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Zou H, Wang R, Morbeck DE. Diagnostic or prognostic? Decoding the role of embryo selection on in vitro fertilization treatment outcomes. Fertil Steril 2024; 121:730-736. [PMID: 38185198 DOI: 10.1016/j.fertnstert.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 12/22/2023] [Accepted: 01/03/2024] [Indexed: 01/09/2024]
Abstract
In this review, we take a fresh look at embryo assessment and selection methods from the perspective of diagnosis and prognosis. On the basis of a systematic search in the literature, we examined the evidence on the prognostic value of different embryo assessment methods, including morphological assessment, blastocyst culture, time-lapse imaging, artificial intelligence, and preimplantation genetic testing for aneuploidy.
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Affiliation(s)
- Haowen Zou
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Rui Wang
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Dean E Morbeck
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia; Principle, Morbeck Consulting Ltd, Auckland, New Zealand.
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2
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Cohen A, Meyer R, Levin G. Impact factor bias in randomized controlled trials in reproductive medicine. Fertil Steril 2023; 120:699-700. [PMID: 37290555 DOI: 10.1016/j.fertnstert.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 05/31/2023] [Accepted: 06/01/2023] [Indexed: 06/10/2023]
Affiliation(s)
- Adiel Cohen
- Department of Obstetrics and Gynecology, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Raanan Meyer
- Department of Obstetrics and Gynecology, Chaim Sheba Medical, Center, Ramat-Gan, Israel, Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Gabriel Levin
- Department of Gynecologic Oncology, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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3
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Endometrial Scratching for Improving Endometrial Receptivity: a Critical Review of Old and New Clinical Evidence. Reprod Sci 2022; 30:1701-1711. [DOI: 10.1007/s43032-022-01125-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 11/05/2022] [Indexed: 12/12/2022]
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4
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Anderson K, Blaxall M, Lensen S, Farquhar C. Surveys of clinician and patient attitudes to an add-on for in vitro fertilisation. Aust N Z J Obstet Gynaecol 2022; 62:761-766. [PMID: 35726738 PMCID: PMC9796505 DOI: 10.1111/ajo.13576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 06/02/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Add-ons at the time of in vitro fertilisation (IVF) have become commonplace, despite a general lack of evidence that they are effective and safe. The 'Colorado Protocol' is a commonly used add-on consisting of aspirin, steroid and an antibiotic. Before commencing planning for a clinical trial evaluating the Colorado Protocol, researchers and funders need evidence that the Colorado Protocol is being prescribed, and to be assured that sufficient numbers of participants can be recruited for a clinical trial. AIMS To survey fertility clinicians and patients on attitudes toward use of add-ons during IVF, willingness of patients to be randomly assigned to an add-on trial treatment or placebo, and what would be the clinically meaningful outcomes, using the Colorado Protocol as a test case. MATERIALS AND METHODS Two online surveys were conducted: clinicians from fertility clinics across the United Kingdom, Australia, and New Zealand; and patients from Auckland-based clinics and NZ patient support groups. RESULTS Of 58 clinicians, 44 (75%) had recommended an add-on within the preceding year. Thirty-nine (67%) clinicians were aware of the Colorado Protocol, with 17 (29%) having recommended it within the preceding year. Of the 289 patients, 80% indicated willingness to take trial medications during IVF, and 68% were willing to be randomly assigned to the placebo arm of a trial. The median perceived minimum clinically important difference in live births in both samples was 5%. CONCLUSIONS A future trial of this add-on in IVF would be supported by patients in the context of the New Zealand fertility healthcare system.
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Affiliation(s)
- Karyn Anderson
- Department of Obstetrics and GynaecologyUniversity of AucklandAucklandNew Zealand
| | - Michelle Blaxall
- Department of Obstetrics and GynaecologyUniversity of AucklandAucklandNew Zealand
| | - Sarah Lensen
- Department of Obstetrics and GynaecologyUniversity of MelbourneMelbourneVictoriaAustralia
| | - Cindy Farquhar
- Department of Obstetrics and GynaecologyUniversity of AucklandAucklandNew Zealand,Fertility Plus Clinic, Auckland District Health BoardAucklandNew Zealand
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5
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Evidence in reproductive medicine. REPRODUCTIVE AND DEVELOPMENTAL MEDICINE 2022. [DOI: 10.1097/rd9.0000000000000028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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6
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von Versen-Höynck F, Griesinger G. Should any use of artificial cycle regimen for frozen-thawed embryo transfer in women capable of ovulation be abandoned: yes, but what's next for FET cycle practice and research? Hum Reprod 2022; 37:1697-1703. [PMID: 35640158 DOI: 10.1093/humrep/deac125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 05/10/2022] [Indexed: 11/13/2022] Open
Abstract
Over the past decade, the use of frozen-thawed embryo transfer (FET) treatment cycles has increased substantially. The artificial ('programmed') cycle regimen, which suppresses ovulation, is widely used for that purpose, also in ovulatory women or women capable of ovulation, under the assumption of equivalent efficacy in terms of pregnancy achievement as compared to a natural cycle or modified natural cycle. The advantage of the artificial cycle is the easy alignment of the time point of thawing and transferring embryos with organizational necessities of the IVF laboratory, the treating doctors and the patient. However, recent data indicate that pregnancy establishment under absence of a corpus luteum as a consequence of anovulation may cause relevant maternal and fetal risks. Herein, we argue that randomized controlled trials (RCTs) are not needed to aid in the clinical decision for or against routine artificial cycle regimen use in ovulatory women. We also argue that RCTs are unlikely to answer the most burning questions of interest in that context, mostly because of lack of power and precision in detecting rare but decisive adverse outcomes (e.g. pre-eclampsia risk or long-term neonatal health outcomes). We pinpoint that, instead, large-scale observational data are better suited for that purpose. Eventually, we propose that the existing understanding and evidence is sufficient already to discourage the use of artificial cycle regimens for FET in ovulatory women or women capable of ovulation, as these may cause a strong deviation from physiology, thereby putting patient and fetus at avoidable health risk, without any apparent health benefit.
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Affiliation(s)
| | - Georg Griesinger
- Department of Gynecological Endocrinology and Reproductive Medicine, University Hospital of Schleswig-Holstein, Lübeck, Germany
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7
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Wilkinson J, Showell M, Taxiarchi VP, Lensen S. Are we leaving money on the table in infertility RCTs? Trialists should statistically adjust for prespecified, prognostic covariates to increase power. Hum Reprod 2022; 37:895-901. [PMID: 35199145 PMCID: PMC9071217 DOI: 10.1093/humrep/deac030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 11/30/2021] [Indexed: 11/13/2022] Open
Abstract
Infertility randomized controlled trials (RCTs) are often too small to detect realistic treatment effects. Large observational studies have been proposed as a solution. However, this strategy threatens to weaken the evidence base further, because non-random assignment to treatments makes it impossible to distinguish effects of treatment from confounding factors. Alternative solutions are required. Power in an RCT can be increased by adjusting for prespecified, prognostic covariates when performing statistical analysis, and if stratified randomization or minimization has been used, it is essential to adjust in order to get the correct answer. We present data showing that this simple, free and frequently necessary strategy for increasing power is seldom employed, even in trials appearing in leading journals. We use this article to motivate a pedagogical discussion and provide a worked example. While covariate adjustment cannot solve the problem of underpowered trials outright, there is an imperative to use sound methodology to maximize the information each trial yields.
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Affiliation(s)
- J Wilkinson
- Centre for Biostatistics, Manchester Academic Health Science Centre, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, UK
| | - M Showell
- Cochrane Gynaecology and Fertility, The University of Auckland, Auckland City Hospital, Auckland, New Zealand
| | - V P Taxiarchi
- Centre for Biostatistics, Manchester Academic Health Science Centre, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, UK
| | - S Lensen
- Department of Obstetrics and Gynaecology, Royal Women’s Hospital, University of Melbourne, Melbourne, VIC, Australia
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Gan J, Rozen G, Polyakov A. Treatment outcomes of blastocysts thaw cycles, comparing the presence and absence of a corpus luteum: a systematic review and meta-analysis. BMJ Open 2022; 12:e051489. [PMID: 35473741 PMCID: PMC9045106 DOI: 10.1136/bmjopen-2021-051489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
PURPOSE This study aims to review the literature and perform a meta-analysis to determine if the presence of a corpus luteum has an impact on treatment outcomes in thaw cycles, where blastocyst embryos are transferred. METHOD PUBMED, EMBASE, CENTRAL and CINAHL were searched for papers published between January 2017 and 27 July 2020. Additional articles were selected from the reference list of the results and previous reviews. Three reviewers independently reviewed and extracted data. The meta-analysis was conducted though RevMan V.5.4.1. Studies were quality assessed with the Cochrane risk of bias tool and the Newcastle-Ottawa Scale. RESULTS Nine publications were included for data extraction and subsequent meta-analysis. Two studies were randomised controlled trials, and seven were cohort studies. Subgroup analysis of the different study designs was performed. While the rates of positive human chorionic gonadotropin results (relative risk, RR 1.0, 95% CI 0.95 to 1.05) and clinical pregnancies (RR 1.06, 95% CI 0.96 to 1.18) were comparable between the two groups, the rates of live births were higher in thaw cycles with a corpus luteum (RR 1.14, 95% CI 1.06 to 1.22). Analysis of pregnancy losses demonstrated that both biochemical pregnancy (early miscarriage) (RR 0.71, 95% CI 0.62 to 0.82) and miscarriages (RR 0.72, 95% CI 0.62 to 0.83) were increased in cycles without a corpus luteum. CONCLUSION Where clinically appropriate, the use of cycle types that have a functional corpus luteum should be favoured. There were several limitations to this study, including the quality of studies and the inherent bias of retrospective cohort studies. Further, high-quality research, particularly randomised controlled trials with blastocysts embryos, is required to further explore these findings. PROSPERO REGISTRATION NUMBER CRD42020209583.
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Affiliation(s)
- Joscelyn Gan
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Genia Rozen
- Reproductive Services, Royal Women's Hospital, Parkville, Victoria, Australia
- Melbourne IVF, East Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Alex Polyakov
- Reproductive Services, Royal Women's Hospital, Parkville, Victoria, Australia
- Melbourne IVF, East Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
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9
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Wilkinson J, Stocking K. Study design flaws and statistical challenges in evaluating fertility treatments. REPRODUCTION AND FERTILITY 2022; 2:C9-C21. [PMID: 35128452 PMCID: PMC8812412 DOI: 10.1530/raf-21-0015] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 05/21/2021] [Indexed: 12/16/2022] Open
Abstract
Health interventions should be tested before being introduced into clinical practice, to find out whether they work and whether they are harmful. However, research studies will only provide reliable answers to these questions if they are appropriately designed and analysed. But these are not trivial tasks. We review some methodological challenges that arise when evaluating fertility interventions and explain the implications for a non-statistical audience. These include flexibility in outcomes and analyses; use of surrogate outcomes instead of live birth; use of inappropriate denominators; evaluating cumulative outcomes and time to live birth; allowing each patient or couple to contribute to a research study more than once. We highlight recurring errors and present solutions. We conclude by highlighting the importance of collaboration between clinical and methodological experts, as well as people with experience of subfertility, for realising high-quality research. Lay summary We do research to find out whether fertility treatments are beneficial and to make sure they don't cause harm. However, research will only provide reliable answers if it is done properly. It is not unusual for researchers to make mistakes when they are designing research studies and analysing the data that we get from them. In this review, we describe some of the mistakes people make when they do research about fertility treatments and explain how to avoid them. These include challenges which arise due to the large number of things that can be measured and reported when looking to see if fertility treatments work; failure to check whether the treatment increases the number of live births; failing to include all study participants in calculations;challenges in studies where participants may have more than one treatment attempt. We conclude by highlighting the importance of collaboration between clinical and methodological experts, as well as people with experience of fertility problems.
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Affiliation(s)
- Jack Wilkinson
- Centre for Biostatistics, Division of Population Health, Health Services Research and Primary Care, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, UK
| | - Katie Stocking
- Centre for Biostatistics, Division of Population Health, Health Services Research and Primary Care, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, UK
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10
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Vončina SM, Stenqvist A, Bungum M, Schyman T, Giwercman A. Sperm DNA fragmentation index and cumulative live birth rate in a cohort of 2,713 couples undergoing assisted reproduction treatment. Fertil Steril 2021; 116:1483-1490. [PMID: 34376283 DOI: 10.1016/j.fertnstert.2021.06.049] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 06/26/2021] [Accepted: 06/30/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To study how the choice of the first assisted reproductive technology treatment type affects the cumulative live birth rate (CLBR) in couples with high sperm DNA fragmentation index (DFI). DESIGN Longitudinal cohort study. SETTING University-affiliated fertility clinic. PATIENT(S) A total of 2,713 infertile couples who underwent assisted reproductive technology treatment between 2007 and 2017 were included in the study. All in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) treatments (up to three fresh treatments and all associated frozen-thawed embryo transfers) offered to the couples by the public health care system were included, in total 5,422 cycles. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) The primary outcome was the CLBR. The secondary outcomes were the fertilization rate and the miscarriage rate. The IVF and ICSI groups were defined according to the method applied in the first treatment cycle. RESULT(S) In the IVF group, the CLBR values were higher for couples with normal DFI compared with those for couples with high DFI (≥20%) (48.1% vs. 41.6% for conservative CLBR estimate and 55.6% vs. 51.4% for optimal CLBR estimate after adjustment for female age, respectively). No DFI-dependent difference was seen in the ICSI group. CONCLUSION(S) Our results demonstrated that a high DFI predicts a statistically significantly lower CLBR if IVF and not ICSI is applied in the first cycle of assisted reproduction.
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Affiliation(s)
- Sladjana Malić Vončina
- Molecular Reproductive Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden; Reproductive Medicine Centre, Skåne University Hospital, Malmö, Sweden
| | - Amelie Stenqvist
- Molecular Reproductive Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden; Reproductive Medicine Centre, Skåne University Hospital, Malmö, Sweden; Department of Gynecology and Obstetrics, Skåne University Hospital, Malmö, Sweden.
| | | | - Tommy Schyman
- Clinical Studies Sweden - Forum South, Skåne University Hospital, Lund, Sweden
| | - Aleksander Giwercman
- Molecular Reproductive Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden; Reproductive Medicine Centre, Skåne University Hospital, Malmö, Sweden
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11
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Wilkinson J, Huang JY, Marsden A, Harhay MO, Vail A, Roberts SA. The implications of outcome truncation in reproductive medicine RCTs: a simulation platform for trialists and simulation study. Trials 2021; 22:520. [PMID: 34362422 PMCID: PMC8344218 DOI: 10.1186/s13063-021-05482-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 07/22/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Randomised controlled trials in reproductive medicine are often subject to outcome truncation, where the study outcomes are only defined in a subset of the randomised cohort. Examples include birthweight (measurable only in the subgroup of participants who give birth) and miscarriage (which can only occur in participants who become pregnant). These outcomes are typically analysed by making a comparison between treatment arms within the subgroup (for example, comparing birthweights in the subgroup who gave birth or miscarriages in the subgroup who became pregnant). However, this approach does not represent a randomised comparison when treatment influences the probability of being observed (i.e. survival). The practical implications of this for the design and interpretation of reproductive trials are unclear however. METHODS We developed a simulation platform to investigate the implications of outcome truncation for reproductive medicine trials. We used this to perform a simulation study, in which we considered the bias, type 1 error, coverage, and precision of standard statistical analyses for truncated continuous and binary outcomes. Simulation settings were informed by published assisted reproduction trials. RESULTS Increasing treatment effect on the intermediate variable, strength of confounding between the intermediate and outcome variables, and the presence of an interaction between treatment and confounder were found to adversely affect performance. However, within parameter ranges we would consider to be more realistic, the adverse effects were generally not drastic. For binary outcomes, the study highlighted that outcome truncation could cause separation in smaller studies, where none or all of the participants in a study arm experience the outcome event. This was found to have severe consequences for inferences. CONCLUSION We have provided a simulation platform that can be used by researchers in the design and interpretation of reproductive medicine trials subject to outcome truncation and have used this to conduct a simulation study. The study highlights several key factors which trialists in the field should consider carefully to protect against erroneous inferences. Standard analyses of truncated binary outcomes in small studies may be highly biassed, and it remains to identify suitable approaches for analysing data in this context.
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Affiliation(s)
- Jack Wilkinson
- Centre for Biostatistics, Manchester Academic Health Science Centre, Division of Population Health, Health Services Research and Primary Care, University of Manchester, M13 9PL, Manchester, UK.
| | - Jonathan Y Huang
- Biostatistics and Human Development; Singapore Institute for Clinical Sciences; Agency for Science, Technology, and Research, Singapore, Singapore
| | - Antonia Marsden
- Centre for Biostatistics, Manchester Academic Health Science Centre, Division of Population Health, Health Services Research and Primary Care, University of Manchester, M13 9PL, Manchester, UK
| | - Michael O Harhay
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Andy Vail
- Centre for Biostatistics, Manchester Academic Health Science Centre, Division of Population Health, Health Services Research and Primary Care, University of Manchester, M13 9PL, Manchester, UK
| | - Stephen A Roberts
- Centre for Biostatistics, Manchester Academic Health Science Centre, Division of Population Health, Health Services Research and Primary Care, University of Manchester, M13 9PL, Manchester, UK
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12
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Cecchino GN, Roque M, Cerrillo M, Filho RDR, Chiamba FDS, Hatty JH, García-Velasco JA. DuoStim cycles potentially boost reproductive outcomes in poor prognosis patients. Gynecol Endocrinol 2021; 37:519-522. [PMID: 32954881 DOI: 10.1080/09513590.2020.1822804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
AIM To evaluate the overall performance and oocyte quality of follicular phase stimulation (FPS) vs. luteal phase stimulation (LPS) among patients undergoing double ovarian stimulation (DuoStim). MATERIALS AND METHODS Observational retrospective two-center cohort study including 79 infertile women who underwent a total of 87 DuoStim cycles between January 2017 and May 2019. Besides assessing baseline characteristics in order to determine the patients' clinical profile, we analyzed the FPS and LPS regarding the total dose of gonadotropin received, the duration of stimulation, the number and maturity of oocytes, fertilization and blastocyst formation rates, and the number of blastocysts obtained. RESULTS The patients' baseline characteristics were compatible with a diminished ovarian reserve and poor reproductive prognosis. While the luteal phase needed longer stimulation (12 days (5-19) vs. 11 (7-16), p < .001) and slightly higher gonadotropin doses (2946 ± 890 IU vs. 2550 ± 970 IU, p < .001), no significant differences were detected in the oocyte maturity, fertilization, and blastocyst formation rates. However, the number of oocytes retrieved (5 (0-16) vs. 4 (0-15), p = .006), mature oocytes (4 (0-15) vs. 3 (0-11), p = .032), and blastocysts obtained (70 vs. 53) were substantially greater after LPS. CONCLUSIONS The DuoStim strategy in poor prognosis patients increases the number of oocytes and blastocysts available. Moreover, the number of oocytes and blastocysts obtained are higher after LPS when compared to FPS. Thus, it should be considered for selected patients in order to not only improve reproductive outcomes but also shorten the time to pregnancy.
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Affiliation(s)
- Gustavo N Cecchino
- Department of Gynecology, Federal University of São Paulo, São Paulo, Brazil
- Department of Gynecology and Obstetrics, Rey Juan Carlos University, Madrid, Spain
- IVIRMA Global Madrid, Madrid, Spain
- Mater Prime, São Paulo, Brazil
| | | | | | | | | | | | - Juan A García-Velasco
- Department of Gynecology and Obstetrics, Rey Juan Carlos University, Madrid, Spain
- IVIRMA Global Madrid, Madrid, Spain
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13
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Castillo CM, Johnstone ED, Horne G, Falconer DA, Troup SA, Cutting R, Sharma V, Brison DR, Roberts SA. Associations of IVF singleton birthweight and gestation with clinical treatment and laboratory factors: a multicentre cohort study. Hum Reprod 2021; 35:2860-2870. [PMID: 33190155 DOI: 10.1093/humrep/deaa244] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 07/01/2020] [Indexed: 11/13/2022] Open
Abstract
STUDY QUESTION Do IVF treatment and laboratory factors affect singleton birthweight (BW)? SUMMARY ANSWER BWs of IVF-conceived singleton babies are increasing with time, but we cannot identify the specific treatment factors responsible. WHAT IS KNOWN ALREADY IVF-conceived singleton babies from fresh transfers have slightly lower BW than those conceived naturally, whilst those from frozen embryo transfer (FET) cycles are heavier and comparable to naturally conceived offspring. Our recent studies have shown that BW varies significantly between different IVF centres, and in a single centre, is also increasing with time, without a corresponding change in BWs of naturally conceived infants. Although it is likely that factors in the IVF treatment cycle, such as hormonal stimulation or embryo laboratory culture conditions, are associated with BW differences, our previous study designs were not able to confirm this. STUDY DESIGN, SIZE, DURATION Data relating to BW outcomes, IVF treatment and laboratory parameters were collated from pre-existing electronic records in five participating centres for all singleton babies conceived between August 2007 and December 2014. PARTICIPANTS/MATERIALS, SETTING, METHODS Seven thousand, five hundred and eighty-eight births, 6207 from fresh and 1381 from FET. Infants with severe congenital abnormalities were excluded. The primary outcome of gestation-adjusted BW and secondary outcomes of unadjusted BW and gestation were analysed using multivariable regression models with robust standard errors to allow for the correlation between infants with the same mother. The models tested treatment factors allowing for confounding by centre, time and patient characteristics. A similar matched analysis of a subgroup of 379 sibling pairs was also performed. MAIN RESULTS AND THE ROLE OF CHANCE No significant associations of birth outcomes with IVF embryo culture parameters were seen independent of clinic or time, including embryo culture medium, incubator type or oxygen level, although small differences cannot be ruled out. We did not detect any significant differences associated with hormonal stimulation in fresh cycles or hormonal synchronization in FET cycles. Gestation-adjusted BW increased by 13.4 (95% CI 0.6-26.1) g per year over the period of the study, and babies born following FET were 92 (95% CI 57-128) g heavier on average than those from the fresh transfer. LIMITATIONS, REASONS FOR CAUTION Although no specific relationships have been identified independent of clinic and time, the confidence intervals remain large and do not exclude clinically relevant effect sizes. As this is an observational study, residual confounding may still be present. WIDER IMPLICATIONS OF THE FINDINGS This study demonstrates the potential for large scale analysis of routine data to address critical questions concerning the long-term implications of IVF treatment, in accordance with the Developmental Origins of Health and Disease hypothesis. However, much larger studies, at a national scale with sufficiently detailed data, are required to identify the treatment parameters associated with differences in BW or other relevant outcomes. STUDY FUNDING/COMPETING INTEREST(S) This work was supported by the EU FP7 project grant, EpiHealthNet (FP7-PEOPLE-2012-ITN-317146). No competing interests were identified. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- Catherine M Castillo
- Division of Developmental Biology and Medicine, Maternal & Fetal Health Research Centre, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Sciences Centre, Manchester M13 9WL, UK
| | - Edward D Johnstone
- Division of Developmental Biology and Medicine, Maternal & Fetal Health Research Centre, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Sciences Centre, Manchester M13 9WL, UK.,Maternal & Fetal Health Research Centre, St. Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester M13 9WL, UK
| | - Greg Horne
- Department of Reproductive Medicine, Old St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester M13 9WL, UK
| | | | - Stephen A Troup
- Hewitt Fertility Centre, Liverpool Women's NHS Foundation Trust, Liverpool L8 7SS, UK
| | - Rachel Cutting
- Jessop Fertility, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield S10 2SF, UK
| | - Vinay Sharma
- Leeds Centre of Reproductive Medicine, Leeds Teaching Hospitals NHS Trust, Seacroft Hospital, Leeds LS14 6UH, UK
| | - Daniel R Brison
- Division of Developmental Biology and Medicine, Maternal & Fetal Health Research Centre, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Sciences Centre, Manchester M13 9WL, UK.,Department of Reproductive Medicine, Old St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester M13 9WL, UK
| | - Stephen A Roberts
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, Centre for Biostatistics, The University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK
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14
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Correia KF, Dodge LE, Farland LV, Hacker MR, Ginsburg E, Whitcomb BW, Wise LA, Missmer SA. Confounding and effect measure modification in reproductive medicine research. Hum Reprod 2021; 35:1013-1018. [PMID: 32424412 DOI: 10.1093/humrep/deaa051] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 02/17/2020] [Indexed: 01/04/2023] Open
Abstract
The majority of research within reproductive and gynecologic health, or investigating ART, is observational in design. One of the most critical challenges for observational studies is confounding, while one of the most important for discovery and inference is effect modification. In this commentary, we explain what confounding and effect modification are and why they matter. We present examples illustrating how failing to adjust for a confounder leads to invalid conclusions, as well as examples where adjusting for a factor that is not a confounder also leads to invalid or imprecise conclusions. Careful consideration of which factors may act as confounders or modifiers of the association of interest is critical to conducting sound research, particularly with complex observational studies in reproductive medicine.
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Affiliation(s)
| | - Laura E Dodge
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, MA, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Leslie V Farland
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA
| | - Michele R Hacker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, MA, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Elizabeth Ginsburg
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, USA
| | - Brian W Whitcomb
- Department of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA, USA
| | - Lauren A Wise
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Stacey A Missmer
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Obstetrics, Gynecology and Reproductive Biology, Michigan State University College of Human Medicine, Grand Rapids, MI, USA
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15
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Sunkara SK, Zheng W, D'Hooghe T, Longobardi S, Boivin J. Time as an outcome measure in fertility-related clinical studies: long-awaited. Hum Reprod 2021; 35:1732-1739. [PMID: 32644107 PMCID: PMC7398622 DOI: 10.1093/humrep/deaa138] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 04/27/2020] [Indexed: 01/11/2023] Open
Abstract
Time taken to achieve a live birth is an important consideration that is central to managing patient expectations during infertility treatment. However, time-related endpoints are not reported as standard in the majority of fertility-related clinical studies and there is no internationally recognized consensus definition for such endpoints. There is, therefore, a need for meaningful discussions around the selection of appropriate time-related treatment outcome measures for studies evaluating fertility treatments that will be relevant to diverse stakeholders (e.g. patients, healthcare professionals, clinical scientists, authorities and industry). Here, we provide a proposal for the evaluation of time-related outcome measures in fertility-related clinical studies, alongside associated definitions.
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Affiliation(s)
- Sesh K Sunkara
- Division of Women's Health, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Wenjing Zheng
- Global Medical Affairs Fertility, Research and Development, Merck KGaA, Darmstadt, Germany
| | - Thomas D'Hooghe
- Global Medical Affairs Fertility, Research and Development, Merck KGaA, Darmstadt, Germany.,Research Group Reproductive Medicine, Department of Development and Regeneration, Organ Systems, Group Biomedical Sciences, KU Leuven (University of Leuven), Leuven, Belgium.,Department of Obstetrics and Gynecology, Yale University, New Haven, CT, USA
| | - Salvatore Longobardi
- Global Clinical Development, Merck Serono S.p.A, Rome, Italy, an affiliate of Merck KGaA, Darmstadt, Germany
| | - Jacky Boivin
- School of Psychology, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
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16
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Roque M, Haahr T, Esteves SC, Humaidan P. The POSEIDON stratification - moving from poor ovarian response to low prognosis. JBRA Assist Reprod 2021; 25:282-292. [PMID: 33565297 PMCID: PMC8083858 DOI: 10.5935/1518-0557.20200100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Poor ovarian response remains one of the most challenging tasks for an IVF clinician. In this review, we aim to highlight the ongoing research for optimizing the prognosis in poor ovarian response patients. The newly introduced POSEIDON criteria argue that the first step is to move from a poor response to a poor prognosis concept, while improving identification and stratification of the different sub-types of poor prognosis patients prior to ovarian stimulation. The immediate marker of success is the ability of the ovarian stimulation to retrieve the number of oocytes needed to obtain at least one euploid blastocyst for transfer in each patient. This surrogate marker of success should not replace live birth as the most important outcome, but it should be approached as a useful tool for clinicians to evaluate their strategy for achieving live birth in the shortest timespan possible in the individual patient/ couple.
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Affiliation(s)
- Matheus Roque
- MATER PRIME - Reproductive Medicine, São Paulo, SP, Brazil
| | - Thor Haahr
- The Fertility Clinic Skive Regional Hospital, 7800 Skive, Denmark
- Faculty of Health, Aarhus University, 8000 Aarhus C, Denmark
| | - Sandro C. Esteves
- Faculty of Health, Aarhus University, 8000 Aarhus C, Denmark
- ANDROFERT, Andrology and Human Reproduction Clinic, Campinas, SP, Brazil
| | - Peter Humaidan
- The Fertility Clinic Skive Regional Hospital, 7800 Skive, Denmark
- Faculty of Health, Aarhus University, 8000 Aarhus C, Denmark
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17
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Lensen S, Chen S, Goodman L, Rombauts L, Farquhar C, Hammarberg K. IVF add-ons in Australia and New Zealand: A systematic assessment of IVF clinic websites. Aust N Z J Obstet Gynaecol 2021; 61:430-438. [PMID: 33594674 DOI: 10.1111/ajo.13321] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/17/2020] [Accepted: 01/15/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND In vitro fertilisation (IVF) 'add-ons' are extra (non-essential) procedures, techniques or medicines, which usually claim to increase the chance of a successful IVF outcome. Use of IVF add-ons is believed to be widespread in many settings; however, information about add-on availability in Australasia is lacking. AIMS To understand which add-ons are advertised on Australasian IVF clinic websites, and what is the evidence for their benefit. MATERIALS AND METHODS A systematic assessment of website content was undertaken between December 2019-April 2020, capturing IVF add-ons advertised, including costs, claims of benefit, statements of risk or limitations, and evidence of effectiveness for improving live birth and pregnancy. A literature review assessed the strength and quality of evidence for each add-on. RESULTS Of the 40 included IVF clinics websites, 31 (78%) listed one or more IVF add-ons. A total of 21 different add-ons or add-on groups were identified, the most common being preimplantation genetic testing for aneuploidies (offered by 63% of clinics), time-lapse systems (33%) and assisted hatching (28%). In most cases (77%), descriptions of the IVF add-ons were accompanied by claims of benefit. Most claims (90%) were not quantified and very few referenced scientific publications to support the claims (9.8%). None of the add-ons were supported by high-quality evidence of benefit for pregnancy or live birth rates. The cost of IVF add-ons varied from $0 to $3700 (AUD/NZD). CONCLUSIONS There is widespread advertising of add-ons on IVF clinic websites, which report benefits for add-ons that are not supported by high-quality evidence.
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Affiliation(s)
- Sarah Lensen
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Sheng Chen
- Victorian Assisted Reproductive Treatment Authority, Melbourne, Victoria, Australia
| | - Lucy Goodman
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - Luk Rombauts
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Cindy Farquhar
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - Karin Hammarberg
- Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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18
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Bergh C, Kamath MS, Wang R, Lensen S. Strategies to reduce multiple pregnancies during medically assisted reproduction. Fertil Steril 2020; 114:673-679. [PMID: 32826048 DOI: 10.1016/j.fertnstert.2020.07.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/09/2020] [Accepted: 07/13/2020] [Indexed: 02/07/2023]
Abstract
Multiple birth rates after fertility treatment are still high in many countries. Multiple births are associated with increased rates of preterm birth and low birth weight babies, in turn increasing the risk of severe morbidity for the children. The multiple birth rates vary in different countries between 2% and 3% and up to 30% in some settings. Elective single-embryo transfer, particularly in combination with frozen-embryo transfer and milder stimulation in ovulation induction/intrauterine insemination, to avoid multifollicular development is an effective strategy to decrease the multiple birth rates while still achieving acceptable live-birth rates. Although this procedure is used successfully in many countries, it ought to be implemented broadly to improve the health of the children. One at a time should be the normal routine.
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Affiliation(s)
- Christina Bergh
- Department of Obstetrics and Gynecology, Institute of Clinical Science, Sahlgrenska Academy, Gothenburg University, Reproductive Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Mohan S Kamath
- Department of Reproductive Medicine, Christian Medical College, Vellore, India
| | - Rui Wang
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Sarah Lensen
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
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19
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AYDIN F, DÜLGER D, ALBUZ Ö. The importance of the chosen statistical methods in medical research: study over modelling in estimation superficial varicose vein risk factors in young male population. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2020. [DOI: 10.32322/jhsm.695341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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20
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Perrotta M, Geampana A. The trouble with IVF and randomised control trials: Professional legitimation narratives on time-lapse imaging and evidence-informed care. Soc Sci Med 2020; 258:113115. [PMID: 32593117 PMCID: PMC7369645 DOI: 10.1016/j.socscimed.2020.113115] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Revised: 03/09/2020] [Accepted: 06/04/2020] [Indexed: 01/28/2023]
Abstract
Focusing on the case of time-lapse imaging (TLI), this paper analyses how medical professionals negotiate the use of new 'add-on' fertility treatments in light of the limited evidence available. The data produced by TLI technologies is meant to help professionals identify the best embryo to be implanted. Embryo selection is essential in IVF practice for increasing pregnancy rates and reducing the negative effects of repeated failures. More than 5 years after the introduction of TLI in IVF labs, however, there has been no conclusive randomised control trial (RCT) evidence to show that the tools do indeed have a significant impact on pregnancy rates. Nonetheless, many public clinics in the UK have adopted such technologies. Consequently, our research asks: How is the use of TLI tools legitimised by professionals, in light of contradictory evidence? Focusing on 25 semi-structured staff interviews, we argue that professionals use several strategies to legitimise the use of TLI in the clinic without, however, challenging the tenets of evidence-based medicine (EBM) and the value it places on RCTs. Rather, professionals emphasise various advantages that TLI offers, including its use as a lab tool, its potential for knowledge production in embryology, and the role it plays in the management of patient expectations and course of treatment. This paper contributes to debates on the role of EBM in modern medicine and fertility care specifically - an area where this inter-relationship has been underexplored. We conclude by suggesting avenues towards a more nuanced understanding of EBM as it relates to IVF treatment and a rapidly changing biotechnology context.
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Affiliation(s)
- Manuela Perrotta
- Department of People and Organisations, School of Business and Management, Queen Mary University of London, United Kingdom.
| | - Alina Geampana
- Department of People and Organisations, School of Business and Management, Queen Mary University of London, United Kingdom
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21
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Esteves SC, Roque M, Sunkara SK, Conforti A, Ubaldi FM, Humaidan P, Alviggi C. Oocyte quantity, as well as oocyte quality, plays a significant role for the cumulative live birth rate of a POSEIDON criteria patient. Hum Reprod 2020; 34:2555-2557. [PMID: 31756248 DOI: 10.1093/humrep/dez181] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Sandro C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Campinas, São Paulo, Brazil.,Faculty of Health, Aarhus University, Aarhus, Denmark
| | | | - Sesh K Sunkara
- Department of Women's Health, Faculty of Life Sciences, King's College London, UK
| | - Alessandro Conforti
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | | | - Peter Humaidan
- Faculty of Health, Aarhus University, Aarhus, Denmark.,Fertility Clinic, Skive Regional Hospital, Skive, Denmark
| | - Carlo Alviggi
- Department of Women's Health, Faculty of Life Sciences, King's College London, UK
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22
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Large randomized controlled trials in infertility. Fertil Steril 2020; 113:1093-1099. [DOI: 10.1016/j.fertnstert.2020.04.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 04/15/2020] [Accepted: 04/16/2020] [Indexed: 01/12/2023]
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23
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Lensen S, Shreeve N, Barnhart KT, Gibreel A, Ng EHY, Moffett A. In vitro fertilization add-ons for the endometrium: it doesn't add-up. Fertil Steril 2020; 112:987-993. [PMID: 31843098 DOI: 10.1016/j.fertnstert.2019.10.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/28/2019] [Accepted: 10/04/2019] [Indexed: 12/13/2022]
Abstract
The probability of live birth from an in vitro fertilization (IVF) cycle is modest. Many additional treatments (add-ons) are available which promise to improve the success of IVF. This review summarizes the current evidence for common IVF add-ons which are suggested to improve endometrial receptivity. Systematic reviews of randomized controlled trials and individual trials were included. Five add-ons were included: immune therapies, endometrial scratching, endometrial receptivity array, uterine artery vasodilation, and human chorionic gonadotropin instillation. The results suggest there is no robust evidence that these add-ons are effective or safe. Many IVF add-ons are costly, consuming precious resources which may be better spent on evidence-based treatments or further IVF. Large randomized controlled trials and appropriate safety assessment should be mandatory before the introduction of IVF add-ons into routine practice.
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Affiliation(s)
- Sarah Lensen
- Department of Obstetrics and Gynaecology, University of Auckland, New Zealand.
| | - Norman Shreeve
- Department of Obstetrics & Gynaecology, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Kurt T Barnhart
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ahmed Gibreel
- Department of Obstetrics & Gynaecology, Mansoura University, Mansoura, Egypt
| | - Ernest Hung Yu Ng
- Department of Obstetrics & Gynecology, The University of Hong Kong, Hong Kong
| | - Ashley Moffett
- Department of Pathology and Centre for Trophoblast Research, University of Cambridge, Cambridge, United Kingdom
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24
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Affiliation(s)
- Georg Griesinger
- Department of Gynecological Endocrinology and Reproductive Medicine, University Hospital of Schleswig-Holstein, Lübeck, Germany
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25
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Wilkinson J, Brison DR, Duffy JMN, Farquhar CM, Lensen S, Mastenbroek S, van Wely M, Vail A. Don’t abandon RCTs in IVF. We don’t even understand them. Hum Reprod 2019. [PMCID: PMC6994932 DOI: 10.1093/humrep/dez199] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The conclusion of the Human Fertilisation and Embryology Authority that ‘add-on’ therapies in IVF are not supported by high-quality evidence has prompted new questions regarding the role of the randomized controlled trial (RCT) in evaluating infertility treatments. Critics argue that trials are cumbersome tools that provide irrelevant answers. Instead, they argue that greater emphasis should be placed on large observational databases, which can be analysed using powerful algorithms to determine which treatments work and for whom. Although the validity of these arguments rests upon the sciences of statistics and epidemiology, the discussion to date has largely been conducted without reference to these fields. We aim to remedy this omission, by evaluating the arguments against RCTs in IVF from a primarily methodological perspective. We suggest that, while criticism of the status quo is warranted, a retreat from RCTs is more likely to make things worse for patients and clinicians.
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Affiliation(s)
- J Wilkinson
- Centre for Biostatistics, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - D R Brison
- Department of Reproductive Medicine, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, UK
- Maternal and Fetal Health Research Centre, Faculty of Life Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - J M N Duffy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Balliol College, University of Oxford, Oxford, UK
| | - C M Farquhar
- Cochrane Gynecology and Fertility Group, Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - S Lensen
- Cochrane Gynecology and Fertility Group, Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - S Mastenbroek
- Amsterdam UMC, University of Amsterdam, Center for Reproductive Medicine, Amsterdam Reproduction & Development Research Institute, Amsterdam, Netherlands
| | - M van Wely
- Amsterdam UMC, University of Amsterdam, Center for Reproductive Medicine, Amsterdam Reproduction & Development Research Institute, Amsterdam, Netherlands
| | - A Vail
- Centre for Biostatistics, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
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26
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Wang R, Danhof NA, Tjon‐Kon‐Fat RI, Eijkemans MJC, Bossuyt PMM, Mochtar MH, van der Veen F, Bhattacharya S, Mol BWJ, van Wely M. Interventions for unexplained infertility: a systematic review and network meta-analysis. Cochrane Database Syst Rev 2019; 9:CD012692. [PMID: 31486548 PMCID: PMC6727181 DOI: 10.1002/14651858.cd012692.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Clinical management for unexplained infertility includes expectant management as well as active treatments, including ovarian stimulation (OS), intrauterine insemination (IUI), OS-IUI, and in vitro fertilisation (IVF) with or without intracytoplasmic sperm injection (ICSI).Existing systematic reviews have conducted head-to-head comparisons of these interventions using pairwise meta-analyses. As this approach allows only the comparison of two interventions at a time and is contingent on the availability of appropriate primary evaluative studies, it is difficult to identify the best intervention in terms of effectiveness and safety. Network meta-analysis compares multiple treatments simultaneously by using both direct and indirect evidence and provides a hierarchy of these treatments, which can potentially better inform clinical decision-making. OBJECTIVES To evaluate the effectiveness and safety of different approaches to clinical management (expectant management, OS, IUI, OS-IUI, and IVF/ICSI) in couples with unexplained infertility. SEARCH METHODS We performed a systematic review and network meta-analysis of relevant randomised controlled trials (RCTs). We searched electronic databases including the Cochrane Gynaecology and Fertility Group Specialised Register of Controlled Trials, the Cochrane Central Register of Studies Online, MEDLINE, Embase, PsycINFO and CINAHL, up to 6 September 2018, as well as reference lists, to identify eligible studies. We also searched trial registers for ongoing trials. SELECTION CRITERIA We included RCTs comparing at least two of the following clinical management options in couples with unexplained infertility: expectant management, OS, IUI, OS-IUI, and IVF (or combined with ICSI). DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts identified by the search strategy. We obtained the full texts of potentially eligible studies to assess eligibility and extracted data using standardised forms. The primary effectiveness outcome was a composite of cumulative live birth or ongoing pregnancy, and the primary safety outcome was multiple pregnancy. We performed a network meta-analysis within a random-effects multi-variate meta-analysis model. We presented treatment effects by using odds ratios (ORs) and 95% confidence intervals (CIs). For the network meta-analysis, we used Confidence in Network Meta-analysis (CINeMA) to evaluate the overall certainty of evidence. MAIN RESULTS We included 27 RCTs (4349 couples) in this systematic review and 24 RCTs (3983 couples) in a subsequent network meta-analysis. Overall, the certainty of evidence was low to moderate: the main limitations were imprecision and/or heterogeneity.Ten RCTs including 2725 couples reported on live birth. Evidence of differences between OS, IUI, OS-IUI, or IVF/ICSI versus expectant management was insufficient (OR 1.01, 95% CI 0.51 to 1.98; low-certainty evidence; OR 1.21, 95% CI 0.61 to 2.43; low-certainty evidence; OR 1.61, 95% CI 0.88 to 2.94; low-certainty evidence; OR 1.88, 95 CI 0.81 to 4.38; low-certainty evidence). This suggests that if the chance of live birth following expectant management is assumed to be 17%, the chance following OS, IUI, OS-IUI, and IVF would be 9% to 28%, 11% to 33%, 15% to 37%, and 14% to 47%, respectively. When only including couples with poor prognosis of natural conception (3 trials, 725 couples) we found OS-IUI and IVF/ICSI increased live birth rate compared to expectant management (OR 4.48, 95% CI 2.00 to 10.1; moderate-certainty evidence; OR 4.99, 95 CI 2.07 to 12.04; moderate-certainty evidence), while there was insufficient evidence of a difference between IVF/ICSI and OS-IUI (OR 1.11, 95% CI 0.78 to 1.60; low-certainty evidence).Eleven RCTs including 2564 couples reported on multiple pregnancy. Compared to expectant management/IUI, OS (OR 3.07, 95% CI 1.00 to 9.41; low-certainty evidence) and OS-IUI (OR 3.34 95% CI 1.09 to 10.29; moderate-certainty evidence) increased the odds of multiple pregnancy, and there was insufficient evidence of a difference between IVF/ICSI and expectant management/IUI (OR 2.66, 95% CI 0.68 to 10.43; low-certainty evidence). These findings suggest that if the chance of multiple pregnancy following expectant management or IUI is assumed to be 0.6%, the chance following OS, OS-IUI, and IVF/ICSI would be 0.6% to 5.0%, 0.6% to 5.4%, and 0.4% to 5.5%, respectively.Trial results show insufficient evidence of a difference between IVF/ICSI and OS-IUI for moderate/severe ovarian hyperstimulation syndrome (OHSS) (OR 2.50, 95% CI 0.92 to 6.76; 5 studies; 985 women; moderate-certainty evidence). This suggests that if the chance of moderate/severe OHSS following OS-IUI is assumed to be 1.1%, the chance following IVF/ICSI would be between 1.0% and 7.2%. AUTHORS' CONCLUSIONS There is insufficient evidence of differences in live birth between expectant management and the other four interventions (OS, IUI, OS-IUI, and IVF/ICSI). Compared to expectant management/IUI, OS may increase the odds of multiple pregnancy, and OS-IUI probably increases the odds of multiple pregnancy. Evidence on differences between IVF/ICSI and expectant management for multiple pregnancy is insufficient, as is evidence of a difference for moderate or severe OHSS between IVF/ICSI and OS-IUI.
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Affiliation(s)
- Rui Wang
- Monash UniversityDepartment of Obstetrics and GynaecologyClaytonVICAustralia3168
- The University of AdelaideRobinson Research Institute and Adelaide Medical SchoolAdelaideSAAustralia5005
| | - Nora A Danhof
- Academic Medical Center, University of AmsterdamCenter for Reproductive MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Raissa I Tjon‐Kon‐Fat
- Academic Medical Center, University of AmsterdamCenter for Reproductive MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Marinus JC Eijkemans
- UMC UtrechtDepartment of Biostatistics and Research Support, Julius CenterPO Box 85500UtrechtNetherlands3508GA
| | - Patrick MM Bossuyt
- Academic Medical Center, University of AmsterdamDepartment of Clinical Epidemiology, Biostatistics and BioinformaticsRoom J1b‐217, PO Box 22700AmsterdamNetherlands1100 DE
| | - Monique H Mochtar
- Academic Medical Center, University of AmsterdamCenter for Reproductive MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Fulco van der Veen
- Amsterdan UMC, University of AmsterdamCenter for Reproductive MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
| | | | - Ben Willem J Mol
- Monash UniversityDepartment of Obstetrics and GynaecologyClaytonVICAustralia3168
| | - Madelon van Wely
- Amsterdam UMC, University of AmsterdamCenter for Reproductive MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
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