C R Gracia
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Pennsylvania, 3701 Market Street, Suite 800, Philadelphia, PA 19104, USA
| | - C Racowsky
- Division of Reproductive Medicine, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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Abstract
In 2004, Human Reproduction published a debate series focusing on the rising tide of multiple pregnancy associated with IVF. The premise of the primary report in that debate was that by considering IVF outcomes differently-by focusing on healthy singleton birth at term rather than clinical pregnancy, the standard currency at that time-the necessary shift toward reduced numbers of embryos transferred might be accelerated. The choice of end-point in that debate-Birth Emphasizing a Successful Singleton at Term (BESST)-was not an effort to 'dumb down' the complex equation linking risks and benefits. That balance is a dynamic and various mix of issues that clinicians discuss with patients on a daily basis. And BESST was certainly not proposed as a new primary outcome for application to other treatment modalities in reproductive medicine, such as ovulation induction. It was simply a responsible and brave call for change in the accelerating and competitive world of IVF.
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Affiliation(s)
- Edward G Hughes
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, ON, Canada L8N 3Z5
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Abstract
In this issue of Human Reproduction, a debate article presents a charge to balance effectiveness and safety in Reproductive Medicine. This debate contribution applauds the dialogue opened and constructive opinions that are presented. However, several additional issues are suggested for consideration. Safety must be more broadly considered beyond the achievement of a healthy singleton pregnancy, with reproductive medicine a unique field that has the potential to impact the health and wellbeing of multiple people at one time. Many fields have grappled with the need to balance effective treatment with unintended harms, and reproductive medicine should capitalize upon that body of literature. Finally, to maximize both efficacy and safety in reproductive medicine, there is no replacement for the conduct of well powered, rigorously designed, highly generalizable, multidisciplinary studies.
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Affiliation(s)
- Stacey A Missmer
- Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA Boston Center for Endometriosis, Boston Children's Hospital and Brigham and Women's Hospital, Boston, MA, USA Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA
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Nastri CO, Nóbrega BN, Teixeira DM, Amorim J, Diniz LM, Barbosa MW, Giorgi VS, Pileggi VN, Martins WP. Low versus atmospheric oxygen tension for embryo culture in assisted reproduction: a systematic review and meta-analysis. Fertil Steril 2016; 106:95-104.e17. [DOI: 10.1016/j.fertnstert.2016.02.037] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 02/18/2016] [Accepted: 02/22/2016] [Indexed: 01/02/2023]
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