Cumulative live birth rates following intrauterine insemination using donor and husband sperm in different age groups: A cohort study of 10 415 insemination cycles

OBJECTIVES

To assess the age-specific cumulative live birth rates (CLBRs) in intrauterine insemination (IUI) cycles using either donor or husband sperm, and to investigate the impact of sperm sources on IUI success among women within the same age group.

METHODS

This retrospective cohort study comprised women who underwent IUI with donor sperm (IUI-D) or husband sperm (IUI-H) from 2017 to 2021. The women were stratified based on their age at the initiation of insemination into four categories: <35, 35-37, 38-39 and ≥40 years.

RESULTS

A total of 5253 women undergoing 10 415 insemination cycles (3354 with IUI-D and 7061 with IUI-H) were included. The CLBRs decreased significantly with increasing maternal age within donor and husband insemination groups (P < 0.001). In the IUI-D group, the crude CLBRs were 61.50% in women aged <35, 48.91% in 35-37, 24.14% in 38-39 and 11.76% in the ≥40-year age category, respectively. The corresponding rates in the IUI-H group were 27.62%, 22.96%, 13.73% and 6.90%, respectively. Within the <35 and 35-37-year age categories, the CLBRs were significantly higher following IUI-D cycles compared to IUI-H cycles, with hazard ratios (HR) of 1.85 (1.68-2.04) and 1.69 (1.16-2.47), respectively. However, within the 38-39 and ≥40-year age categories, both IUI-D and IUI-H resulted in comparable low CLBRs, with HRs of 1.91 (0.77-4.76) and 1.80 (0.33-9.86), respectively.

CONCLUSION

Advanced maternal age affects the whole process of fertility. Therefore, it could be reasonable to limit the number of IUI performed in women aged 40 years and older, even in couple using donor sperm for reproduction.

A 10-year follow-up of reproductive outcomes in women attempting motherhood after elective oocyte cryopreservation

STUDY QUESTION

Which reproductive treatment outcomes are observed in women who underwent elective oocyte cryopreservation (EOC) and who returned to the clinic with a desire for a child?

SUMMARY ANSWER

Whether to warm oocytes or to first use fresh own oocytes for ART depends on age upon returning, but both strategies result in favorable reproductive outcomes.

WHAT IS KNOWN ALREADY

Most affluent countries have observed a trend toward postponement of childbearing, and EOC is increasingly used based on the assumption that oocytes cryopreserved at a younger age may extend a woman's reproductive lifespan and mitigate her age-related fertility decline. Although most follow-up studies after EOC have focused on women who requested oocyte warming, a substantial proportion of women who do not conceive naturally will embark on fertility treatment without using their cryopreserved oocytes. Reports on reproductive outcomes in past EOC users are scarce, and the lack of reproductive treatment algorithms in this group of women hampers counseling toward the most efficient clinical strategy.

STUDY DESIGN, SIZE, DURATION

This retrospective observational single-center study encompasses 843 women who had elective oocyte vitrification between 2009 and 2019 at our fertility clinic. Women who underwent fertility preservation for medical or oncological reasons were excluded. This study describes the outcomes of the diverse reproductive treatment strategies performed until May 2022 in women returning to our clinic to attempt motherhood.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Using descriptive statistics, patient characteristics and data of ovarian stimulation (OS) of EOC cycles were analyzed, as well as data related to OS and laboratory data of ART in women who pursued fertility treatment with and/or without using their cryopreserved oocytes. The primary outcome was live birth rate (LBR) per patient after oocyte warming and after ART using fresh oocytes. Secondary outcomes were return rate, utilization rate of the cryopreserved oocytes, laboratory outcomes upon return, and LBR per embryo transfer. A multivariable regression model was developed to identify factors associated with the decision to thaw oocytes as the primary strategy and factors associated with ongoing pregnancy upon return to the clinic.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 1353 EOC cycles (mean ± SD, 1.6 ± 0.9 per patient) were performed. At the time of EOC, the mean age was 36.5 ± 2.8 years, mean anti-Müllerian hormone (AMH) was 2.3 ± 2.0 ng/ml, and 174 (20.6%) women had a partner. On average, 13.9 ± 9.2 mature oocytes were cryopreserved. Two hundred thirty-one (27.4%) women returned to the clinic, an average of 39.9 ± 23.4 months after EOC. Upon returning, their mean age was 40.4 ± 3.1 years, mean AMH was 1.5 ± 1.5 ng/ml, and 158/231 (68.3%) patients had a partner. As a primary approach, 110/231 (47.6%) past EOC users embarked on oocyte warming, 50/231 (21.6%) had intrauterine insemination, and 71/231 (30.7%) had ART using fresh own oocytes. Cumulative LBR (CLBR) was 45.9% (106/231) notwithstanding a miscarriage rate (MR) of 30.7% (51/166) in the entire cohort. In total, 141 women performed oocyte warming at some stage in their treatment trajectory. A subset of 90/231 (39.0%) patients exclusively had oocyte warming (41.6 ± 3.0 years, with 10.0 ± 5.2 oocytes warmed per patient). 52/231 (22.5%) patients exclusively had ART using fresh own oocytes (mean age of 39.0 ± 2.8 years, with 9.9 ± 7.4 mature oocytes retrieved per patient). CLBR was 37/90 (41.1%) in the oocyte warming-only group and 25/52 (48.1%) in the OS-only group. MR/transfer was 25.0% and 29.3% in the oocyte warming-only group and the OS-only group, respectively.

LIMITATIONS, REASONS FOR CAUTION

Both sample size and the retrospective design are limitations of this study. The decision to embark on a specific reproductive treatment strategy was based on patient preference, after counseling on their treatment options. This precludes direct comparison of the efficiency of reproductive treatment options in past EOC users in this study.

WIDER IMPLICATIONS OF THE FINDINGS

Reporting on clinical outcomes of women who underwent EOC and returned to the clinic to embark on divergent reproductive treatment strategies is mandatory to establish guidelines for best clinical practice in this growing patient population.

STUDY FUNDING/COMPETING INTEREST(S)

None.

TRIAL REGISTRATION NUMBER

N/A.

Should IUI replace IVF as first-line treatment for unexplained infertility? A literature review

BACKGROUND

Unexplained infertility accounts for 25% of infertility causes in the UK. Active intervention methods, such as intrauterine insemination (IUI) or in vitro fertilisation (IVF), are often sought. Despite the National Institute for Health and Care Excellence (NICE) recommending IVF for unexplained infertility, this recommendation has generated an ongoing debate, with few fertility clinics discontinuing the use of IUI as the first-line management of choice. In contrast to NICE, recent guidance released from the European Society for Human Reproduction and Embryology (ESHRE) in August 2023 supports the use of IUI as first-line. High-quality evidence behind such interventions is lacking, with current literature providing conflicting results.

AIMS

This review aims to provide a literature overview exploring whether IUI or IVF should be used as first-line treatment for couples with unexplained infertility, in the context of current guidelines.

METHODS

The primary outcome used to assess efficacy of both treatment methods is live birth (LB) rates. Secondary outcomes used are clinical pregnancy (CP) and ongoing pregnancy (OP) rates. A comprehensive literature search of 4 databases: Ovid MEDLINE, EMBASE, Maternity & Infant Care and the Cochrane Library were searched in January 2022. Upon removal of duplications, abstract screening, and full-text screening, a total of 34 papers were selected.

DISCUSSION/CONCLUSION

This review highlights a large discrepancy in the literature when examining pregnancy outcomes of IUI and IVF treatments. Evidence shows IUI increases LB and CP rates 3-fold compared to expectant management. Literature comparing IUI to IVF is less certain. The review finds the literature implies IVF should be used for first-line management but the paucity of high-quality randomised controlled trials (RCTs), coupled with heterogeneity of the identified studies and a lack of research amongst women > 40 years warrants the need for further large RCTs. The decision to offer IUI with ovarian stimulation (IUI-OS) or IVF should be based upon patient prognostic factors. We suggest that IUI-OS could be offered as first-line treatment for unexplained infertility for women < 38 years, with good prognosis, and IVF could be offered first to those > 38 years. Patients should be appropriately counselled to enable informed decision making.

Aspiration with Diosmin Intake in Endometrial Cavity Fluid Accumulation in ART Cycles: A Randomized Controlled Trial

Background

This was a prospective randomized controlled trial in 200 cases presented with endometrial cavity fluid at the day of oocyte retrieval at a private fertility center from 2013 to 2021. The cases were randomized at day of ovum pickup into 2 groups: Group 1 (control group) (n = 100): conventional management with follow-up and reassessment by transvaginal ultrasound on day 5. Group 2 (interventional group) (n = 100): aspiration of the fluid was done and cases were given diosmin 500 mg 3 times per day till reassessment at embryo transfer day. In both groups, we proceeded with fresh embryo transfer if no fluid is present on day 5 or freeze-all policy if persistent fluid was detected.

Results

Endometrial fluid on the 5th day was significantly higher in the control group (28.0%) than in the interventional group (6.0%) (P < 0.001). Regarding pregnancy rate, although being higher in the interventional group (54.3% vs 50.0%), the difference was not statistically significant (P = 0.5). It was found that the intervention was associated with risk reduction of endometrial fluid (OR = 0.168, 95% CI = 0.065-0.429, P < 0.001.

Conclusion

Aspiration of endometrial cavity fluid with diosmin intake increased the likelihood of fresh embryo transfer and with a slightly better pregnancy rate compared to conservative management.Clinical trial number: NCT02158000, Date of registration: 6/6/2014, Date of initial enrollment (first patient recruiting): 1/11/2014, URL: https://clinicaltrials.gov/ct2/show/NCT02158000.

Risk of ovarian cancer in women who give birth after assisted reproductive technology (ART)-a registry-based Nordic cohort study with follow-up from first pregnancy

BACKGROUND

There is concern that assisted reproductive technology (ART) may increase ovarian cancer risk, but previous studies are inconclusive. We compared ovarian cancer risk for women who gave birth after ART vs natural conception.

METHODS

Through linkage of nationwide registry data, we followed 3,303,880 initially nulliparous women in Denmark (1994-2014), Finland (1990-2014), Norway (1984-2015) and Sweden (1985-2015) from first pregnancy ≥22 weeks to ovarian cancer, emigration, death or end of follow-up (2014/2015). We estimated hazard ratios (HRs), adjusting for age, parity, maternal birth year and country, and for body mass index and smoking in subsamples.

RESULTS

Mean age at first birth was 27.7 years. During a mean follow-up of 14.4 person-years, 2683 participants (0.08%) developed ovarian cancer; 135 after ART and 2548 after natural conception only (incidence rates 11.6 and 5.5 per 100,000 person-years, respectively). The risk was higher for women who ever gave birth after ART (HR 1.70, 95% confidence interval 1.42-2.03) compared to natural conception. Associations were stronger for conventional in vitro fertilisation than for intracytoplasmic sperm injection.

CONCLUSIONS

Among parous women, ART-conception was associated with a higher risk of ovarian cancer than natural conception. Further studies should decipher whether this is causal or confounded by infertility or other factors.

Low-grade inflammation is negatively associated with live birth in women undergoing IVF

RESEARCH QUESTION

Is low-grade inflammation, detected by C-reactive protein (CRP), a marker of IVF outcome addressing both blastocyst quality and pregnancy outcome?

DESIGN

This sub-study of a multicentre randomized controlled trial included 440 women undergoing IVF treatment with a gonadotrophin-releasing hormone (GnRH) antagonist protocol. Serum CRP was measured on cycle day 2-3 (baseline) and on the day of ovulation triggering. The association between CRP concentrations and reproductive outcomes (number of retrieved oocytes, number of good-quality blastocysts, pregnancy, pregnancy loss and live birth), were analysed, adjusting for relevant confounders.

RESULTS

A negative association was found between higher baseline CRP concentrations and live birth rate (odds ratio [OR] 0.77, 95% confidence interval [CI] 0.62-0.96, P = 0.02) and higher CRP concentrations at baseline were associated with pregnancy loss among women who conceived (OR 1.37, 95% CI 1.07-1.76, P = 0.01). When testing for a specific cut-off, CRP concentrations above 2.34 (the highest quartile) were more likely to be associated with pregnancy loss (P = 0.02) and a lower chance of live birth (P = 0.04) compared with the lowest quartile. No associations were found between CRP concentrations and pregnancy outcomes on the day of ovulation triggering, and there were no associations between CRP concentrations and the number of good-quality blastocysts.

CONCLUSIONS

Higher CRP concentrations at cycle day 2-3, before starting ovarian stimulation, are negatively associated with chance of live birth, possibly because of an increased risk of pregnancy loss. No association was found between the number of good-quality blastocysts and CRP concentration. More studies are needed to investigate the impact of low-grade inflammation.

Predicting IVF outcome in poor ovarian responders

Background

Poor responders to ovarian stimulation are one of the most challenging populations to treat. As a failed cycle can cause a considerable emotional and economical loss, adequate fertility counseling addressing patients’ expectations are highly important when facing patients with poor ovarian response. The study aimed to evaluate reproductive outcomes and to identify factors associated with live birth (LB) after fresh autologous IVF/intracytoplasmic sperm injection (ICSI) cycles of patients fulfilling the Bologna criteria for poor ovarian response (POR).

Methods

A retrospective study included 751 IVF/ICSI treatment cycles which yielded up to three retrieved oocytes, at a tertiary referral hospital between January 2016 and February 2020. A logistic regression analysis was used to adjust for confounders.

Results

Clinical pregnancy and LB rate per cycle were significantly higher among women younger versus older than 40 years (9.8% and 6.8% vs 4.5% and 2.1%, p < 0.01, respectively). Patients who achieved LB were significantly younger, had higher number of oocytes retrieved, fertilization rate and top-quality embryos (p < 0.05). Multivariable regression analysis identified patient’s age (OR 0.90; 95% CI 0.845–0.97; p = 0.005) and mean number retrieved oocytes (OR 1.95; 95% CI 1.20–3.16; p = 0.007) as factors significantly associated with the probability of a LB.

Conclusions

The woman’s age and the number of retrieved oocytes are both independent predicting factors of live birth in poor ovarian responders. Considering the risks, the high financial investment and poor reproductive outcomes involved in IVF treatments, raises questions regarding the adequacy of providing treatments in these patients' population. POR younger than 40 years may represent a possible exception due to acceptable probability for a LB.

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.

Predicting cumulative live birth for couples beginning their second complete cycle of in vitro fertilization treatment

STUDY QUESTION

Can we develop an IVF prediction model to estimate individualized chances of a live birth over multiple complete cycles of IVF in couples embarking on their second complete cycle of treatment?

SUMMARY ANSWER

Yes, our prediction model can estimate individualized chances of cumulative live birth over three additional complete cycles of IVF.

WHAT IS KNOWN ALREADY

After the completion of a first complete cycle of IVF, couples who are unsuccessful may choose to undergo further treatment to have their first child, while those who have had a live birth may decide to have more children. Existing prediction models can estimate the overall chances of success in couples before commencing IVF but are unable to revise these chances on the basis of the couple’s response to a first treatment cycle in terms of the number of eggs retrieved and pregnancy outcome. This makes it difficult for couples to plan and prepare emotionally and financially for the next step in their treatment.

STUDY DESIGN, SIZE, DURATION

For model development, a population-based cohort was used of 49 314 women who started their second cycle of IVF including ICSI in the UK from 1999 to 2008 using their own oocytes and their partners’ sperm. External validation was performed on data from 39 442 women who underwent their second cycle from 2010 to 2016.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Data about all UK IVF treatments were obtained from the Human Fertilisation and Embryology Authority (HFEA) database. Using a discrete time logistic regression model, we predicted the cumulative probability of live birth from the second up to and including the fourth complete cycles of IVF. Inverse probability weighting was used to account for treatment discontinuation. Discrimination was assessed using c-statistic and calibration was assessed using calibration-in-the-large and calibration slope.

MAIN RESULTS AND THE ROLE OF CHANCE

Following exclusions, 49 314 women with 73 053 complete cycles were included. 12 408 (25.2%) had a live birth resulting from their second complete cycle. Cumulatively, 17 394 (35.3%) had a live birth over complete cycles two to four. The model showed moderate discriminative ability (c-statistic: 0.65, 95% CI: 0.64 to 0.65) and evidence of overprediction (calibration-in-the-large = −0.08) and overfitting (calibration slope 0.85, 95% CI: 0.81 to 0.88) in the validation cohort. However, after recalibration the fit was much improved. The recalibrated model identified the following key predictors of live birth: female age (38 versus 32 years—adjusted odds ratio: 0.59, 95% CI: 0.57 to 0.62), number of eggs retrieved in the first complete cycle (12 versus 4 eggs; 1.34, 1.30 to 1.37) and outcome of the first complete cycle (live birth versus no pregnancy; 1.78, 1.66 to 1.91; live birth versus pregnancy loss; 1.29, 1.23 to 1.36). As an example, a 32-year-old with 2 years of non-tubal infertility who had 12 eggs retrieved from her first stimulation and had a live birth during her first complete cycle has a 46% chance of having a further live birth from the second complete cycle of IVF and an 81% chance over a further three cycles.

LIMITATIONS, REASONS FOR CAUTION

The developed model was updated using validation data that was 6 to 12 years old. IVF practice continues to evolve over time, which may affect the accuracy of predictions from the model. We were unable to adjust for some potentially important predictors, e.g. BMI, smoking and alcohol intake in women, as well as measures of ovarian reserve such as antral follicle count. These were not available in the linked HFEA dataset.

WIDER IMPLICATIONS OF THE FINDINGS

By appropriately adjusting for couples who discontinue treatment, our novel prediction model will provide more realistic chances of live birth in couples starting a second complete cycle of IVF. Clinicians can use these predictions to inform discussion with couples who wish to plan ahead. This prediction tool will enable couples to prepare emotionally, financially and logistically for IVF treatment.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by an Elphinstone scholarship scheme at the University of Aberdeen and Aberdeen Fertility Centre, University of Aberdeen. The authors have no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Womens’ preferences concerning IVF treatment: a discrete choice experiment with particular focus on embryo transfer policy

STUDY QUESTION

What outcomes are important for women to decide on the day of embryo transfer (ET) in IVF?

SUMMARY ANSWER

The highest cumulative live birth rate (cLBR) per treatment was the most important treatment outcome for women undergoing an IVF treatment, regardless of the number of transfers needed until pregnancy and impact on quality of life.

WHAT IS KNOWN ALREADY

Cleavage stage (Day 3) and blastocyst stage (Day 5) ETs are common transfer policies in IVF. The choice for one or the other day of ET differs between clinics. From the literature, it remains unclear whether the day of transfer impacts the cLBR. Patient preferences for the day of ET have not been examined yet.

STUDY DESIGN, SIZE, AND DURATION

A discrete choice experiment (DCE) was performed to investigate female patients’ preferences and their values concerning various aspects of an IVF treatment, with a particular focus on ET policy. A multicenter DCE was conducted between May 2020 and June 2020 in which participants were asked to choose between different treatments. Each treatment was presented using hypothetical scenarios containing the following attributes: the probability of a healthy live birth per IVF treatment cycle, the number of embryos available for transfer (for fresh and frozen-thawed ET), the number of ETs until pregnancy and the impact of the treatment on the quality of life.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women (n = 445) were asked to participate in the DCE at the start of an IVF treatment cycle in 10 Dutch fertility clinics. Participating women received an online questionnaire. The attributes’ relative importance was analyzed using logistic regression analyses.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 164 women participated. The most important attribute chosen was the cLBR. The total number of embryos suitable for transfer also influenced women’s treatment preferences. Neither the number of transfers needed until pregnancy, nor the impact on quality of life influenced the treatment preferences in the aggregated data. For women in the older age group (age ≥36 years) and the multipara subgroup, the impact on quality of life was more relevant. Naive patients (patients with no prior experience with IVF treatment) assigned less value to the number of ETs needed until pregnancy and assigned more value to the cLBR than the patients who had experienced IVF.

LIMITATIONS REASONS FOR CAUTION

An important limitation of a DCE study is that not all attributes can be included, which might be relevant for making choices. Patients might make other choices in real life as the DCE scenarios presented here are hypothetical and might not exactly represent their personal situation. We tried to avoid potential bias by selecting the attributes that mattered most to the patients obtained through patient focus groups. The final selection of attributes and the assigned levels were established using the input of an expert panel of professionals and by performing a pilot study to test the validity of our questionnaire. Furthermore, because we only included women in our study, we cannot draw any conclusions on preferences for partners.

WIDER IMPLICATIONS OF THE FINDINGS

The results of this study may help fertility patients, clinicians, researchers and policymakers to prioritize the most important attributes in the choice for the day of ET. The present study shows that cLBR per IVF treatment is the most important outcome for women. However, currently, there is insufficient information in the literature to conclude which day of transfer is more effective regarding the cLBR. Randomized controlled trials on the subject of Day 3 versus Day 5 ETs and cLBR are needed to allow evidence-based counseling.

STUDY FUNDING/COMPETING INTEREST(S)

This work received no specific funding and there are no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Association between Stigma and Anxiety, Depression, and Psychological Distress among Japanese Women Undergoing Infertility Treatment

Japan has the highest number of cases of infertility treatment in the world. Studies have indicated that women undergoing infertility treatment feel stigmatized and suffer from psychological symptoms such as anxiety and depression. However, in Japan, few studies have quantitatively examined the association between the stigma of infertility and psychological symptoms, and, to our knowledge, no study has examined its association using a scale with tested reliability and validity. This study aims to quantitatively examine the relationship between infertility stigma and anxiety, depression, and psychological distress among women undergoing infertility treatment, using a scale that has been validated for reliability and validity. The cross-sectional study was conducted in December 2021 through a web-based survey of 254 participants undergoing infertility treatment. A multiple regression analysis was performed to examine the relationship between stigma and anxiety, depression, and psychological distress. Stigma was a statistically significant predictor of anxiety, depression, and psychological distress (standardized β = 0.58, p < 0.001; β = 0.50, p < 0.001; β = 0.62, p < 0.001, respectively) after controlling for sociodemographic and infertility characteristics. Future studies should examine the causal relationship between stigma and anxiety, depression, and psychological distress and how to intervene to reduce stigma among women undergoing infertility treatment.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Challenges in the successful management of asthma during conception, pregnancy and delivery

Asthma and infertility are the most common disorders among women of reproductive age. Time to pregnancy is prolonged in women with asthma, and importantly, age seems to be a more important risk factor regarding fertility in women with asthma compared to women without asthma. Some data have shown a higher frequency of miscarriages in women with asthma, although the data are conflicting on this issue as studies have observed no association between asthma and pregnancy loss. Furthermore, studies have shown no negative effect of asthma on the total number of offspring. Pregnancy may, thus, have a significant impact on women with asthma, as well as on their offspring.

The age of the women has an important impact on ability to conceive, but also for the pregnancy itself, with higher risk of uncontrolled asthma as well as asthma exacerbations with increasing age. Well-controlled asthma decreases the risk of maternal and fetal complications, while poorly controlled and undertreated asthma is associated with a range of risks for both mother and fetus. Asthma treatment should follow the general guidelines for asthma therapy, irrespective of pregnancy status, including treatment with inhaled corticosteroids, β2-agonists and muscarinic antagonists. Targeted treatment with biologics for severe asthma seems to be without important adverse effects. The use of systemic corticosteroids may be associated with adverse events during the first trimester; however, an exacerbation with the associated risk of hypoxaemia is worse for the fetus. Best possible asthma control may be achieved using repeated measurements of fractional exhaled nitric oxide (FENO), as the use of FENO compared with symptoms registration only has been shown to reduce exacerbation rate.

In conclusion, women with asthma should be encouraged to conceive at an early age, might experience miscarriages, but the number of offspring are the same as in women without asthma. Well treated asthma is important for the well-being of both the mother and the unborn fetus.

A comparative study of Mesenchymal Stem Cells transplantation approach to antagonize age-associated ovarian hypofunction with consideration of safety and efficiency

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Mesenchymal stem cells transplantation (MSCs’) to the ovaries of POF patients could lead to effective clinical outcomes.

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Assessment of MSCs’ effect for single transplantation was performed using 3 transplantation methods.

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MSCs into ovaries by ovarian local injection was determined as the most effective route.

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This technique exerted marked effect on antagonizing age-associated ovarian hypofunction.

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Histopathological data showed that no neoplasms and obvious prosoplasia were found after MSCs transplantation.

Introduction

The transplantation of mesenchymal stem cells (MSCs) in patients with premature ovarian failure (POF) could lead to clinical improvement. The transplantation to the ovaries among other transplantation methods have been reported in various animal models, however, there is little evidence regarding the optimal method, including the clinical safety and the efficiency for the treatment of age associated ovarian hypofunction.

Objectives

To establish the most effective transplantation route of MSCs, explore the resistance to therapy, its safety and role in the natural aging process of the ovaries.

Methods

Highly purified MSCs were injected intraperitoneally, directly into the ovaries or tail-intravenously in mice animal model. The ovarian function, quantity and quality of oocytes, cell viability/apoptosis, were evaluated, applying chemiluminescence analysis (CLIA), western blotting, immunofluorescence staining, transmission electron microscope (TEM), TdT mediated dUTP Nick End Labeling (TUNEL) assay and other techniques. The organ tumorigenicity was also evaluated by long-term observation and histopathological examination. The efficiency of MSCs was further verified in non-human primates by the most effective transplantation route.

Results

The 32nd week was ultimately determined as the time point of MSCs transplantation. Our results showed that the intra-ovarian injection was the best transplantation method with a more conspicuous effect. With deeper investigations, we found that the transplanted MSCs showed an effective influence on the follicular number, promoted follicle maturation and inhibited cell apoptosis, which was further verified in non-human primates. In addition, the long-term observation and the histopathological examinations ruled out neoplasms or obvious prosoplasia after MSCs transplantation.

Conclusion

MSCs transplantation by intra-ovarian injection could within a month exert the most conspicuous anti-age-associated ovarian hypofunction effects, which may improve the quantity and quality of oocytes by changing the mitochondrial structure, regulating mitochondrial function and attenuating cell apoptosis to increase the storage of the follicle pool without a remarkable potential of tumorigenicity.

The circulating alarin level was elevated in infertile women with poor ovarian reserve

OBJECTIVE

We aimed to reveal the association of serum alarin level with POR status of the infertile women in the present study.

METHODS

The eligibility criteria for this prospective cross-sectional study included a total of 92 infertile women attending the Hitit University Hospital, and all participant women were categorized into two main groups of ovarian reserve: (i) Poor ovarian reserve (POR) group (n = 40) based on ESHRE consensus and (ii) Control group (NOR) (n = 52).

RESULTS

The mean adjusted-ages and BMI values of the NOR and POR groups were statistically comparable (p = .057 and p = .600, respectively). The mean E2, FSH, and LH levels were elevated in the POR group (p < .001, for all). The mean AFC and AMH concentration were significantly reduced in the POR group (p < .001, for both). In addition, there was a significant increase in the serum alarin level in the POR group (p < .001). Pearson's analysis revealed that the mean BMI value of the POR group had a weak and negative correlation (r = 0.318, p = .046). Also, there was no correlation between serum alarin with E2 and FSH levels in both study groups. A weak and positive correlation was found between serum alarin and LH concentration only in the POR group (r = 0.318, p = .045). The mean AMH and AFC values were not significantly correlated with serum alarin levels.

CONCLUSION

The circulating alarin level was significantly elevated in infertile women with POR patterns. In addition, the alarin level was significantly correlated with the serum LH concentration in the POR pattern.

RUBIC (ReproUnion Biobank and Infertility Cohort): A binational clinical foundation to study risk factors, life course, and treatment of infertility and infertility-related morbidity

BACKGROUND

Infertility affects 15%-25% of all couples during their reproductive life span. It is a significant societal and public health problem with potential psychological, social, and economic consequences. Furthermore, infertility has been linked to adverse long-term health outcomes. Despite the advanced diagnostic and therapeutic techniques available, approximately 30% of infertile couples do not obtain a live birth after fertility treatment. For these couples, there are no further options to increase their chances of a successful pregnancy and live birth.

OBJECTIVES

Three overall questions will be studied: (1) What are the risk factors and natural life courses of infertility, early embryonic loss, and adverse pregnancy outcomes? (2) Can we develop new diagnostic and prognostic biomarkers for fecundity and treatment success? And (3) what are the health characteristics of women and men in infertile couples at the time of fertility treatment and during long-term follow-up?

MATERIAL AND METHODS

ReproUnion Biobank and Infertility Cohort (RUBIC) is established as an add-on to the routine fertility management at Copenhagen University Hospital Departments in the Capital Region of Denmark and Reproductive Medicine Centre at Skåne University Hospital in Sweden. The aim is to include a total of 5000 couples equally distributed between Denmark and Sweden. The first patients were enrolled in June 2020. All eligible infertile couples are prospectively asked to participate in the project. Participants complete an extensive questionnaire and undergo a physical examination and collection of biospecimens (blood, urine, hair, saliva, rectal swabs, feces, semen, endometrial biopsies, and vaginal swabs). After the cohort is established, the couples will be linked to the Danish and Swedish national registers to obtain information on parental, perinatal, childhood, and adult life histories, including disease and medication history. This will enable us to understand the causes of infertility and identify novel therapeutic options for this important societal problem.

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.

Current perspectives on social oocyte freezing

Demand for oocyte freezing in absence of a medical indication is growing as women delay childbirth and seek to extend the window of opportunity for parenthood. The optimum age for oocyte freezing is below 35 years, whereas currently the mean age of women undergoing oocyte freezing in the UK is 38 years. Nearly half of women undergoing oocyte freezing are not in a relationship. The treatment is not publicly funded and the average price for a complete oocyte freezing and thawing cycle, including annual storage fees, could reach over £7000. The live birth rate per oocyte thaw cycle is 18% and is influenced by age at the time of oocyte freezing. Women considering social oocyte freezing should be thoroughly counselled about the efficacy, limitations, cost implications and alternatives to oocyte freezing and provided with the appropriate support to enable a truly informed reproductive choice.

The Danish National Register of assisted reproductive technology: content and research potentials

The Danish National Register of assisted reproductive technology (ART) was initially established in 1994. The register comprises complete information on all ART procedures in public and private clinics in Denmark from 2013 and onwards, including baseline information on the cause of infertility and a number of health-related patient characteristics. The register enables monitoring and research on infertility treatment and reproductive topics in single women or couples seeking assisted reproduction, and the register is thus a key component of the Danish health information system within human reproduction. We aimed to provide an updated description of the register including advantages and pitfalls when using the register for reproductive epidemiological research, and a description of the accessibility for researchers. The Danish ART register is a valuable tool for epidemiological research. However, the inherent strengths and limitations ought to be in perspective when designing studies and interpreting the study results. Reports with annually aggregated data on ART treatments, can be accessed on the Danish Health Data Authority web page and researchers may obtain access to individual pseudonomized data via secure servers at the Danish Health Data Authority and Statistics Denmark.

Sterility, an Overlooked Health Condition

Clinically, infertility is defined as the inability to conceive after a certain period. In contrast, sterility is defined as the inability to produce a biological child; however, this is not a practical definition that can be applied in a clinical setting to a patient’s diagnosis. Unlike infertility, sterility is rarely discussed in biomedical and clinical literature and is often used synonymously with infertility. Infertility affects about 10% of couples globally, but the prevalence of sterility remains unknown. We divide sterility into three subtypes natural, clinical, and hardship. To estimate sterility prevalence, we analyzed primary literature and meta-analysis papers on the rates of live births and pregnancies throughout several treatments of infertile couples (e.g., untreated patients, in vitro fertilization-treated, and patients administered other treatments). This analysis indicates that all treatments fail in delivering a biological child to most couples, suggesting that most infertile couples may fail to conceive. More comprehensive primary studies are needed to provide a precise estimate of sterility. Furthermore, research is needed to study the causes of sterility, as well as develop methods for diagnosis and treatment that are financially affordable and emotionally tolerable. Altogether, sterility is an under-discussed condition that is more common than expected, as many infertile couples are unable to conceive and are, in effect, sterile.

Long-term outcome of patients undergoing in-vitro fertilisation in France: The outcome study

The Outcome study examines the fate of 4083 patients beginning IVF in 41 IVF centres, between January 2010 and December 2013. Cumulative live birth rate per patient (CLBR), the best reflection of IVF efficacy, is rarely presented in publications as it requires long-term follow-up, including all successive cycles, and pregnancies outcome. Analysis of international publications shows an average CLBR of 41.6 % and a drop-out rate of 49.5 %, both greatly varying by country and IVF centres. Because of the frequency with which patients change centre (8%), the Outcome study distinguishes patients with a past history of IVF in another centre (CLBR=47.2 %) and patients undergoing their first true cycle (CLBR=56.4 %). Survival techniques by Competing Risk, intended to take account of drop-out and lost to follow-up, assessed the overall CLBR as being 65.4 %. Differences in performance between centres are considerable for both CLBR (32-64%) and Performance Index, taking account of the number of cycles required to achieve a pregnancy (2-5). Multiple variance logistic regression analysis shows that the indicators influencing performance are age, parity, number of oocytes, smoking habit and overweight. These indicators are independent each other and are influencing performance in a high significant way. After adjusting for these indicators, the differences between centres are reduced but remain large and very significant. No centre appears to have specific expertise in the management of patients with adverse indicators. The Outcome study therefore confirms that the large differences in performance between centres are not explained by a difference in the treated population.

Cumulative live birth rates following insemination with donor spermatozoa in single women, same-sex couples and heterosexual patients

RESEARCH QUESTION

What is the cumulative live birth rate (LBR) following donor intrauterine insemination (IUI-D) treatment in a large, retrospective, single-centre cohort of single women, same-sex couples and heterosexual patients?

DESIGN

Outcomes from 8922 treatments performed in 3333 consecutive women (45% single, 43% from same-sex and 12% from heterosexual couples) were analysed in a 13-year retrospective study from a private, HFEA-regulated UK centre between January 2004 and December 2016.

RESULTS

A total of 795 live births resulted in an overall delivery rate of 8.9% per cycle, including 24 (3%) twins. Age-specific crude and expected cumulative LBR calculated in four age groups (<35, 35-37, 38-39 and 40-42 years) were 29, 23, 21, 12% and 66, 49, 54, 28%, respectively. A plateau was reached after six cycles, beyond which there were few additional live births. There was no significant difference in cumulative LBR between single women and same-sex couples. In a multivariate analysis, female age (adjusted odds ratio [aOR] 0.92; 95% confidence interval [CI] 0.90-0.93; P < 0.0001), previous live birth following IUI-D (aOR 2.15; 95% CI 1.69-2.73; P < 0.0001) and mild stimulation (aOR 1.27; 95% CI 1.09-1.48; P = 0.02) had a significant effect on outcome, but relationship status or cycle rank did not.

CONCLUSIONS

These results indicate there is little benefit performing more than six cycles of IUI-D in all women up to 40 years old, including those from same-sex relationships, while only three attempts seem reasonable in those aged 40-42 years. These results do not reflect current clinical guidelines in the UK. The authors found that consecutive IUI cycles, especially with mild stimulation, were an efficient treatment in all indications.

Differences in the Sexual Function and Sexual Healthcare Needs of Pregnant Women Who Underwent in Vitro Fertilization and Women Who Conceived Naturally at Each Trimester: A Prospective Cohort Study

Introduction

Infertility may negatively impact sexual function. Women with fertility problems usually prioritize treatment for infertility, but their sexual function in each trimester of pregnancy is poorly researched.

Aim

To compare the sexual function and sexual healthcare needs of women who underwent successful in vitro fertilization (IVF group) and women who conceived naturally (CN group) during each trimester.

Methods

Longitudinal prospective cohort study was conducted from August 2016 to July 2018. The IVF group (n = 100) was recruited from a leading reproductive treatment center; the CN group (n = 100), at the prenatal clinic of a medical center in central Taiwan. Questionnaires were mailed to women in the 10th–11th gestational week; 70 women in the IVF group and 75 in the CN group completed all 3 questionnaires, during the 10th–11th, 20th–21st, and 30th–31st gestational weeks.

Main Outcome Measures

Female Sexual Function Index and Nursing Intervention on Sexual Healthcare needs were compared between groups in each trimester.

Results

Most participants reported sexual dysfunction concerns during pregnancy. In the first trimester, the Female Sexual Function Index score was significantly lower in the IVF group than in the CN group (18.13 ± 6.27 vs 20.34 ± 5.87, respectively; P < .05). Sexual healthcare needs at the permission level were significantly lower in the IVF group than in the CN group (10.78 ± 2.41 vs 11.79 ± 2.67, respectively; P < .05).

Conclusion

The IVF group had lower sexual function in the first trimester than the CN group. Sexual function improved in the second trimester in the IVF group but decreased throughout pregnancy in the CN group. The CN group had a greater need for sexual healthcare nursing intervention at the permission level than the IVF group.

Huang C-Y, Liou C-F, Lu Y-C, et al. Differences in the Sexual Function and Sexual Healthcare Needs of Pregnant Women Who Underwent In Vitro Fertilization and Women Who Conceived Naturally at Each Trimester: A Prospective Cohort Study. Sex Med 2020;8:709–717.

Male factor infertility and risk of death: a nationwide record-linkage study

STUDY QUESTION

What is the risk of death among men with oligospermia, unspecified male factor and azoospermia in the years following fertility treatment?

SUMMARY ANSWER

No significantly elevated risk was observed among men with oligospermia and unspecified male factor, while an increased risk was found among men with azoospermia.

WHAT IS KNOWN ALREADY

Previous studies have shown associations between male factor infertility and risk of death, but these studies have relied on internal reference groups and the risk of death according to type of male infertility is not well characterized.

STUDY DESIGN, SIZE, DURATION

In this prospective record-linkage cohort study, we identified men who had undergone medically assisted reproduction (MAR) between 1994 and 2015. Data was linked to the Danish causes of death register and sociodemographic registers through personal identification numbers assigned to all Danish citizens at birth.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Men that had undergone MAR in Denmark (MAR Cohort; n = 64 563) were identified from the Danish IVF register, which includes data on whether infertility was due to male factor. For each man in the MAR cohort, five age-matched men who became fathers without fertility treatment were selected from the general population (non-MAR fathers; n = 322 108). Men that could not adequately be tracked in the Danish CPR register (n = 1259) and those that were censored prior to study entry (n = 993) were excluded, leaving a final population of 384 419 men. Risk of death was calculated by Cox regression analysis with age as an underlying timeline and adjustments for educational attainment, civil status and year of study entry. The risk of death was compared among men with and without male factor infertility identified from the IVF register (internal comparisons) as well as to the non-MAR fathers (external comparison).

MAIN RESULTS AND THE ROLE OF CHANCE

The risk of death between the MAR cohort (all men, regardless of infertility) and the non-MAR fathers was comparable [hazard ratio (HR), 1.07; 95% CI, 0.98-1.15]. When the MAR cohort was limited to infertile men, these men were at increased risk of death [HR, 1.27; 95% CI, 1.12-1.44]. However, when stratified by type of male factor infertility, men with azoospermia had the highest risk of death, which persisted when in both the internal [HR, 2.30; 95% CI, 1.54-3.41] and external comparison [HR, 3.32; 95% CI, 2.02-5.40]. No significantly elevated risk of death was observed among men with oligospermia [HR, 1.14; 95% CI, 0.87-1.50] and unspecified male factor [HR, 1.10; 95% CI, 0.75-1.61] compared with the non-MAR fathers. The same trends were observed for the internal comparison.

LIMITATIONS, REASONS FOR CAUTION

Duration of the follow-up was limited and there is limited generalizability to infertile men who do not seek fertility treatment.

WIDER IMPLICATIONS OF THE FINDINGS

Using national health registers, we found an increased risk of death among azoospermic men while no increased risk was found among men with other types of infertility. For the azoospermic men, further insight into causal pathways is needed to identify options for monitoring and prevention.

STUDY FUNDING/COMPETING INTEREST(S)

This study is part of the ReproUnion collaborative study, co-financed by the European Union, Interreg V ÖKS. C.G.'s research stay at Stanford was funded by grants from the University of Copenhagen, Kong Christian den Tiendes Fond, Torben og Alice Frimodt Fond and Julie Von Müllen Fond. M.E. is an advisor for Sandstone and Dadi. All other authors declare no conflict of interests.

TRIAL REGISTRATION NUMBER

Not relevant.

IVF, from the past to the future: the inheritance of the Capri Workshop Group

Today IVF use is booming all over the world and has even started to play a role in demographic analyses. Prognosis-adjusted estimates suggest that up to two-thirds of couples could achieve a live birth. However, the scenario is less exciting in reality. Discontinuation during the cycles is common, and age and ovarian response continue to be crucial in modulating this rate of success. A growing interest is now given to the risk of abuses and in particular to overtreatment and to prescriptions of useless, if not harmful, expensive additional treatments (‘add-ons’). A more rational, evidence-based and wise approach is needed. From a scientific perspective, several obscure aspects remain and warrant future investigations. Of particular interest are the neglected role of sperm selection, the potential adult implications of early embryo life in vitro and the issue of sustainability.

Treatment-independent live birth after in-vitro fertilisation: a retrospective cohort study of 2,133 women

STUDY QUESTION

What is the chance of a treatment-independent live birth following IVF (including ICSI) treatment?

SUMMARY ANSWER

Over 5 years of follow-up, the treatment-independent live birth rate was 17% in unsuccessfully treated women and 15% in those who had a live birth after IVF.

WHAT IS KNOWN ALREADY

A limited number of studies have investigated the chance of treatment-independent conception following completion of IVF, but most of them have been based on surveys with poor response rates and limited sample sizes.

STUDY DESIGN, SIZE, DURATION

This is a population-based, retrospective cohort study of 2133 women who received IVF treatment between 1998 and 2011 at a single regional IVF Unit and were followed for a minimum of 1 year and maximum of 15 years after their last IVF or ICSI treatment cycle.

PARTICIPANTS/MATERIALS, SETTING, METHODS

This study included all women, residing in the north-east of the UK, who attended the Aberdeen Fertility Clinic and received IVF treatment between 1998 and 2011. Clinical and diagnostic information of all women was linked with treatment and pregnancy outcome data. A total of 2133 women were divided into two groups: (i) those who achieved a live birth following successful IVF or ICSI treatment (n = 1060) and (ii) those in whom treatment was unsuccessful i.e. resulted in either no pregnancy or pregnancy loss (n = 1073). The two groups were followed from the date of the last embryo transfer until the first treatment-independent live birth or 31 December 2012, whichever came first. The primary outcome was the treatment-independent live birth rate at 1, 2.5, 5 and 10 years of follow-up. Cox regression was used to determine factors associated with treatment-independent live birth in each group.

MAIN RESULTS AND THE ROLE OF CHANCE

Within 5 years of follow-up, the treatment-independent live birth rate was 17% (95% CI, 15-19%) among women whose IVF or ICSI treatment was unsuccessful and 15% (95% CI, 12-17%) among women whose treatment resulted in live birth. In both groups, shorter duration of infertility, younger female age and IVF as compared to ICSI were associated with a higher chance of achieving treatment-independent live birth. Among unsuccessfully treated women, the chance of post-IVF live birth was reduced in those with tubal factor infertility. Three or more previous IVF or ICSI embryo transfers were associated with a lower chance of treatment-independent live birth among successfully treated women.

LIMITATIONS, REASONS FOR CAUTION

The study was conducted in a single fertility centre, which could compromise the generalizability of the findings. Moreover, data were unavailable on the women's use of contraception or active attempts to get pregnant, both of which could influence treatment-independent live birth rates.

WIDER IMPLICATIONS OF THE FINDINGS

This study provides a better understanding of the long-term prognosis for treatment-independent live birth after completion of IVF or ICSI treatment. The results will inform women of their chances of a treatment-independent live birth following failed or successful treatment and the factors that are associated with it.

STUDY FUNDING/COMPETING INTEREST(S)

This work was funded by a Chief Scientist Office Postdoctoral Training Fellowship in Health Services Research and Health of the Public Research (Ref PDF/12/06). The views expressed here are those of the authors and not necessarily those of the Chief Scientist Office. The authors have no competing interests.

TRIAL REGISTRATION NUMBER

Not applicable.

Age-related natural fertility outcomes in women over 35 years: a systematic review and individual participant data meta-analysis

STUDY QUESTION

What is the rate of natural conception leading to ongoing pregnancy or livebirth over 6–12 months for infertile women of age ≥35 years?

SUMMARY ANSWER

Natural conception rates were still clinically relevant in women aged 35 years and above and were significantly higher in women with unexplained infertility compared to those with other diagnoses.

WHAT IS KNOWN ALREADY

In recent years, increasing numbers of women have attempted to conceive at a later age, resulting in a commensurate increase in the need for ART. However, there is a lack of data on natural fertility outcomes (i.e. no interventions) in women with increasing age.

STUDY DESIGN, SIZE, DURATION

A systematic review with individual participant data (IPD) meta-analysis was carried out. PubMed, MEDLINE, EMBASE, the Cochrane Library, clinicaltrials.gov were searched until 1 July 2018 including search terms ‘fertility service’, ‘waiting list’, ‘treatment-independent’ and ‘spontaneous conception’. Language restrictions were not imposed.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Inclusion criteria were studies (at least partly) reporting on infertile couples with female partner of age ≥35 years who attended fertility services, underwent fertility workup (e.g. history, semen analysis, tubal status and ovulation status) and were exposed to natural conception (e.g. independent of treatment such as IVF, ovulation induction and tubal surgery). Studies that exclusively studied only one infertility diagnosis, without including other women presenting to infertility services for other causes of infertility, were excluded. For studies that met the inclusion criteria, study authors were contacted to provide IPD, after which fertility outcomes for women of age ≥35 years were retrieved. Time to pregnancy or livebirth and the effect of increasing age on fertility outcomes after adjustment for other prognostic factors were analysed. Quality of studies was graded with the Newcastle–Ottawa Scale (non-randomised controlled trials (RCTs)) or the Cochrane Risk of Bias tool (for RCTs).

MAIN RESULTS AND THE ROLE OF CHANCE

We included nine studies (seven cohort studies and two RCTs) (n = 4379 women of at least age 35 years), with the observed composite primary outcome of ongoing pregnancy or livebirth occurring in 429 women (9.8%) over a median follow-up of 5 months (25th to 75th percentile: 2.5–8.5 months). Studies were of moderate to high quality. The probability of natural conception significantly decreased with any diagnosis of infertility, when compared with unexplained infertility. We found non-linear effects of female age and duration of infertility on ongoing pregnancy and tabulated the predicted probabilities for unexplained infertile women aged 35–42 years with either primary or secondary infertility and with a duration of infertility from 1 to 6 years. For a 35-year-old woman with 2 years of primary unexplained infertility, the predicted probability of natural conception leading to ongoing pregnancy or livebirth was 0.15 (95% CI 0.11–0.19) after 6 months and 0.24 (95% CI 0.17–0.30) after 12 months. For a 42-year-old woman, this decreased to 0.08 (95% CI 0.04–0.11) after 6 months and 0.13 (95% CI 0.07–0.18) after 12 months.

LIMITATIONS, REASONS FOR CAUTION

In the studies selected, there were different study designs, recruitment strategies in different centres, protocols and countries and different methods of assessment of infertility. Data were limited for women above the age of 40 years.

WIDER IMPLICATIONS OF THE FINDINGS

Women attending fertility services should be encouraged to pursue natural conception while waiting for treatment to commence and after treatment if it is unsuccessful. Our results may aid in counselling women, and, in particular, for those with unexplained infertility.

STUDY FUNDING/COMPETING INTEREST(S)

S.J.C. received funding from the University of Adelaide Summer Research Scholarship. B.W.M. is supported by a NHMRC Investigator grant (GNT1176437), B.W.M. reports consultancy for ObsEva, Merck, Merck KGaA, iGenomix and Guerbet. B.W.M. reports research support by Merck and Guerbet.

PROSPERO REGISTRATION NUMBER

CRD42018096552.

Ovarian reserve as a predictor of cumulative live birth

OBJECTIVES

Develop an up to date prediction model using recent cycle data and key pre-treatment predictor variables to estimate a couple's individualised probability of a cumulative live birth after one cycle of ovarian stimulation and transfer of all frozen embryos, before the first embryo transfer.

STUDY DESIGN

This was a retrospective cohort study. To estimate the cumulative live birth rate we only included couples who had used all embryos from their initial stimulation or achieved a live birth. We constructed a logistic regression model using live birth as a dependent variable and age group, duration of infertility, primary vs. secondary infertility, insemination method, cause of infertility, Anti-Mullerian Hormone (AMH), Follicle Stimulating Hormone (FSH) and antral follicle count (AFC) as our independent variables and used a backward elimination method to create the best fitting regression models to predict the probability of a cumulative live birth (p < 0.05 for elimination).

RESULTS

There were 516 complete cycles of ovarian stimulation resulting in 357 livebirths giving a cumulative livebirth rate of 69.2 % (95 % CI 66.0-74.0). Women with a live birth had significantly lower median age (34 years [IQR 31-37] vs. 36 years [IQR 33-39], p = 0.01) and FSH (6.7 iu/L [IQR 5.8-7.9] vs. 7.4 iu/L [IQR 6.2-8.6] and a significantly higher median AMH (22.1 pmol/L [IQR 12.1-30.9] vs. 10.5 pmol/L [IQR 7.3-20.7], p = 0.01) and AFC (18 [IQR 12-26] vs. 12 [IQR 9-19], p = 0.01). The backward conditional logistic regression model retained age category, FSH category and AMH category as significant independent predictors. The area under the curve for this model was 0.68 (95 % CI 0.63 - 0.73).

CONCLUSION

Our prediction model estimates a couple's individualised probability of achieving a live birth after their first complete cycle of IVF using all known pre-treatment predictors.

LIMITATIONS, REASONS FOR CAUTION

The study population were only those eligible for NHS funded IVF treatment which have strict ovarian reserve criteria. Exclusion of those with very low egg reserve is likely to influence the predictive capacity of out model. Furthermore, our model was developed using cycle data from one unit and thus its predictive capacity has not been assessed on an independent cohort of women. We therefore welcome external geographical validation of our model prior to its use in clinical practice.

Cumulative live birth rates for women returning to ART treatment for a second ART-conceived child

STUDY QUESTION

What are the success rates for women returning to ART treatment in the hope of having a second ART-conceived child.

SUMMARY ANSWER

The cumulative live birth rate (LBR) for women returning to ART treatment was between 50.5% and 88.1% after six cycles depending on whether women commenced with a previously frozen embryo or a new ovarian stimulation cycle and the assumptions made regarding the success rates for women who dropped-out of treatment.

WHAT IS KNOWN ALREADY

Previous studies have reported the cumulative LBR for the first ART-conceived child to inform patients about their chances of success. However, most couples plan to have more than one child to complete their family and, for that reason, patients commonly return to ART treatment after the birth of their first ART-conceived child. To our knowledge, there are no published data to facilitate patient counseling and clinical decision-making regarding the success rates for these patients.

STUDY DESIGN, SIZE, DURATION

A population-based cohort study with 35 290 women who commenced autologous (using their own oocytes) ART treatment between January 2009 and December 2013 and achieved their first treatment-dependent live birth from treatment performed during this period. These women were then followed up for a further 2 years of treatment to December 2015, providing a minimum of 2 years and a maximum of 7 years of treatment follow-up.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Cycle-specific LBR and cumulative LBR were calculated for up to six complete ART cycles (one ovarian stimulation and all associated transfers). Three cumulative LBR were calculated based on the likelihood of success in women who dropped-out of treatment (conservative, optimal and inverse probability-weighted (IPW)). A multivariable logistic regression model was used to predict the chance of returning to ART treatment for a second ART-conceived child, and a discrete time logistic regression model was used to predict the chance of achieving a second ART-conceived child up to a maximum of six complete cycles. The models were adjusted for patient characteristics and previous and current treatment characteristics.

MAIN RESULTS AND THE ROLE OF CHANCE

Among the women who had their first ART-conceived live birth, 15 325 (43%) returned to treatment by December 2015. LBRs were consistently better in women who recommenced treatment with a previously frozen embryo, compared to women who underwent a new ovarian stimulation cycle. After six complete cycles, plus any surplus frozen embryos, the cumulative LBR was between 60.9% (95% CI: 60.0–61.8%) (conservative) and 88.1% (95% CI: 86.7–89.5%) (optimal) [IPW 87.2% (95% CI: 86.2–88.2%)] for women who recommenced treatment with a frozen embryo, compared to between 50.5% (95% CI: 49.0–52.0%) and 69.8% (95% CI: 67.5–72.2%) [IPW 68.1% (95% CI: 67.3–68.9%)] for those who underwent a new ovarian stimulation cycle. The adjusted odds of a second ART-conceived live birth decreased for women ≥35 years, who waited at least 3 years before returning to treatment, or who required a higher number of ovarian stimulation cycles or double embryo transfer to achieve their first child.

LIMITATIONS, REASONS FOR CAUTION

Our estimates do not fully account for a number of individual prognostic factors, including duration of infertility, BMI and ovarian reserve.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first study to report success rates for women returning to ART treatment to have second ART-conceived child. These age-specific success rates can facilitate individualized counseling for the large number of patients hoping to have a second child using ART treatment.

STUDY FUNDING/COMPETING INTEREST(S)

No funding was received to undertake this study. R. Paul and O. Fitzgerald have nothing to declare. D. Lieberman reports being a fertility specialist and receiving non-financial support from MSD and Merck outside the submitted work. C. Venetis reports being a fertility specialist and receiving personal fees and non-financial support from MSD, personal fees and non-financial support from Merck Serono and Beisins and non-financial support from Ferring outside the submitted work. G.M. Chambers reports being a paid employee of the University of New South Wales, Sydney (UNSW) and Director of the National Perinatal Epidemiology and Statistics Unit (NPESU), UNSW. The Fertility Society of Australia (FSA) contracts UNSW to prepare the Australian and New Zealand Assisted Reproductive Technology Database (ANZARD) annual report series and benchmarking reports.

TRIAL REGISTRATION NUMBER

NA.

Social freezing of oocytes: a means to take control of your fertility

In the last few decades, there have been tremendous developments of assisted reproductive technologies, but the outcome of in vitro fertilization is highly dependent on the age of the oocyte. The introduction of vitrification offers a possibility to freeze eggs proactively in younger years and use them at later ages, also called social egg freezing. Knowledge about age-related fertility decline is insufficient among many women, and there is an overoptimistic trust that in vitro fertilization can overcome this. The awareness of proactive egg freezing is limited, both among doctors and in the general population. This review aims at increasing the knowledge about proactive egg freezing and offers a means to advise women correctly. It deals with national guidelines, the best age and optimal number of eggs to freeze, and the chance to succeed. Creating more public awareness about age-linked fertility decline and elective egg freezing may help women reproduce at their own pace - to take control of their fertility.

Risk of hospitalization for early onset of cardiovascular disease among infertile women: a register-based cohort study

STUDY QUESTION

Is female infertility predictive of a woman’s future risk of early cardiovascular disease (CVD)?

SUMMARY ANSWER

Female infertility does not seem to be predictive of early CVD during a mean follow-up of 9 years.

WHAT IS KNOWN ALREADY

Associations between infertility and comorbidity have been found in several studies, but data on the association between female infertility and risk of CVD are scarce and inconclusive.

STUDY DESIGN, SIZE, DURATION

In this nationwide cohort study, we included 87 221 women registered in the Danish National IVF register, undergoing medically assisted reproduction (MAR) between 1st of January 1994 and 31st of December 2015. The cohort was followed for incident hospitalization due to CVD in the Danish National Patient Register from enrollment to 31 December 2015. Women with a history of CVD prior to enrollment were excluded. Cox proportional hazard models with age as the underlying time scale were used to estimate hazard ratios (HR) with 95% CI of CVD among women with an infertility diagnosis, compared to women without an infertility diagnosis. All analyses were adjusted for educational attainment.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Female infertility and the reason for infertility was diagnosed and registered in the IVF register by specialists in Danish public and private fertility clinics since 1st of January 1994. In our cohort, 53 806 women (61.7%) were diagnosed with female factor infertility, while 33 415 (38.3%) did not have a female factor infertility diagnosis and made up the reference group.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 686 (1.3%) infertile women were hospitalized for CVD compared to 250 (0.7%) among women without an infertility diagnosis during a mean follow-up time of 9 years. We found no increased risk of early CVD in our analyses (adjusted HR 0.98, 95% CI: 0.85;1.14). Likewise, analyses stratified by specific infertility diagnosis, showed no risk difference.

LIMITATIONS, REASONS FOR CAUTION

We were unable to adjust for confounding parameters such as body mass index, cigarette smoking or alcohol consumption. These results may not be generalizable to infertile women who do not seek out fertility treatment, or infertile women with other lifestyle characteristics than Danish women.

WIDER IMPLICATIONS OF THE FINDINGS

Diagnosing female infertility or the time of MAR does not seem to be a window of opportunity where early screening for cardiovascular disease risk factors can have a prophylactic potential.

STUDY FUNDING/COMPETING INTEREST(S)

This study is part of the ReproUnion collaborative study, co-financed by the European Union, Interreg V ÖKS. None of the authors declare any conflict of interest.

Cumulative live birth rate prognosis based on the number of aspirated oocytes in previous ART cycles

STUDY QUESTION

Is the number of aspirated oocytes in the first ART cycle associated with the cumulative live birthrates (CLBR) in subsequent cycles?

SUMMARY ANSWER

The number of aspirated oocytes in the first cycle was associated with CLBR in subsequent cycles. Previous treatment response predicts outcome in future cycles.

WHAT IS KNOWN ALREADY

Previous reports have shown a positive association between the number of retrieved oocytes and live birthrate per fresh treatment cycle. This has also been shown for the CLBR in one complete ART-cycle, including possible subsequent frozen-thawed transfers (FER). It has been shown that women with less than five oocytes in the first cycle have poorer outcome within six complete cycles than women with more than 12 oocytes, suggesting that the number of aspirated oocytes in the first cycle may be reproduced in later cycles. However, other studies have shown that an initial low treatment response may be improved with increased gonadotrophin start-dose.

STUDY DESIGN, SIZE, DURATION

The Danish National IVF-registry includes all ART treatments in public and private clinics since 1994. Treatment-cycles were cross-linked with the Medical Birth Registry, identifying treatment-related births and natural conception births. This national cohort study includes all women starting ART treatments with homologous eggs between 2002 and 2011, N = 30 486. Subjects were followed for up to four fresh ART-cycles including subsequent FER-cycles (=four complete cycles), until the first livebirth, or until December 2011.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The CLBR within 1-4 complete ART-cycles were calculated as the proportion of women with a livebirth, out of all women initiating ART-treatment, including drop-outs (no livebirth or no continued treatment within follow-up). In women with one year follow-up from last treatment, multivariate logistic regression analysis assessed impact of retrieved oocytes on CLBR, adjusting results for female age and cause of infertility. Hospital admission due to ovarian hyperstimulation syndrome (OHSS) was reported.

MAIN RESULTS AND THE ROLE OF CHANCE

After one, two and three complete ART-cycles, the CLBRs attributable to ART treatment were 26.4% [95%CI 25.9-26.9], 42.6% [42.0-43.1] and 51.3% [50.7-51.9], respectively. The CLBR attributable to non-ART related conception (natural conception or intrauterine insemination) were 5.3% [5.0-5.6], 8.3% [8.0-8.7] and 10.6% [10.3-11.0], after one, two and three complete cycles. In women without a live birth in the first complete cycle, the number of aspirated oocytes predicted the outcome in the second and third cycle: When compared to women with 0-3 aspirated oocytes in the first cycle, the odds for live birth in the second and third cycle was 1.18 [1.07-1.30] for women with 4-9 aspirated oocytes in the first cycle, 1.41 [1.27-1.57] for women with 10-15 aspirated oocytes and 1.63 [1.42-1.88] for women with more than 15 aspirated oocytes. For women without a livebirth in the first and second cycle, the sum of aspirated oocytes predicted outcome in the third complete cycle. Women with a sum larger than six aspirated oocytes, had marked increased odds ratios for livebirth in the third complete cycle, compared to women with a sum of 0-6 oocytes in the first and second fresh cycle. Incidence of hospital-admission due to OHSS was 1.7% in the first cycle, decreasing to 1.3% and 1.0% in the second and third cycles.

LIMITATIONS, REASONS FOR CAUTION

Although mandatory, there may be treatment-cycles not registered in the IVF-registry. Missing information in number of aspirated oocytes are most likely random losses of information. There were few observations in women with more than 15 aspirated oocytes and these birthrates should be interpreted cautiously. Information on gonadotrophin dose used for stimulation was not available, nor was information on dose adjustments in subsequent cycles.

WIDER IMPLICATIONS OF THE FINDINGS

With these results we can counsel couples returning for fertility treatments, providing an age-stratified revised prognosis for chances of live birth and risk of OHSS, reflecting prior failed attempts and previous ovarian response.

STUDY FUNDING/COMPETING INTEREST(S)

This study was unconditionally funded by Ferring Pharmaceuticals and ReproUnion. The funders had no role in the study design, data collection and interpretation, or decision to submit the work for publication. The authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

The study was approved by the Danish Data Protection Agency (J.nr. 2012-41-1330).

Intrauterine insemination: simultaneous with or 36 h after HCG? A randomized clinical trial

RESEARCH QUESTION

Does intrauterine insemination (IUI) carried out simultaneously with HCG triggering ('simultaneous IUI') increase the ongoing pregnancy rate compared with IUI 32-36 h after HCG triggering ('regular IUI')?

STUDY DESIGN

An open-label randomized clinical trial was conducted in seven Dutch fertility clinics. One hundred and sixty-six couples were randomized to receive simultaneous IUI and 208 couples to receive regular IUI. Treatment was allocated using a computer-based randomization algorithm using sealed opaque envelopes. Data were analysed according to the intention-to-treat principle. Couples with unexplained or mild-to-moderate male factor subfertility were eligible. Exclusion criteria were female age 42 years or older, female body mass index 35 kg/m² or over, double-sided tubal pathology or severe male factor subfertility. Mild ovarian stimulation was carried out by subcutaneous FSH self-administration. 'Simultaneous IUI' was carried out at the point of HCG triggering for ovulation. 'Regular IUI' was carried out 32-36 h after HCG triggering.

RESULTS

The cumulative ongoing pregnancy rate after a maximum of four cycles was 26.2% for simultaneous IUI (43 ongoing pregnancies) and 33.7% for regular IUI (70 ongoing pregnancies) (RR 0.78 95% CI 0.57 to 1.07). Ongoing pregnancy rates per cycle in the simultaneous IUI group were 6.8%, 10.5%, 9.5% and 7.4% for the first, second, third and fourth IUI cycle. In the regular IUI group, ongoing pregnancy rates were 8.3%, 16.4%, 13.5% and 9.0% for the first, second, third and fourth IUI cycle.

CONCLUSIONS

This multicentre randomized controlled trial did not demonstrate that IUI carried out at the point of HCG triggering increases pregnancy rates compared with IUI carried out around the time of ovulation.

Concerns about treatment for infertility in a probability-based sample of US women

Objective: Many women experience infertility as distressing, but only about half of US women seek medical services. It is unknown whether concerns about fertility treatment are related to receiving fertility treatment or to distress levels.Methods: Using the nationally representative National Survey of Fertility Barriers, we constructed a nine-item scale measuring fertility treatment concerns. The analytical sample for this study included 1218 women who said that they were trying to become pregnant and who were asked questions regarding treatment concerns. We conducted multiple regression analysis to discover factors associated with treatment concerns and whether treatment concerns were associated with depressive symptoms and fertility-specific distress. We used logistic regression to determine whether treatment concerns were associated with receiving fertility tests.Results: Desiring a(nother) child, infertility stigma, higher family income, higher economic hardship and claiming a Hispanic identity were associated with higher levels of treatment concerns than those in the comparison groups. Having friends and family with children and having private health insurance were associated with lower levels of concern. Treatment concerns were not associated with receiving fertility tests. Higher levels of treatment concern were associated with higher levels of fertility-specific distress and depressive symptoms. Higher infertility stigma was related both directly and indirectly to higher levels of fertility-specific distress and depressive symptoms.Conclusion: For US women, fertility treatment concerns are not associated with whether women pursue fertility testing, but they are associated with higher levels of fertility-specific and general distress.

Elective egg freezing without medical indications

The aim of this review is to provide current knowledge on fertility preservation for non-medical reasons in women willing to postpone childbearing. The topic is highly debatable, starting from disagreement about its terminology, the number of eggs necessary to predict chances of success, and the safety and socio/ethical point of view. Cost analysis and discrepancies among countries' recommendations and regulations are described to confirm the controversies and unsolved issues around this very interesting topic. Finally, an overview on the returning rate of women among "egg bankers" and reasons behind their decisions are illustrated.

Fertility treatment among women with asthma: a case-control study of 3689 women with live births

Asthma has been linked with prolonged time to pregnancy. Our aim was to explore a possible association between asthma and need for fertility treatment among women with live births.All women enrolled in the Management of Asthma during Pregnancy (MAP) programme at Hvidovre Hospital, Denmark were each matched with the next three consecutive women giving birth at Hvidovre Hospital. Information from the Danish National Assisted Reproductive Technology (ART) registry was cross-linked with the Danish Medical Birth registry to identify live births. The primary outcome of interest was births following fertility treatment.Our sample comprised pregnancies from asthmatic mothers (n=932, described as "cases") and non-asthmatic mothers (n=2757, described as "controls"), with 12% (n=114) and 8% (n=212), respectively, having had fertility treatment (OR 1.67, 95% CI 1.32-2.13; p<0.001). This association remained statistically significant after adjusting for confounders, including body mass index (OR 1.31, 95% CI 1.00-1.70; p=0.047). In women ≥35 years, 25% of cases (n=63) and 13% of controls (n=82) received fertility treatment (OR 2.12, 95% CI 1.47-3.07; p<0.001), which also remained statistically significant after adjusting for confounders (OR 1.65, 95% CI 1.11-2.46; p=0.013).A higher proportion of the births from asthmatic mothers involved fertility treatment compared to non-asthmatic mothers, not least among women aged ≥35 years.

Growing body of evidence supports intrauterine insemination as first line treatment and rejects unfounded concerns about its efficacy, risks and cost effectiveness

IUI has been practiced for five decades but only three unconvincing trials attempted to demonstrate the superiority of IUI over sexual intercourse (SI). In the absence of evidence of its effectiveness, the National Institute for Clinical Excellence (NICE) recommended IVF over IUI after 2 years of unprotected SI. High-quality recent data in well-constructed studies suggest that biases against IUI procedures and in favour of IVF are invalid. It is unethical to continue to misinform patients and stakeholders. The well-constructed randomised controlled trials (RCT) show IUI procedure to be efficient, with minimal risk, and above all improved cost-effectiveness when compared to IVF for live birth. IUI as first-line treatment should be offered to most patients, while funding agencies and stakeholders need to be urgently informed of the cost-benefit in offering IUI. Fertility clinics, IVF interest groups, and regulatory bodies should amend their patient information and guidance to state that IUI should be the first line treatment and that IVF should be offered only when essential. Reappraising and promoting IUI based on evidence enhances patient autonomy, choices, and trust, while allowing the fertility industry to operate within an ethical and acceptable framework not seen as exploitative toward vulnerable patients.

Attitudes towards family formation among men attending fertility counselling

Men and women are increasingly postponing childbearing until an age where fertility has decreased, meaning that they might have difficulties in achieving their desired family size. This study explored childless men's attitudes towards family formation. Data were collected through semi-structured qualitative interviews with 21 men attending the Fertility Assessment and Counselling Clinic in Copenhagen or Horsens, Denmark. Data were analysed using content analysis. The men envisioned a nuclear family with their own biological children, but they experienced doubts and ambivalence about parenthood and feeling 'ready'. Their lack of readiness was linked to their awareness of the sacrifices and costs involved with parenthood, and their belief that they could safely delay parenthood. The men did not consider that they may be unable to have their own biological children. This study highlights the importance of considering men's attitudes and preferences towards family formation when understanding couples' decision-making. Contrary to common understanding, the findings show that men are as concerned with the planning and timing of parenthood as women, but their knowledge of the age-related decline in fertility is poor. Men need to gain more awareness of the limitations of fertility and the impact of female and male age on the ability to achieve parenthood aspirations.

Can a quality-of-life assessment assist in identifying women at risk of prematurely discontinuing IVF treatment? A prospective cohort study utilizing the FertiQoL questionnaire

PURPOSE

This study aimed at assessing quality of life (QoL) by means of a validated measurement tool (FertiQoL) in German infertile patients before a first IVF/ICSI cycle with ancillary assessment of changes in FertiQoL scores after a failed first cycle and the predictive capacity of FertiQoL scores for treatment discontinuation.

METHODS

The validated FertiQoL tool consisting of 24 questions regarding fertility-specific aspects of QoL was used for this prospective cohort study conducted at a university affiliated IVF center in Germany. Female patients (n = 119) filled out the FertiQoL form and questionnaire on sociodemographic variables on initiation of a first- and second-cycle IVF/ICSI treatment, respectively.

RESULTS

On initiation of a first IVF/ICSI cycle, the mean scores (± standard deviation) for subscales emotional, mind-body, relational, and social items were 62 (± 19), 75 (± 17), 82 (± 13), and 78 (± 14), respectively; the total FertiQoL score was 73 (± 12). The mean total FertiQoL score at initiation of a first treatment cycle did not differ between patients who continued vs. discontinued treatment in case of no pregnancy achievement in the first cycle (73) (± 10) vs. 74 (± 14), p = 0.46). Furthermore, the mean total FertiQoL score did not change after an unsuccessful first IVF cycle (74 vs. 76, p = 0.46).

CONCLUSIONS

There was no statistical difference in a small sample size for FertiQoL scores between all groups. In this study, FertiQoL scores were, therefore, not usable to predict withdrawal from infertility treatment.

Individualized controlled ovarian stimulation in expected poor-responders: an update

Controlled ovarian stimulation with subsequent multi-follicular development continues to be a keystone in ART. Evidence supports an individualized approach to ovarian stimulation, usually involving combinations of ovarian reserve tests, body mass index and age to tailor the exogenous gonadotropin dose, and potentially adjuvant treatment aiming for high safety and a shortening of time to live birth. While stimulation and trigger concepts have been developed successfully in normo- and hyperresponder patients, the poor responder patient remains difficult to manage. However, recent advances in definition and classification of the expected poor ovarian responder patient might enable a more accurate and clinically useful interpretation of new treatment concepts in a more homogenous study population. In the present review, we discuss the classification of the expected poor ovarian responder patient as well as clinically useful measurements of efficacy for controlled ovarian stimulation, and finally, we discuss the evidence for clinical management of patients with expected poor ovarian response, including adjuvant treatments such as growth hormone, androgens, and LH activity.In conclusion, the best available evidence supports that the treatment of the expected poor ovarian response patient should be individualized in all steps of ART, including the choice of GnRH analogue, the gonadotropin type and dose, ovulation trigger, and the possible use of adjuvant therapies.

Defining Low Prognosis Patients Undergoing Assisted Reproductive Technology: POSEIDON Criteria-The Why

Women with impaired ovarian reserve or poor ovarian response (POR) to exogenous gonadotropin stimulation present a challenge for reproductive specialists. The primary reasons relate to the still limited knowledge about the POR pathophysiology and the lack of practical solutions for the management of these conditions. Indeed, clinical trials using the current standards to define POR failed to show evidence in favor of a particular treatment modality. Furthermore, critical factors for reproductive success, such as the age-dependent embryo aneuploidy rates and the intrinsic ovarian resistance to gonadotropin stimulation, are not taken into consideration by the current POR criteria. As a result, the accepted definitions for POR have been criticized for their inadequacy concerning the proper patient characterization and for not providing clinicians a guide for therapeutic management. A novel system to classify infertility patients with "expected" or "unexpected" inappropriate ovarian response to exogenous gonadotropins-the POSEIDON criteria-was developed to provide a more nuanced picture of POR and to guide physicians in the management of such patients. The new standards are provoking as they challenge the current terminology of POR in favor of the newly defined concept of "low prognosis." This article provides readers a critical appraisal of the existing criteria that standardize the definition of POR and explains the primary reasons for the development of the POSEIDON criteria.