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Perrotta M, Zampino L, Geampana A, Bhide P. Analysing adherence to guidelines for time-lapse imaging information on UK fertility clinic websites. HUM FERTIL 2024; 27:2346595. [PMID: 38769878 DOI: 10.1080/14647273.2024.2346595] [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: 12/11/2023] [Accepted: 04/12/2024] [Indexed: 05/22/2024]
Abstract
This study aims to systematically analyze the provision of information on Time-lapse Imaging (TLI) by UK fertility clinic websites. We conducted an analysis of 106 clinic websites that offer fertility treatment to self-funded patients. The analysis aimed to examine whether these clinics offer TLI, the associated cost for patients, and the clarity and quality of the provided information. Out of the 106 websites analysed, 71 (67%) claimed to offer TLI. Among these websites, 25 (35.2%) mentioned charging patients between £300 and £850, 25 (35.8%) claimed not to charge patients, and 21 (29.6%) did not provide any cost information for TLI. Furthermore, 64 (90.1%) websites made claims or implied that TLI leads to improved clinical outcomes by enhancing embryo selection. Notably, 34 (47.9%) websites did not mention or provide any links to the HFEA rating system. It is crucial to provide patients with clear and accurate information to enable them to make fully informed decisions about TLI, particularly when they are responsible for the associated costs. The findings of this study raise concerns about the reliability and accuracy of the information available on fertility clinic websites, which are typically the primary source of information for patients.
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Affiliation(s)
- Manuela Perrotta
- Department of People and Organisation, Queen Mary University of London, London, UK
| | - Letizia Zampino
- Department of People and Organisation, Queen Mary University of London, London, UK
- Department of Social Sciences and Economics, University of Rome "La Sapienza", Rome, Italy
| | | | - Priya Bhide
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Cirkovic S, Wilkinson J, Lensen S, Jackson E, Harper J, Lindemann K, Costa-Font J. Is the use of IVF add-on treatments driven by patients or clinics? Findings from a UK patient survey. HUM FERTIL 2023; 26:365-372. [PMID: 37063051 DOI: 10.1080/14647273.2023.2197628] [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: 09/06/2022] [Accepted: 03/15/2023] [Indexed: 04/18/2023]
Abstract
There are conflicting narratives over what drives demand for add-ons. We undertook an online survey of IVF patients to determine whether patients perceive that use of IVF add-ons is driven by patients or practitioners. People who underwent IVF in the UK in the previous five years were recruited via social media Survey questions focussed on the roles of clinician offer and patient request, including who first suggested use of add-ons in IVF consultations, where patients first heard about them, and which information sources they trusted. From a total of 261 responses, 224 met the inclusion criteria. Overall, 67% of respondents had used one or more IVF add-ons, most commonly: time-lapse imaging (27%), EmbryoGlue (27%), and endometrial scratching (26%). Overall, 81% of the add-ons used were offered to participants by clinicians (compared to 19% requested by themselves). Half (54%) reported being offered add-ons during consultations, compared to 24% who initiated discussion about add-ons. Higher proportions of private patients reported being offered (90%), requesting (47%) and using (74%) add-ons than those with NHS funding (74%, 29%, 52%, respectively). The main limitations of this study are the small sample size, recruitment via a convenience sample, and the self-reported data capture which is subject to recall bias.
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Affiliation(s)
- Stevan Cirkovic
- Law School, London School for Economics and Political Science (LSE), London, UK
- Human Fertilisation and Embryology Authority (HFEA), London, UK
| | - Jack Wilkinson
- Centre for Biostatistics, Manchester Academic Health Science Centre, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Sarah Lensen
- Department of Obstetrics and Gynaecology, Royal Women's Hospital, University of Melbourne, Melbourne, Australia
| | - Emily Jackson
- Law School, London School for Economics and Political Science (LSE), London, UK
| | - Joyce Harper
- Institute of Women's Health, University College London (UCL), London, UK
| | | | - Joan Costa-Font
- Department of Health Policy and Ageing and Health Incentives Lab (AHIL), London School for Economics and Political Science (LSE), London, UK
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Geampana A, Perrotta M. Accounting for complexity in healthcare innovation debates: Professional views on the use of new IVF treatments. Health (London) 2023; 27:907-923. [PMID: 35105230 PMCID: PMC10588277 DOI: 10.1177/13634593221074874] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Social scientists have long been interested in the forces and values driving healthcare innovation. The simultaneous rise of 20th century healthcare reforms, increased importance of evidence and upsurge in lay health activism have shaped modern medicine. On this backdrop, fertility care emerged in the 1970s. Recent developments reveal a contentious relationship between new fertility treatments and clinical evidence, with emerging technologies being used without conclusive evidence of effectiveness despite being sold to patients. Initial critiques of this phenomenon emphasise commercial interests as the culprit, suggesting that the problematic use of unproven treatments is mainly driven by the private sector. Here, we challenge this over-simplified view of IVF care. Drawing on a qualitative analysis of key documents and 43 in-depth professional interviews, this article identifies three main stakeholder approaches to new treatment adoption. We argue that viewpoints are anchored within three critical overarching 'modes of coordination' or core values in modern healthcare: efficiency, effectiveness and patient-centeredness. This analysis encourages a more contextualised overview of fertility care than previous literatures have afforded. The IVF case shows that an emphasis on private versus public clinic practices obscure similarities between the two along with the values motivating healthcare professionals' approaches to new treatments.
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Wrigley A, Watts G, Lipworth W, Newson AJ. Hope and Exploitation in Commercial Provision of Assisted Reproductive Technologies. Hastings Cent Rep 2023; 53:30-41. [PMID: 37963135 PMCID: PMC10946894 DOI: 10.1002/hast.1513] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
Innovation is a key driver of care provision in assisted reproductive technologies (ART). ART providers offer a range of add-on interventions, aiming to augment standard in vitro fertilization protocols and improve the chances of a live birth. Particularly in the context of commercial provision, an ever-increasing array of add-ons are marketed to ART patients, even when evidence to support them is equivocal. A defining feature of ART is hope-hope that a cycle will lead to a baby or that another test or intervention will make a difference. Yet such hope also leaves ART patients vulnerable in a variety of ways. This article argues that previous attempts to safeguard ART patients have neglected how the use of add-ons in commercial ART can exploit patients' hopes. Commercial providers of ART should provide add-ons only free of charge, under a suitable research protocol.
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Palomba S, Carone D, Vitagliano A, Costanzi F, Fracassi A, Russo T, Del Negro S, Biello A, Di Filippo A, Mangiacasale A, Monaco A, Ranieri A, Ermini B, Barba BF, Castello C, Di Guardo F, Pastorella F, Bernasconi E, Tricarico EM, Filippi F, Polsinelli F, Monte GL, Sosa Fernandez LM, Galletta M, Giardina P, Totaro P, Laganara R, Liguori R, Buccheri M, Montanino Oliva M, Piscopo R, Iuliano A, Innantuoni N, Romanello I, Sinatra F, Liprino A, Thiella R, Tiezzi A, Bartolotti T, Tomasi A, Finocchiaro V, Thiella M, Fuggetta G, Messineo S, Isabella F, Tripodi M, Iaccarino S, La Sala GB, Papaleo E, Caserta D, Marci R, Somigliana E, Guglielmino A. Fertility specialists' views, behavior, and attitudes towards the use of endometrial scratching in Italy. BMC Womens Health 2023; 23:397. [PMID: 37516869 PMCID: PMC10386779 DOI: 10.1186/s12905-023-02564-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 07/22/2023] [Indexed: 07/31/2023] Open
Abstract
BACKGROUND Endometrial scratching (ES) or injury is intentional damage to the endometrium performed to improve reproductive outcomes for infertile women desiring pregnancy. Moreover, recent systematic reviews with meta-analyses and randomized controlled trials demonstrated that ES is not effective, data on the safety are limited, and it should not be recommended in clinical practice. The aim of the current study was to assess the view and behavior towards ES among fertility specialists throughout infertility centers in Italy, and the relationship between these views and the attitudes towards the use of ES as an add-on in their commercial setting. METHODS Online survey among infertility centers, affiliated to Italian Society of Human Reproduction (SIRU), was performed using a detailed questionnaire including 45 questions with the possibility to give "closed" multi-choice answers for 41 items and "open" answers for 4 items. Online data from the websites of the infertility centers resulting in affiliation with the specialists were also recorded and analyzed. The quality of information about ES given on infertility centers websites was assessed using a scoring matrix including 10 specific questions (scored from 0 to 2 points), and the possible scores ranged from 0 to 13 points ('excellent' if the score was 9 points or more, 'moderate' if the score was between 5 and 8, and 'poor' if it was 4 points or less). RESULTS The response rate was of 60.6% (43 questionnaires / 71 infertility SIRU-affiliated centers). All included questionnaires were completed in their entirety. Most physicians (~ 70%) reported to offer ES to less than 10% of their patients. The procedure is mainly performed in the secretory phase (69.2%) using pipelle (61.5%), and usually in medical ambulatory (56.4%) before IVF cycles to improve implantation (71.8%) without drugs administration (e.g., pain drugs, antibiotics, anti-hemorrhagics, or others) before (76.8%) or after (64.1%) the procedure. Only a little proportion of infertility centers included in the analysis proposes formally the ES as an add-on procedure (9.3%), even if, when proposed, the full description of the indications, efficacy, safety, and costs is never addressed. However, the overall information quality of the websites was generally "poor" ranging from 3 to 8 and having a low total score (4.7 ± 1.6; mean ± standard deviation). CONCLUSIONS In Italy, ES is a procedure still performed among fertility specialists for improving the implantation rate in IVF patients. Moreover, they have a poor attitude in proposing ES as an add-on in the commercial setting.
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Affiliation(s)
- Stefano Palomba
- Sant'Andrea Hospital, University "Sapienza" of Rome, Rome, Italy.
| | | | | | - Flavia Costanzi
- Sant'Andrea Hospital, University "Sapienza" of Rome, Rome, Italy
| | | | - Tiziana Russo
- Grande Ospedale Metropolitano, Reggio Calabria, Italy
- Gatjc Fertility Center, Gioia Tauro, Reggio Calabria, Italy
| | - Serena Del Negro
- Gatjc Fertility Center, Gioia Tauro, Reggio Calabria, Italy
- Presidio Ospedaliero Di Soverato "Basso Ionio", Soverato, Catanzaro, Italy
| | | | | | | | | | | | - Beatrice Ermini
- Centro Italiano Di Procreazione Assistita - CIPA, Rome, Italy
| | | | - Claudio Castello
- Centro FIVET Città Di Torino, Casa Della Salute Valdese, Turin, Italy
| | - Federica Di Guardo
- Azienda Ospedaliero Universitaria Policlinico "G. Rodolico - San Marco", Catania, Italy
| | | | | | | | - Francesca Filippi
- Fondazione IRCCS Ca' Grande - Ospedale Maggiore - University of Milan, Milan, Italy
| | | | - Giuseppe Lo Monte
- Centro Di Medicina Della Riproduzione E Crioconservazione Dei Gameti, Ospedale Di Brunico, Bolzano, Italy
| | | | - Marco Galletta
- Centro Di Procreazione Medicalmente Assistita, Azienda Ospedaliera "Papardo", Messina, Italy
| | | | - Pasquale Totaro
- Centro Di Procreazione Medicalmente Assistita, Ospedale Santa Maria, Bari, Italy
| | | | | | | | | | | | - Assunta Iuliano
- UOC Di Ostetricia E Ginecologia, Azienda Ospedaliera "San Carlo", Potenza, Italy
| | | | - Irene Romanello
- SSD Di Procreazione Medicalmente Assistita, Azienza Sanitaria Friuli Occidentale, Sacile, Pordenone, Italy
| | | | | | | | | | | | | | | | | | - Giuseppa Fuggetta
- SSD Di Procreazione Medicalmente Assistita, Azienza Sanitaria Friuli Occidentale, Sacile, Pordenone, Italy
| | | | | | | | | | | | | | | | | | - Edgardo Somigliana
- Fondazione IRCCS Ca' Grande - Ospedale Maggiore - University of Milan, Milan, Italy
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Taylor F, Turner-Moore R, Pacey A, Jones G. Accessing publicly funded donor insemination treatment in the UK: is funding information available on fertility clinic websites? HUM FERTIL 2023; 26:512-518. [PMID: 37161825 DOI: 10.1080/14647273.2023.2202830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 03/24/2023] [Indexed: 05/11/2023]
Abstract
We sought to find out if information about public funding for regulated donor insemination (DI) was available on UK fertility clinic websites, and if so, what information was provided for same-sex couples and single women; and if the available information was easily readable. The 'Choose a fertility clinic' pages of the Human Fertilisation and Embryology Authority (HFEA) website were used to identify all licensed fertility clinics in the UK, and any available text on public funding for DI treatment was extracted. The Flesch reading ease scores were calculated to determine the readability of the extracted text. Of the 52 clinics included in the synthesis, 23 mentioned public funding, and for 16 of these, it was unclear whether public funding was available. Six of the 23 clinics mentioned public funding for same-sex couples, and two mentioned public funding for single women. The Flesch reading ease scores indicated that none of the text about funding for DI treatment on any of the clinic websites met the NHS-advised level of readability for health information. Fertility clinic websites should specify whether they offer publicly funded treatment, and to whom, as well as clearly stating the eligibility criteria, using suitably readable language to communicate this.
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Affiliation(s)
- Francesca Taylor
- Leeds School of Social Sciences, Leeds Beckett University, Leeds, UK
| | - Rhys Turner-Moore
- Leeds School of Social Sciences, Leeds Beckett University, Leeds, UK
| | - Allan Pacey
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Georgina Jones
- Leeds School of Social Sciences, Leeds Beckett University, Leeds, UK
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7
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Hamper J, Perrotta M. Blurring the divide: Navigating the public/private landscape of fertility treatment in the UK. Health Place 2023; 80:102992. [PMID: 36841196 DOI: 10.1016/j.healthplace.2023.102992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 02/25/2023]
Abstract
It is widely assumed that fertility patients in the UK are either privately funded or publicly funded through the National Health Service. This article challenges this distinction and demonstrates how the boundaries between public and private fertility treatment provision are increasingly blurred. It draws on interviews with 42 fertility patients and partners who had accessed in vitro fertilisation (IVF) through both the National Health Service and private providers, to demonstrate how participants were compelled to engage with a consumerist model of healthcare, even when they had access to publicly funded IVF cycles. Patients' experiences of navigating fertility treatment revealed a hybrid public/private consumption landscape, which reflects the uneven process of privatisation across the fertility sector. This article demonstrates how healthcare privatisation has had profound consequences for all IVF patients.
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Affiliation(s)
- Josie Hamper
- School of Business and Management, Queen Mary University of London, 327 Mile End Road, London, E1 4NS, UK.
| | - Manuela Perrotta
- School of Business and Management, Queen Mary University of London, 327 Mile End Road, London, E1 4NS, UK.
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8
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Jones CA, Hawkins L, Friedman C, Hitkari J, McMahon E, Born KB. Choosing Wisely Canada: Canadian fertility and andrology society’s list of top items physicians and patients should question in fertility medicine. Arch Gynecol Obstet 2022; 306:267-275. [PMID: 35278119 PMCID: PMC8917376 DOI: 10.1007/s00404-022-06453-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/10/2022] [Indexed: 11/24/2022]
Abstract
Purpose To create a Choosing Wisely Canada list of the top 5 diagnostic and therapeutic interventions that should be questioned in Reproductive Endocrinology and Infertility in Canada. Methods The Canadian Fertility and Andrology Society (CFAS) National Working Group developed an initial list of recommendations of diagnostic and therapeutic interventions that are commonly used, but are not supported by evidence, and could expose patients to unnecessary harm. These were chosen based on their prevalence, cost, potential for harm, and quality of supporting evidence. A modified Delphi consensus was used over 5 rounds to generate ideas, review supporting evidence, assess clinical relevance, estimate recommendation impact and narrow the recommendations list to 5 items. Results Fifty unique ideas were first proposed by the working group, and after 5 rounds including a survey of Canadian Fertility and Andrology Society (CFAS) members, the final list of recommendations was created, including topics related to unnecessary investigations and interventions for patients with infertility and recurrent pregnancy loss, and those undergoing IVF. In this article, we describe not only the Delphi process used to determine the list, but also provide a summary of the evidence behind each of the final recommendations. Conclusions The list of five recommendations highlights opportunities to initiate conversations between clinicians and patients about the risks, benefits, harms and costs of unnecessary fertility treatments and procedures in a Canadian context.
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Affiliation(s)
- C A Jones
- Department of Obstetrics and Gynaecology, University of Toronto, 123 Edward St, Toronto, ON, M5G 1E2, Canada
- Mount Sinai Fertility, Sinai Health System, 700-250 Dundas Street West, Toronto, ON, M5T 2Z5, Canada
| | - L Hawkins
- Department of Obstetrics and Gynaecology, University of Toronto, 123 Edward St, Toronto, ON, M5G 1E2, Canada
- Department of Obstetrics and Gynaecology, Humber River Hospital, 1235 Wilson Ave, North York, ON, M3M 0B2, Canada
| | - Catherine Friedman
- Department of Obstetrics and Gynaecology, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada.
| | - J Hitkari
- Department of Obstetrics and Gynaecology, University of British Columbia, 930-1125 Howe Street, Vancouver, BC, V6Z 2K8, Canada
- Olive Fertility Centre, 300-East Tower, 555 West 12th Avenue, Vancouver, BC, V5Z 3X7, Canada
| | - E McMahon
- Mount Sinai Fertility, Sinai Health System, 700-250 Dundas Street West, Toronto, ON, M5T 2Z5, Canada
- Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, ON, M5T 1P8, Canada
| | - K B Born
- Institute of Health Policy, Management and Evaluation, Dalla School of Public Health, University of Toronto, 155 College St. 4th Floor, Toronto, ON, M5T 3M6, Canada
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9
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Sanderman EA, Willis SK, Wise LA. Female dietary patterns and outcomes of in vitro fertilization (IVF): a systematic literature review. Nutr J 2022; 21:5. [PMID: 35042510 PMCID: PMC8764863 DOI: 10.1186/s12937-021-00757-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 12/18/2021] [Indexed: 01/14/2023] Open
Abstract
Background Infertility affects up to 15% of couples. In vitro fertilization (IVF) treatment has modest success rates and some factors associated with infertility and poor treatment outcomes are not modifiable. Several studies have assessed the association between female dietary patterns, a modifiable factor, and IVF outcomes with conflicting results. We performed a systematic literature review to identify female dietary patterns associated with IVF outcomes, evaluate the body of evidence for potential sources of heterogeneity and methodological challenges, and offer suggestions to minimize heterogeneity and bias in future studies. Methods We performed systematic literature searches in EMBASE, PubMed, CINAHL, and Cochrane Central Register of Controlled Trials for studies with a publication date up to March 2020. We excluded studies limited to women who were overweight or diagnosed with PCOS. We included studies that evaluated the outcome of pregnancy or live birth. We conducted an initial bias assessment using the SIGN 50 Methodology Checklist 3. Results We reviewed 3280 titles and/or titles and abstracts. Seven prospective cohort studies investigating nine dietary patterns fit the inclusion criteria. Higher adherence to the Mediterranean diet, a ‘profertility’ diet, or a Dutch ‘preconception’ diet was associated with pregnancy or live birth after IVF treatment in at least one study. However, causation cannot be assumed. Studies were potentially hindered by methodological challenges (misclassification of the exposure, left truncation, and lack of comprehensive control for confounding) with an associated risk of bias. Studies of the Mediterranean diet were highly heterogenous in findings, study population, and methods. Remaining dietary patterns have only been examined in single and relatively small studies. Conclusions Future studies with rigorous and more uniform methodologies are needed to assess the association between female dietary patterns and IVF outcomes. At the clinical level, findings from this review do not support recommending any single dietary pattern for the purpose of improving pregnancy or live birth rates in women undergoing IVF treatment. Supplementary Information The online version contains supplementary material available at 10.1186/s12937-021-00757-7.
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Affiliation(s)
| | | | - Lauren A Wise
- Boston University School of Public Health, Boston, USA
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10
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Perrotta M, Hamper J. The crafting of hope: Contextualising add-ons in the treatment trajectories of IVF patients. Soc Sci Med 2021; 287:114317. [PMID: 34492406 PMCID: PMC8505791 DOI: 10.1016/j.socscimed.2021.114317] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 08/04/2021] [Accepted: 08/13/2021] [Indexed: 11/26/2022]
Abstract
The proliferation and popularity of additional treatments in IVF, also known as add-ons, has generated widespread discussion and controversy in the UK, where concerns have addressed the lack of evidence to support the efficacy and safety of these treatments, their cost, and their connection to a wider context of privatisation of fertility treatment. Drawing on 42 interviews with IVF patients, this article explores the role of hope in the appeal of add-ons from the patient perspective. The analysis is presented in two parts: firstly, we investigate the role of hope in patients' decision-making on treatment, contextualising add-ons in the broader trajectory of their IVF experience; secondly, we examine how patients navigate the offer of add-ons, focusing on the role of hope in how they rationalise their decisions on whether to include them in their fertility treatment. Our analysis shows how patients craft their hope to navigate the increasing number of available options in their quest to find the treatment(s) that will "work" for them. We suggest that the imperative for patients to explore all options is intensified with the emergence of add-ons, which produces a novel context and version of a "hope technology".
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Affiliation(s)
- Manuela Perrotta
- Department of People and Organisations, School of Business and Management, Queen Mary University of London, UK.
| | - Josie Hamper
- Department of People and Organisations, School of Business and Management, Queen Mary University of London, UK
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11
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Foyle KL, Sharkey DJ, Moldenhauer LM, Green ES, Wilson JJ, Roccisano CJ, Hull ML, Tremellen KP, Robertson SA. Effect of Intralipid infusion on peripheral blood T cells and plasma cytokines in women undergoing assisted reproduction treatment. Clin Transl Immunology 2021; 10:e1328. [PMID: 34408876 PMCID: PMC8358997 DOI: 10.1002/cti2.1328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/26/2021] [Accepted: 07/27/2021] [Indexed: 12/12/2022] Open
Abstract
Objectives Intravenous infusion of Intralipid is an adjunct therapy in assisted reproduction treatment (ART) when immune‐associated infertility is suspected. Here, we evaluated the effect of Intralipid infusion on regulatory T cells (Treg cells), effector T cells and plasma cytokines in peripheral blood of women undertaking IVF. Methods This prospective, observational pilot study assessed Intralipid infusion in 14 women exhibiting recurrent implantation failure, a clinical sign of immune‐associated infertility. Peripheral blood was collected immediately prior to and 7 days after intravenous administration of Intralipid. Plasma cytokines were measured by Luminex, and T‐cell subsets were analysed by flow cytometry. Results A small increase in conventional CD8+ T cells occurred after Intralipid infusion, but no change was seen in CD4+ Treg cells, or naïve, memory or effector memory T cells. Proliferation marker Ki67, transcription factors Tbet and RORγt, and markers of suppressive capacity CTLA4 and HLA‐DR were unchanged. Dimensionality‐reduction analysis using the tSNE algorithm confirmed no phenotype shift within Treg cells or other T cells. Intralipid infusion increased plasma CCL2, CCL3, CXCL8, GM‐CSF, G‐CSF, IL‐6, IL‐21, TNF and VEGF. Conclusion Intralipid infusion elicited elevated pro‐inflammatory cytokines, and a minor increase in CD8+ T cells, but no change in pro‐tolerogenic Treg cells. Notwithstanding the limitation of no placebo control, the results do not support Intralipid as a candidate intervention to attenuate the Treg cell response in women undergoing ART. Future placebo‐controlled studies are needed to confirm the potential efficacy and clinical significance of Intralipid in attenuating cytokine induction and circulating CD8+ T cells.
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Affiliation(s)
- Kerrie L Foyle
- Robinson Research Institute Adelaide Medical School University of Adelaide Adelaide SA Australia
| | - David J Sharkey
- Robinson Research Institute Adelaide Medical School University of Adelaide Adelaide SA Australia
| | - Lachlan M Moldenhauer
- Robinson Research Institute Adelaide Medical School University of Adelaide Adelaide SA Australia
| | - Ella S Green
- Robinson Research Institute Adelaide Medical School University of Adelaide Adelaide SA Australia
| | - Jasmine J Wilson
- Robinson Research Institute Adelaide Medical School University of Adelaide Adelaide SA Australia
| | - Cassandra J Roccisano
- School of Pharmacy and Medical Sciences University of South Australia Adelaide SA Australia
| | - M Louise Hull
- Robinson Research Institute Adelaide Medical School University of Adelaide Adelaide SA Australia
| | - Kelton P Tremellen
- School of Medicine Flinders University Adelaide SA Australia.,Repromed Pty Ltd Dulwich SA Australia
| | - Sarah A Robertson
- Robinson Research Institute Adelaide Medical School University of Adelaide Adelaide SA Australia
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12
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Chimote BN, Chimote NM. Fertility interventions 'add-ons' in clinical ART practice: Ethical, Moral and Commercial Considerations. J Assist Reprod Genet 2021; 38:2579-2580. [PMID: 34387793 DOI: 10.1007/s10815-021-02288-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/27/2021] [Indexed: 11/25/2022] Open
Affiliation(s)
- Bindu N Chimote
- Embryology and Reproductive Endocrinology, Vaunshdhara Fertility Centre, Nagpur, India, 440012.
| | - Natchandra M Chimote
- Embryology and Reproductive Endocrinology, Vaunshdhara Fertility Centre, Nagpur, India, 440012
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13
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Copp T, Nickel B, Lensen S, Hammarberg K, Lieberman D, Doust J, Mol BW, McCaffery K. Anti-Mullerian hormone (AMH) test information on Australian and New Zealand fertility clinic websites: a content analysis. BMJ Open 2021; 11:e046927. [PMID: 34233986 PMCID: PMC8264877 DOI: 10.1136/bmjopen-2020-046927] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES The anti-Mullerian hormone (AMH) test has been promoted as a way to inform women about their future fertility. However, data consistently show the test is a poor predictor of natural fertility potential for an individual woman. As fertility centre websites are often a primary source of information for reproductive information, it is essential the information provided is accurate and reflects the available evidence. We aimed to systematically record and categorise information about the AMH test found on Australian and New Zealand fertility clinic websites. DESIGN Content analysis of online written information about the AMH test on fertility clinic websites. SETTING Accredited Australian and New Zealand fertility clinic websites. METHODS Data were extracted between April and June 2020. Any webpage that mentioned the AMH test, including blogs specifically about the AMH test posted since 2015, was analysed and the content categorised. RESULTS Of the 39 active accredited fertility clinics' websites, 25 included information about the AMH test. The amount of information varied widely, and embodied four overarching categories; (1) the utility of the AMH test, (2) who the test is suitable for, (3) possible actions in response to the test and (4) caveats and limitations of the test. Eight specific statements about the utility of the test were identified, many of which are not evidence-based. While some websites were transparent regarding the test's limitations, others mentioned no caveats or included persuasive statements actively promoting the test as empowering for a range of women in different circumstances. CONCLUSIONS Several websites had statements about the utility of the AMH test that are not supported by the evidence. This highlights the need for higher standards for information provided on fertility clinic websites to prevent women being misled to believe the test can reliably predict their fertility.
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Affiliation(s)
- Tessa Copp
- Faculty of Medicine and Health, Wiser Healthcare, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Sydney Health Literacy Lab, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Brooke Nickel
- Faculty of Medicine and Health, Wiser Healthcare, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Sydney Health Literacy Lab, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Sarah Lensen
- Obstetrics and Gynaecology, The University of Melbourne, Parkville, Victoria, Australia
| | - Karin Hammarberg
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Victorian Assisted Reproductive Treatment Authority, Melbourne, Victoria, Australia
| | - Devora Lieberman
- City Fertility Centre Pty Ltd, Sydney, New South Wales, Australia
| | - Jenny Doust
- Centre of Longitudinal and Life Course Research, School of Public Health, The University of Queensland, Herston, Queensland, Australia
| | - Ben W Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Kirsten McCaffery
- Faculty of Medicine and Health, Wiser Healthcare, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Sydney Health Literacy Lab, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
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Lensen SF, Armstrong S, Gibreel A, Nastri CO, Raine-Fenning N, Martins WP. Endometrial injury in women undergoing in vitro fertilisation (IVF). Cochrane Database Syst Rev 2021; 6:CD009517. [PMID: 34110001 PMCID: PMC8190981 DOI: 10.1002/14651858.cd009517.pub4] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Implantation of an embryo within the endometrial cavity is a critical step in the process of in vitro fertilisation (IVF). Previous research has suggested that endometrial injury (also known as endometrial scratching), defined as intentional damage to the endometrium, can increase the chance of pregnancy in women undergoing IVF. OBJECTIVES To assess the effectiveness and safety of endometrial injury performed before embryo transfer in women undergoing in vitro fertilisation (IVF) including intracytoplasmic sperm injection (ICSI) and frozen embryo transfer. SEARCH METHODS In June 2020 we searched the Cochrane Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, LILACS, DARE and two trial registries. We also checked the reference sections of relevant studies and contacted experts in the field for any additional trials. SELECTION CRITERIA Randomised controlled trials comparing intentional endometrial injury before embryo transfer in women undergoing IVF, versus no intervention or a sham procedure. DATA COLLECTION AND ANALYSIS We used standard methodological procedures recommended by Cochrane. Two independent review authors screened studies, evaluated risk of bias and assessed the certainty of the evidence by using GRADE (Grading of Recommendation, Assessment, Development and Evaluation) criteria. We contacted and corresponded with study investigators as required. Due to the high risk of bias associated with many of the studies, the primary analyses of all review outcomes were restricted to studies at a low risk of bias for selection bias and other bias. Sensitivity analysis was then performed including all studies. The primary review outcomes were live birth and miscarriage. MAIN RESULTS Endometrial injury versus control (no procedure or a sham procedure) A total of 37 studies (8786 women) were included in this comparison. Most studies performed endometrial injury by pipelle biopsy in the luteal phase of the cycle before the IVF cycle. The primary analysis was restricted to studies at low risk of bias, and included eight studies. The effect of endometrial injury on live birth is unclear as the result is consistent with no effect, or a small reduction, or an improvement (odds ratio (OR) 1.12, 95% confidence interval (CI) 0.98 to 1.28; participants = 4402; studies = 8; I2 = 15%, moderate-certainty evidence). This suggests that if the chance of live birth with IVF is usually 27%, then the chance when using endometrial injury would be somewhere between < 27% and 32%. Similarly, the effect of endometrial injury on clinical pregnancy is unclear (OR 1.08, 95% CI 0.95 to 1.23; participants = 4402; studies = 8; I2 = 0%, moderate-certainty evidence). This suggests that if the chance of clinical pregnancy from IVF is normally 32%, then the chance when using endometrial injury before IVF is between 31% and 37%. When all studies were included in the sensitivity analysis, we were unable to conduct meta-analysis for the outcomes of live birth and clinical pregnancy due to high risk of bias and statistical heterogeneity. Endometrial injury probably results in little to no difference in chance of miscarriage (OR 0.88, 95% CI 0.68 to 1.13; participants = 4402; studies = 8; I2 = 0%, moderate-certainty evidence), and this result was similar in the sensitivity analysis that included all studies. The result suggests that if the chance of miscarriage with IVF is usually 6.0%, then when using endometrial injury it would be somewhere between 4.2% and 6.8%. Endometrial injury was associated with mild to moderate pain (approximately 4 out of 10), and was generally associated with some minimal bleeding. The evidence was downgraded for imprecision due to wide confidence intervals and therefore all primary analyses were graded as moderate certainty. Higher versus lower degree of injury Only one small study was included in this comparison (participants = 129), which compared endometrial injury using two different instruments in the cycle prior to the IVF cycle: a pipelle catheter and a Shepard catheter. This trial was excluded from the primary analysis due to risk of bias. In the sensitivity analysis, all outcomes reported for this study were graded as very-low certainty due to risk of bias, and as such we were not able to interpret the study results. AUTHORS' CONCLUSIONS The effect of endometrial injury on live birth and clinical pregnancy among women undergoing IVF is unclear. The results of the meta-analyses are consistent with an increased chance, no effect and a small reduction in these outcomes. We are therefore uncertain whether endometrial injury improves the chance of live birth or clinical pregnancy in women undergoing IVF. Endometrial injury does not appear to affect the chance of miscarriage. It is a somewhat painful procedure associated with a small amount of bleeding. In conclusion, current evidence does not support the routine use of endometrial injury for women undergoing IVF.
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Affiliation(s)
- Sarah F Lensen
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
| | - Sarah Armstrong
- Department of Oncology & Metabolism, Academic Unit of Reproductive and Developmental Medicine, The University of Sheffield, Sheffield, UK
| | - Ahmed Gibreel
- Obstetrics & Gynaecology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | | | - Nick Raine-Fenning
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
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Oxman M, Larun L, Pérez Gaxiola G, Alsaid D, Qasim A, Rose CJ, Bischoff K, Oxman AD. Quality of information in news media reports about the effects of health interventions: Systematic review and meta-analyses. F1000Res 2021; 10:433. [PMID: 35083033 PMCID: PMC8756300 DOI: 10.12688/f1000research.52894.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/27/2022] [Indexed: 12/21/2022] Open
Abstract
Background Many studies have assessed the quality of news reports about the effects of health interventions, but there has been no systematic review of such studies or meta-analysis of their results. We aimed to fill this gap (PROSPERO ID: CRD42018095032). Methods We included studies that used at least one explicit, prespecified and generic criterion to assess the quality of news reports in print, broadcast, or online news media, and specified the sampling frame, and the selection criteria and technique. We assessed criteria individually for inclusion in the meta-analyses, excluding ineligible criteria and criteria with inadequately reported results. We mapped and grouped criteria to facilitate evidence synthesis. Where possible, we extracted the proportion of news reports meeting the included criterion. We performed meta-analyses using a random effects model to estimate such proportions for individual criteria and some criteria groups, and to characterise heterogeneity across studies. Results We included 44 primary studies in the review, and 18 studies and 108 quality criteria in the meta-analyses. Many news reports gave an unbalanced and oversimplified picture of the potential consequences of interventions. A limited number mention or adequately address conflicts of interest (22%; 95% CI 7%-49%) (low certainty), alternative interventions (36%; 95% CI 26%-47%) (moderate certainty), potential harms (40%; 95% CI 23%-61%) (low certainty), or costs (18%; 95% CI 12%-28%) (moderate certainty), or quantify effects (53%; 95% CI 36%-69%) (low certainty) or report absolute effects (17%; 95% CI 4%-49%) (low certainty). Discussion There is room for improving health news, but it is logically more important to improve the public's ability to critically appraise health information and make judgements for themselves.
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Affiliation(s)
- Matt Oxman
- Centre for Informed Health Choices, Norwegian Institute of Public Health, Oslo, Norway
- Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Lillebeth Larun
- Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway
| | - Giordano Pérez Gaxiola
- Cochrane Associated Centre and Evidence‐based Medicine Department, Sinaloa's Pediatric Hospital, Culiacan, Mexico
| | - Dima Alsaid
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Anila Qasim
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Karin Bischoff
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Andrew David Oxman
- Centre for Informed Health Choices, Norwegian Institute of Public Health, Oslo, Norway
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16
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Oxman M, Larun L, Pérez Gaxiola G, Alsaid D, Qasim A, Rose CJ, Bischoff K, Oxman AD. Quality of information in news media reports about the effects of health interventions: Systematic review and meta-analyses. F1000Res 2021; 10:433. [PMID: 35083033 PMCID: PMC8756300 DOI: 10.12688/f1000research.52894.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/17/2021] [Indexed: 09/23/2023] Open
Abstract
Background Many studies have assessed the quality of news reports about the effects of health interventions, but there has been no systematic review of such studies or meta-analysis of their results. We aimed to fill this gap (PROSPERO ID: CRD42018095032). Methods We included studies that used at least one explicit, prespecified and generic criterion to assess the quality of news reports in print, broadcast, or online news media, and specified the sampling frame, and the selection criteria and technique. We assessed criteria individually for inclusion in the meta-analyses, excluding inappropriate criteria and criteria with inadequately reported results. We mapped and grouped criteria to facilitate evidence synthesis. Where possible, we extracted the proportion of news reports meeting the included criterion. We performed meta-analyses using a random effects model to estimate such proportions for individual criteria and some criteria groups, and to characterise heterogeneity across studies. Results We included 44 primary studies in the qualitative summary, and 18 studies and 108 quality criteria in the meta-analyses. Many news reports gave an unbalanced and oversimplified picture of the potential consequences of interventions. A limited number mention or adequately address conflicts of interest (22%; 95% CI 7%-49%) (low certainty), alternative interventions (36%; 95% CI 26%-47%) (moderate certainty), potential harms (40%; 95% CI 23%-61%) (low certainty), or costs (18%; 95% CI 12%-28%) (moderate certainty), or quantify effects (53%; 95% CI 36%-69%) (low certainty) or report absolute effects (17%; 95% CI 4%-49%) (low certainty). Discussion There is room for improving health news, but it is logically more important to improve the public's ability to critically appraise health information and make judgements for themselves.
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Affiliation(s)
- Matt Oxman
- Centre for Informed Health Choices, Norwegian Institute of Public Health, Oslo, Norway
- Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Lillebeth Larun
- Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway
| | - Giordano Pérez Gaxiola
- Cochrane Associated Centre and Evidence‐based Medicine Department, Sinaloa's Pediatric Hospital, Culiacan, Mexico
| | - Dima Alsaid
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Anila Qasim
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Karin Bischoff
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Andrew David Oxman
- Centre for Informed Health Choices, Norwegian Institute of Public Health, Oslo, Norway
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17
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Armstrong SC, Lensen S, Vaughan E, Wainwright E, Peate M, Balen AH, Farquhar CM, Pacey A. VALUE study: a protocol for a qualitative semi-structured interview study of IVF add-ons use by patients, clinicians and embryologists in the UK and Australia. BMJ Open 2021; 11:e047307. [PMID: 34020980 PMCID: PMC8144055 DOI: 10.1136/bmjopen-2020-047307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION For couples undergoing assisted reproduction, a plethora of adjuncts are available; these are known as 'add-ons'. Most add-ons are not supported by good quality randomised trial evidence of efficacy, with some proven to be ineffective. However, estimates suggest that over 70% of fertility clinics provide at least one add-on, often at extra cost to the patient. This study has three aims. First, to undertake a survey of in vitro fertilisation (IVF) clinics in the UK to ascertain which add-ons are being offered and at what cost. Second, to undertake qualitative semi-structured interviews of patients, clinicians and embryologists, to explore their opinions and beliefs surrounding add-ons. Third, to review the interpretation of the Human Fertilisation and Embryology Authority traffic light system, to better understand the information required by IVF patients, clinicians and embryologists when making decisions about add-ons. METHODS AND ANALYSIS All UK IVF clinics will be contacted by email and invited to complete an online survey. The survey will ask them which add-ons they offer, at what cost per cycle and how information is shared with patients. Semi-structured interviews will be conducted in the UK and Australia with three groups of participants: (i) fertility patients; (ii) clinicians and (iii) embryologists. Participants for the interviews will be recruited via social media channels, website adverts, email and snowball sampling. Up to 20 participants will be recruited for each group in each country. Following an online consent process, interviews will be conducted via video-conferencing software, transcribed verbatim and data subjected to inductive thematic analysis. ETHICS AND DISSEMINATION Ethical approval has been granted by the Universities of Sheffield, Bath Spa and Melbourne. Findings will be published in a peer-reviewed journal and disseminated to regulatory bodies in the UK and Australia. A lay summary of findings will be shared via Fertility Network, UK.
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Affiliation(s)
| | - Sarah Lensen
- Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Emily Vaughan
- Academic Women's Health Unit, North Bristol NHS Trust, Bristol, UK
| | | | - Michelle Peate
- Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Adam H Balen
- Obstetrics and Gynaecology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Cynthia M Farquhar
- Obstetrics and Gynaecology, The University of Auckland, Auckland, New Zealand
| | - Allan Pacey
- Oncology and Metabolism, The University of Sheffield, Sheffield, UK
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18
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"Add-Ons" for Assisted Reproductive Technology: Do Patients Get Honest Information from Fertility Clinics' Websites? Reprod Sci 2021; 28:3466-3472. [PMID: 33939166 DOI: 10.1007/s43032-021-00601-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/25/2021] [Indexed: 10/21/2022]
Abstract
"Add-on" procedures are actively promoted on some fertility clinic websites as proven means to improve IVF success rates, especially for couples with repeated implantation/IVF failures. However, the actual contribution of these interventions to live birth rates remains inconclusive. At present, little is known about the type and quality of the information provided on the IVF clinics' websites regarding the merits of "add-ons." A systematic evaluation of the quality of information on "add-on" procedures in fertility clinic websites was performed using 10-criteria structured questionnaire. We included English language websites that presented in the Google.com search engine after typing the following key-words:"endometrial scratching"(ES), "intralipid infusions"(ILI), "assisted hatching"(AHA), "PGT-A," or "PGS". In total, 254 websites were evaluated. In most cases, an accurate description of the "add-on" procedures was provided (78.8%). However, only a minority (12%) reported their undetermined effectiveness. The use of PGT-A was more often encouraged (52.8%) than ES (23.6%) and AHA (16%). The cost was infrequently presented (6.9%). Scientific references were only rarely provided for ILI, versus 12.7% for ES, 4.0% for AHA, and 5.6% for PGT-A. The information entry date was often missing. None of the websites reported the clinic's pregnancy-rate following the "add-on" procedures. Information on "add-ons" available to patients from IVF clinic websites is often inaccurate. This could perpetuate false myths among infertile patients about these procedures and raises concern regarding possible commercial bias. It is imperative that IVF clinic websites will better communicate the associated risks and uncertainties of "add-ons" to prospective patients.
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19
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Gürtin ZB, Tiemann E. The marketing of elective egg freezing: A content, cost and quality analysis of UK fertility clinic websites. REPRODUCTIVE BIOMEDICINE & SOCIETY ONLINE 2021; 12:56-68. [PMID: 33336090 PMCID: PMC7732876 DOI: 10.1016/j.rbms.2020.10.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/17/2020] [Accepted: 10/22/2020] [Indexed: 05/23/2023]
Abstract
To the authors' knowledge, this is the first UK-based study to analyse the marketing of elective egg freezing (EEF) by fertility clinics. Analyses were based on the websites of the top 15 UK clinics, which together provided 87.8% of all egg freezing cycles in the UK between 2008 and 2017 inclusive. The analyses included three phases: content analysis; systematic cost analysis and comparison; and quality analysis examining the information available on egg freezing and its adherence to the guidelines of the Human Fertilisation and Embryology Authority (HFEA). The results show that clinics frame EEF according to four main themes: as a new and exciting technology; as a solution to (a modern woman's) life circumstances; as a means to gain control, freedom and more reproductive options; and as a means to avoid the reproductive risks of ageing. This study also found that most clinics are not sufficiently clear and transparent about the 'true' cost of an EEF cycle, present an unbalanced view of EEF, and do not provide satisfactory data or information. Most importantly, none of the clinics adhere adequately to the HFEA guidelines regarding advertising and the provision of information. As the EEF market continues to grow, offered exclusively by private clinics, these findings require urgent attention. Clinics must improve the type and quality of EEF information on their websites such that potential patients can make informed choices, and this article provides 10 basic criteria which can be used as a checklist. It is suggested that the time may have come to grant greater economic regulatory powers to HFEA to avoid overcommercialization of the fertility industry.
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Affiliation(s)
- Zeynep B. Gürtin
- EGA Institute for Women’s Health, University College London, London, UK
| | - Emily Tiemann
- EGA Institute for Women’s Health, University College London, London, UK
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20
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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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21
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Lier MCI, Özcan H, Schreurs AMF, van de Ven PM, Dreyer K, van der Houwen LEE, Johnson NP, Vandekerckhove F, Verhoeve HR, Kuchenbecker W, Mol BW, Lambalk CB, Mijatovic V. Uterine bathing with sonography gel prior to IVF/ICSI-treatment in patients with endometriosis, a multicentre randomised controlled trial. Hum Reprod Open 2020; 2020:hoaa054. [PMID: 33225080 PMCID: PMC7668398 DOI: 10.1093/hropen/hoaa054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/09/2020] [Indexed: 01/27/2023] Open
Abstract
STUDY QUESTION What is the effect of uterine bathing with sonography gel prior to IVF/ICSI-treatment on live birth rates after fresh embryo transfer in patients with endometriosis? SUMMARY ANSWER After formal interim analysis and premature ending of the trial, no significant difference between uterine bathing using a pharmacologically neutral sonography gel compared to a sham procedure on live birth rate after fresh embryo transfer in endometriosis patients (26.7% vs. 15.4%, relative risk (RR) 1.73, 95% confidence interval (CI) 0.81-3.72; P-value 0.147) could be found, although the trial was underpowered to draw definite conclusions. WHAT IS KNOWN ALREADY Impaired implantation receptivity contributes to reduced clinical pregnancy rates after IVF/ICSI-treatment in endometriosis patients. Previous studies have suggested a favourable effect of tubal flushing with Lipiodol® on natural conceptions. This benefit might also be explained by enhancing implantation through endometrial immunomodulation. Although recent studies showed no beneficial effect of endometrial scratching, the effect of mechanical stress by intrauterine infusion on the endometrium in endometriosis patients undergoing IVF/ICSI-treatment has not been investigated yet. STUDY DESIGN SIZE DURATION We performed a multicentre, patient-blinded, randomised controlled trial in which women were randomly allocated to either a Gel Infusion Sonography (GIS, intervention group) or a sham procedure (control group) prior to IVF/ICSI-treatment. Since recruitment was slow and completion of the study was considered unfeasible, the study was halted after inclusion of 112 of the planned 184 women. PARTICIPANTS/MATERIALS SETTING METHODS We included infertile women with surgically confirmed endometriosis ASRM stage I-IV undergoing IVF/ICSI-treatment. After informed consent, women were randomised to GIS with intrauterine instillation of ExEm-gel® or sonography with gel into the vagina (sham). This was performed in the cycle preceding the embryo transfer, on the day GnRH analogue treatment was started. The primary endpoint was live birth rate after fresh embryo transfer. Analysis was performed by both intention-to-treat and per-protocol. MAIN RESULTS AND THE ROLE OF CHANCE Between July 2014 to September 2018, we randomly allocated 112 women to GIS (n = 60) or sham procedure (n = 52). The live birth rate after fresh embryo transfer was 16/60 (26.7%) after GIS versus 8/52 (15.4%) after the sham (RR 1.73, 95% CI 0.81-3.72; P-value 0.147). Ongoing pregnancy rate was 16/60 (26.7%) after GIS versus 9/52 (17.3%) in the controls (RR 1.54, 95% CI 0.74-3.18). Miscarriage occurred in 1/60 (1.7%) after GIS versus 5/52 (9.6%) in the controls (RR 0.17, 95% CI 0.02-1.44) women. Uterine bathing resulted in a higher pain score compared with a sham procedure (visual analogue scale score 2.7 [1.3-3.5] vs. 1.0 [0.0-2.0], P < 0.001). There were two adverse events after GIS compared with none after sham procedures. LIMITATIONS REASONS FOR CAUTION The study was terminated prematurely due to slow recruitment and trial fatigue. Therefore, the trial is underpowered to draw definite conclusions regarding the effect of uterine bathing with sonography gel on live birth rate after fresh embryo transfer in endometriosis patients undergoing IVF/ICSI-treatment. WIDER IMPLICATIONS OF THE FINDINGS We could not demonstrate a favourable effect of uterine bathing procedures with sonography gel prior to IVF/ICSI-treatment in patients with endometriosis. STUDY FUNDING/COMPETING INTERESTS Investigator initiated study. IQ Medical Ventures provided the ExEm FOAM® kits free of charge, they were not involved in the study design, data management, statistical analyses and/or manuscript preparation, etc. C.B.L. reports receiving grants from Ferring, Merck and Guerbet, outside the submitted work. C.B.L. is Editor-in-Chief of Human Reproduction. V.M. reports grants and other from Guerbet, outside the submitted work. B.W.M. reports grants from NHMRC (GNT1176437), personal fees from ObsEva, Merck and Merck KGaA, Guerbet and iGenomix, outside the submitted work. N.P.J. reports research funding from Abb-Vie and Myovant Sciences and consultancy for Vifor Pharma, Guerbet, Myovant Sciences and Roche Diagnostics, outside the submitted work. K.D. reports personal fees from Guerbet, outside the submitted work. The other authors do not report any conflicts of interest. No financial support was provided. TRIAL REGISTRATION NUMBER NL4025 (NTR4198). TRIAL REGISTRATION DATE 7 October 2013. DATE OF FIRST PATIENT’S ENROLMENT 22 July 2014.
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Affiliation(s)
- M C I Lier
- Department of Reproductive Medicine, Academic Endometriosis Center, Amsterdam University Medical Center – Location VUmc, Amsterdam, the Netherlands
- Correspondence address. Department of Reproductive Medicine, Academic Endometriosis Center, Amsterdam University Medical Center – Location VUmc, De Boelelaan 1118, 1081 HZ, Amsterdam, the Netherlands. Tel: +31204445278; E-mail: https://orcid.org/0000-0002-9603-7718
| | - H Özcan
- Department of Reproductive Medicine, Academic Endometriosis Center, Amsterdam University Medical Center – Location VUmc, Amsterdam, the Netherlands
| | - A M F Schreurs
- Department of Reproductive Medicine, Academic Endometriosis Center, Amsterdam University Medical Center – Location VUmc, Amsterdam, the Netherlands
| | - P M van de Ven
- Department of Epidemiology & Biostatistics, Amsterdam University Medical Center – Location VUmc, Amsterdam, the Netherlands
| | - K Dreyer
- Department of Reproductive Medicine, Academic Endometriosis Center, Amsterdam University Medical Center – Location VUmc, Amsterdam, the Netherlands
| | - L E E van der Houwen
- Department of Reproductive Medicine, Academic Endometriosis Center, Amsterdam University Medical Center – Location VUmc, Amsterdam, the Netherlands
| | - N P Johnson
- Robinson Research Institute, University of Adelaide, North Adelaide, Australia
- Repromed Auckland and Auckland Gynaecology Group, Auckland, New Zealand
- The University of Auckland, Auckland, New Zealand
| | - F Vandekerckhove
- Department of Reproductive Medicine, Ghent University Hospital, Gent, Belgium
| | - H R Verhoeve
- Department of Reproductive Medicine, OLVG, Amsterdam, the Netherlands
| | - W Kuchenbecker
- Department of Reproductive Medicine, Isala, Zwolle, the Netherlands
| | - B W Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
| | - C B Lambalk
- Department of Reproductive Medicine, Academic Endometriosis Center, Amsterdam University Medical Center – Location VUmc, Amsterdam, the Netherlands
| | - V Mijatovic
- Department of Reproductive Medicine, Academic Endometriosis Center, Amsterdam University Medical Center – Location VUmc, Amsterdam, the Netherlands
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22
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van de Wiel L, Wilkinson J, Athanasiou P, Harper J. The prevalence, promotion and pricing of three IVF add-ons on fertility clinic websites. Reprod Biomed Online 2020; 41:801-806. [PMID: 32888824 PMCID: PMC7645731 DOI: 10.1016/j.rbmo.2020.07.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 07/08/2020] [Accepted: 07/22/2020] [Indexed: 11/19/2022]
Abstract
RESEARCH QUESTION How are IVF clinic websites advertising three common IVF add-ons: assisted hatching, time-lapse embryo imaging and preimplantation genetic testing for aneuploidies (PGT-A)? DESIGN The Human Fertilisation and Embryology Authority 'Choose a fertility clinic' website service was used to identify IVF clinics and their websites. Assisted hatching, time-lapse embryo imaging and PGT-A were examined to determine which websites advertised them, what price they charged and what claims they made in relation to the add-ons. RESULTS Eighty-seven eligible clinics were identified, with 72 unique websites; 37 (43%) clinics were part of one of nine groups of IVF clinics, of sizes ranging from two to eight clinics in the UK. Time-lapse imaging (TLI) was the most frequently advertised of the three add-ons (67% of clinics), followed by PGT-A (47%) and assisted hatching (28%). Very few websites stated that the effectiveness of the add-on was in doubt or unclear (four, two and one websites for TLI, PGT-A and assisted hatching, respectively), and none raised the possibility that an add-on might have negative effects. Claims of efficacy were often based on upstream outcomes (e.g. implantation, pregnancy). Some claims that PGT-A and TLI improved live birth rates were found. There was substantial variation in pricing. CONCLUSIONS IVF clinic websites provide valuable information for patients seeking fertility treatment so it is key that the information is accurate and complete. There is a need for transparent information on interventions, including uncertainties and risks, to be made available by IVF clinics to support well-informed treatment decisions. The selected add-ons are widely advertised, and there is wide variation in pricing.
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Affiliation(s)
| | - Jack Wilkinson
- Centre for Biostatistics, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester Manchester, UK
| | | | - Joyce Harper
- Institute for Women's Health, University College London, London, UK.
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23
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Stocking K, Wilkinson J, Lensen S, Brison DR, Roberts SA, Vail A. Are interventions in reproductive medicine assessed for plausible and clinically relevant effects? A systematic review of power and precision in trials and meta-analyses. Hum Reprod 2020; 34:659-665. [PMID: 30838395 PMCID: PMC6443111 DOI: 10.1093/humrep/dez017] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/11/2018] [Accepted: 02/06/2019] [Indexed: 12/26/2022] Open
Abstract
STUDY QUESTION How much statistical power do randomised controlled trials (RCTs) and meta-analyses have to investigate the effectiveness of interventions in reproductive medicine? SUMMARY ANSWER The largest trials in reproductive medicine are unlikely to detect plausible improvements in live birth rate (LBR), and meta-analyses do not make up for this shortcoming. WHAT IS KNOWN ALREADY Effectiveness of interventions is best evaluated using RCTs. In order to be informative, these trials should be designed to have sufficient power to detect the smallest clinically relevant effect. Similar trials can subsequently be pooled in meta-analyses to more precisely estimate treatment effects. STUDY DESIGN, SIZE, DURATION A review of power and precision in 199 RCTs and meta-analyses from 107 Cochrane Reviews was conducted. PARTICIPANTS/MATERIALS, SETTING, METHODS Systematic reviews published by Cochrane Gynaecology and Fertility with the primary outcome live birth were identified. For each live birth (or ongoing pregnancy) meta-analysis and for the largest RCT in each, we calculated the power to detect absolute improvements in LBR of varying sizes. Additionally, the 95% CIs of estimated treatment effects from each meta-analysis and RCT were recorded, as these indicate the precision of the result. MAIN RESULTS AND THE ROLE OF CHANCE Median (interquartile range) power to detect an improvement in LBR of 5 percentage points (pp) (e.g. 25-30%) was 13% (8-21%) for RCTs and 16% (9-33%) for meta-analyses. No RCTs and only 2% of meta-analyses achieved 80% power to detect an improvement of 5 pp. Median power was high (85% for trials and 93% for meta-analyses) only in relation to 20 pp absolute LBR improvement, although substantial numbers of trials and meta-analyses did not achieve 80% power even for this improbably large effect size. Median width of 95% CIs was 25 pp and 21 pp for RCTs and meta-analyses, respectively. We found that 28% of Cochrane Reviews with LBR as the primary outcome contain no live birth (or ongoing pregnancy) data. LARGE-SCALE DATA The data used in this study may be accessed at https://osf.io/852tn/?view_only=90f1579ce72747ccbe572992573197bd. LIMITATIONS, REASONS FOR CAUTION The design and analysis decisions used in this study are predicted to overestimate the power of trials and meta-analyses, and the size of the problem is therefore likely understated. For some interventions, it is possible that larger trials not reporting live birth or ongoing pregnancy have been conducted, which were not included in our sample. In relation to meta-analyses, we calculated power as though all participants were included in a single trial. This ignores heterogeneity between trials in a meta-analysis, and will cause us to overestimate power. WIDER IMPLICATIONS OF THE FINDINGS Trials capable of detecting realistic improvements in LBR are lacking in reproductive medicine, and meta-analyses are not large enough to overcome this deficiency. This situation will lead to unwarranted pessimism as well as unjustified enthusiasm regarding reproductive interventions, neither of which are consistent with the practice of evidence-based medicine or the idea of informed patient choice. However, RCTs and meta-analyses remain vital to establish the effectiveness of fertility interventions. We discuss strategies to improve the evidence base and call for collaborative studies focusing on the most important research questions. STUDY FUNDING/COMPETING INTEREST(S) There was no specific funding for this study. KS and SL declare no conflict of interest. AV consults for the Human Fertilisation and Embryology Authority (HFEA): all fees are paid directly to AV's employer. JW declares that publishing research benefits his career. SR is a Statistical Editor for Human Reproduction. JW and AV are Statistical Editors for Cochrane Gynaecology and Fertility. DRB is funded by the NHS as Scientific Director of a clinical IVF service. PROSPERO REGISTRATION NUMBER None.
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Affiliation(s)
- K Stocking
- Department of Medical Statistics, Manchester University NHS Foundation Trust, Manchester, UK.,Centre for Biostatistics, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - J Wilkinson
- Centre for Biostatistics, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - S Lensen
- Department of Obstetrics and Gynaecology, University of Auckland, New Zealand.,Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - D R Brison
- Department of Reproductive Medicine, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,Maternal and Fetal Health Research Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
| | - S A Roberts
- Centre for Biostatistics, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - A Vail
- Centre for Biostatistics, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
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24
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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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25
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Ruane PT, Buck CJ, Babbington PA, Aboussahoud W, Berneau SC, Westwood M, Kimber SJ, Aplin JD, Brison DR. The effects of hyaluronate-containing medium on human embryo attachment to endometrial epithelial cells in vitro. Hum Reprod Open 2020; 2020:hoz033. [PMID: 32128453 PMCID: PMC7047226 DOI: 10.1093/hropen/hoz033] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 09/30/2019] [Indexed: 12/13/2022] Open
Abstract
STUDY QUESTION Does embryo transfer medium containing hyaluronate (HA) promote the attachment phase of human embryo implantation? SUMMARY ANSWER HA-containing medium does not promote human blastocyst attachment to endometrial epithelial cells in vitro. WHAT IS KNOWN ALREADY Embryo transfer media containing high concentrations of HA are being used to increase implantation and live birth rates in IVF treatment, although the mechanism of action is unknown. STUDY DESIGN, SIZE, DURATION Expression of HA-interacting genes in frozen-thawed oocytes/embryos was assessed by microarray analysis (n = 21). Fresh and frozen human blastocysts (n = 98) were co-cultured with human endometrial epithelial Ishikawa cell layers. Blastocyst attachment and the effects of a widely used HA-containing medium were measured. PARTICIPANTS/MATERIALS, SETTING, METHODS Human embryos surplus to treatment requirements were donated with informed consent from several ART centres. Blastocyst-stage embryos were transferred at day 6 to confluent Ishikawa cell layers; some blastocysts were artificially hatched. Blastocyst attachment was monitored from 1 to 48 h, and the effects of blastocyst pre-treatment for 10 min with HA-containing medium were determined. MAIN RESULTS AND THE ROLE OF CHANCE Human embryos expressed the HA receptor genes CD44 and HMMR, hyaluronan synthase genes HAS1–3, and hyaluronidase genes HYAL1–3, at all stages of preimplantation development. Attachment of partially hatched blastocysts to Ishikawa cells at 24 and 48 h was related to trophectoderm grade (P = 0.0004 and 0.007, respectively, n = 34). Blastocysts of varying clinical grades that had been artificially hatched were all attached within 48 h (n = 21). Treatment of artificially hatched blastocysts with HA-containing medium did not significantly affect attachment at early (1–6 h) or late (24 and 48 h) time points, compared with control blastocysts (n = 43). LIMITATIONS, REASONS FOR CAUTION Using an adenocarcinoma-derived cell line to model embryo-endometrium attachment may not fully recapitulate in vivo interactions. The high levels of blastocyst attachment seen with this in vitro model may limit the sensitivity with which the effects of HA can be observed. WIDER IMPLICATIONS OF THE FINDINGS Morphological trophectoderm grade can be correlated with blastocyst attachment in vitro. HA-containing medium may increase pregnancy rates by mechanisms other than promoting blastocyst attachment to endometrium. STUDY FUNDING/COMPETING INTEREST(S) This work was funded by a grant from the Wellbeing of Women, the NIHR Local Comprehensive Research Network and NIHR Manchester Clinical Research Facility, the Department of Health Scientist Practitioner Training Scheme, and the Ministry of Higher Education, The State of Libya. None of the authors has any conflict of interest to declare.
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Affiliation(s)
- Peter T Ruane
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre, Manchester M13 9WL, UK.,Maternal and Fetal Health Research Centre, St. Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester M13 9WL UK
| | - Chelsea J Buck
- Department of Reproductive Medicine, Old St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester M13 9WL, UK
| | - Phoebe A Babbington
- Department of Reproductive Medicine, Old St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester M13 9WL, UK
| | - Wedad Aboussahoud
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre, Manchester M13 9WL, UK.,Maternal and Fetal Health Research Centre, St. Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester M13 9WL UK
| | - Stéphane C Berneau
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre, Manchester M13 9WL, UK.,Maternal and Fetal Health Research Centre, St. Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester M13 9WL UK
| | - Melissa Westwood
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre, Manchester M13 9WL, UK.,Maternal and Fetal Health Research Centre, St. Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester M13 9WL UK
| | - Susan J Kimber
- Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre, Michael Smith Building, Manchester M13 9PT, UK
| | - John D Aplin
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre, Manchester M13 9WL, UK.,Maternal and Fetal Health Research Centre, St. Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester M13 9WL UK
| | - Daniel R Brison
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre, Manchester M13 9WL, UK.,Maternal and Fetal Health Research Centre, St. Mary's Hospital, Manchester University NHS Foundation Trust, 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
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26
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Li W, Suke S, Wertaschnigg D, Lensen S, Wang R, Gurrin L, Mol BW. Randomised controlled trials evaluating endometrial scratching: assessment of methodological issues. Hum Reprod 2019; 34:2372-2380. [DOI: 10.1093/humrep/dez207] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 08/27/2019] [Indexed: 11/13/2022] Open
Abstract
AbstractSTUDY QUESTIONDo randomised controlled trials (RCTs) evaluating endometrial scratching suffer from methodological issues including insufficient trial registration, statistical errors or irreproducibility, randomisation errors or miscellaneous issues?SUMMARY ANSWERThe majority of RCTs investigating endometrial scratching have methodological issues.WHAT IS KNOWN ALREADYA large number of small RCTs investigating the effectiveness of endometrial scratching prior to in vitro fertilisation (IVF) and intrauterine insemination (IUI)/intercourse have reported favourable findings. Subsequently, systematic reviews incorporating these RCTs yielded meta-analyses in favour of endometrial scratching. Endometrial scratching has been widely adopted by infertility specialists around the world. Recently, an international RCT including 1364 women reported no benefit from endometrial scratching before IVF.STUDY DESIGN, SIZE, DURATIONWe evaluated several methodological issues of RCTs investigating the effectiveness of endometrial scratching prior to IVF and IUI/intercourse. We identified 25 RCTs for IVF and 12 RCTs for IUI/intercourse with full-text publication.PARTICIPANTS/MATERIALS, SETTING, METHODSWe assessed the RCTs on the following criteria: adequacy of trial registration, statistical issues (description of statistical methods and reproducibility of univariable statistical analysis), excessive similarity or difference in baseline characteristics that is not compatible with chance (Monte Carlo simulations and Kolmogorov–Smirnov test) and miscellaneous methodological issues.MAIN RESULTS AND THE ROLE OF CHANCEOf 25 RCTs evaluating endometrial scratching prior to IVF, only eight (32%) had adequate trial registration. In total, 10 (40%) RCTs had issues regarding statistical methods. Nine (69%, 13 applicable) RCTs had at least one inconsistency between reported and reproduced univariable statistical analysis for categorical baseline/intermediate characteristics. Statistical results of at least one outcome were not reproducible in 14 (74%, 19 applicable) RCTs. Only two (8%) RCTs had none of the above issues. Suggested by the simulations, these RCTs did not significantly violate the null hypothesis that the baseline characteristics were the results of a properly conducted randomisation process (P = 0.4395).Of 12 IUI/intercourse RCTs, only 2 (17%) had adequate trial registration. In total, five (42%) studies had issues of statistical methods. Inconsistency between reported and reproduced univariable analysis for baseline/intermediate categorical variable(s) was found in four (57%, 7 applicable) RCTs. Statistical analysis was not reproducible for at least one outcome in eight (80%, 10 applicable) studies. All RCTs had at least one of the above issues. These RCTs were inconsistent with the null hypothesis that their baseline characteristics were the results of proper randomised allocation (P = 1.659*10−7).LIMITATIONS, REASONS FOR CAUTIONWe were unable to assess RCTs which were not published as full-text papers. We could not analyse individual participant data to investigate possible reasons for statistical inconsistencies. The method to infer the likelihood of proper random sampling rests on assumptions including independent baseline characteristics, simple randomisation and no publication bias.WIDER IMPLICATIONS OF THE FINDINGSThe methodological issues common to RCTs evaluating endometrial scratching may have biased the results of the trials. Further development and validation of these novel methods may be helpful for the critical appraisal of RCTs.STUDY FUNDING/COMPETING INTEREST(S)No external funding was sought to support this work. B.W.M. is supported by a National Health Medical Research Council (NHMRC) Practitioner Fellowship (GNT1082548). B.W.M. reports consultancy for ObsEva, Merck and Guerbet. D.W. is supported by a grant from the Paracelsus Medical University Salzburg, Austria (PMU Research Fund—PMU FFF Number: L-18/02/006-WET) and by Drs Haackert Foundation, Germany. S.L. is an author of a trial included in this study, an author of an included systematic review and a Cochrane editor. All other authors have no conflicts of interest.TRIAL REGISTRATION NUMBERN/A
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Affiliation(s)
- Wentao Li
- Department of Obstetrics and Gynaecology, Monash University, Clayton 3800, Australia
| | - Sophie Suke
- Department of Obstetrics and Gynaecology, Monash University, Clayton 3800, Australia
| | - Dagmar Wertaschnigg
- Department of Obstetrics and Gynaecology, Monash University, Clayton 3800, Australia
- Department of Obstetrics and Gynaecology, Paracelsus Medical University, Salzburg 5020, Austria
| | - Sarah Lensen
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland 1023, New Zealand
| | - Rui Wang
- Department of Obstetrics and Gynaecology, Monash University, Clayton 3800, Australia
- Robinson Research Institute, The University of Adelaide, Adelaide 5006, Australia
| | - Lyle Gurrin
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne 3010, Australia
| | - Ben W Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton 3800, Australia
- Monash Women’s, Monash Health, Clayton 3168, Australia
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27
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Clinical adjuncts in in vitro fertilization: a growing list. Fertil Steril 2019; 112:978-986. [DOI: 10.1016/j.fertnstert.2019.09.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/02/2019] [Accepted: 09/16/2019] [Indexed: 11/19/2022]
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28
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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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29
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Wilkinson J, Malpas P, Hammarberg K, Mahoney Tsigdinos P, Lensen S, Jackson E, Harper J, Mol BW. Do à la carte menus serve infertility patients? The ethics and regulation of in vitro fertility add-ons. Fertil Steril 2019; 112:973-977. [PMID: 31703942 DOI: 10.1016/j.fertnstert.2019.09.028] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/18/2019] [Accepted: 09/20/2019] [Indexed: 01/08/2023]
Abstract
Add-on treatments are the new black. They are provided (most frequently, sold) to patients undergoing in vitro fertilization on the premise that they will improve the chances of having a baby. However, the regulation of add-ons is consistently minimal, meaning that they are introduced into routine practice before they have been shown to improve the live birth rate. Debate on the adequacy of this light-touch approach rages. Defenders argue that demands for a rigorous approval process are paternalistic, as this would delay access to promising treatments. Critics respond that promising treatments may turn out to have adverse effects on patients and their offspring, contradicting the clinician's responsibility to do no harm. Some add-ons, including earlier versions of preimplantation genetic testing for aneuploidy, might even reduce the live birth rate, raising the prospect of desperate patients paying more to worsen their chances. Informed consent represents a solution in principle, but in practice there is a clear tension between impartial information and direct-to-consumer advertising. Because the effects of a treatment cannot be known until it has been robustly evaluated, we argue that strong evidence should be required before add-ons are introduced to the clinic. In the meantime, there is an imperative to identify methods for communicating the associated risks and uncertainties of add-ons to prospective patients.
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Affiliation(s)
- Jack Wilkinson
- Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom.
| | - Phillipa Malpas
- Psychological Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Karin Hammarberg
- Jean Hailes Research Unit, School of Public Health and Preventative Medicine, Monash University, Clayton, Victoria, Australia
| | | | - Sarah Lensen
- Cochrane Gynecology and Fertility Group, University of Auckland, Auckland, New Zealand
| | - Emily Jackson
- Law Department, London School of Economics and Political Science, London, United Kingdom
| | - Joyce Harper
- Department of Reproductive Health, Institute for Women's Health, University College London, London, United Kingdom
| | - Ben W Mol
- Evidence-based Women's Health Care Research Group, Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
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30
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Dieamant F, Vagnini LD, Petersen CG, Mauri AL, Renzi A, Petersen B, Mattila MC, Nicoletti A, Oliveira JBA, Baruffi R, Franco JG. New therapeutic protocol for improvement of endometrial receptivity (PRIMER) for patients with recurrent implantation failure (RIF) - A pilot study. JBRA Assist Reprod 2019; 23:250-254. [PMID: 31091064 PMCID: PMC6724389 DOI: 10.5935/1518-0557.20190035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Objective: To evaluate whether or not one should use a new Protocol for Endometrial
Receptivity Improvement (PRIMER) based on platelet-rich plasma (PRP) and
granulocyte colony-stimulation factor (G-CSF) to enhance ongoing pregnancy
rates in patients with recurrent implantation failure (RIF). Methods: Women undergoing IVF/ICSI were prospectively divided into two groups: -
PRIMER/RIF group (n:33): patients with RIF (defined as ≥2embryo
transfers (ETs) and at least 5 morphologically good embryos transferred) in
which intrauterine PRP injection and subcutaneous G-CSF-injection were
performed. - Control group (n:33): patients in their first IVF/ICSI
attempt/cycle (without PRP or G-CSF injection). The PRP was prepared using
autologous fresh-whole blood processed to increase platelet-concentration in
2 to 4 fold. All patients undergoing the PRP-treatment received 0.7ml of it
through intrauterine-injection 48 hours before the ET. G-CSF (300mg/0.5ml)
started simultaneously to PRP and was administered subcutaneously every
week. Results: Regarding implantation, clinical pregnancy and miscarriage rates, we found no
statistically significant difference (18.2% versus 17.6%,
p=0.90; 36.4% versus 30.3%, p=0.61 and
25.0% versus 9.0%, p=0.43, respectively).
The use of PRIMER enabled RIF patients (previous ET µ:
4.0±1.5) to reach similar ongoing pregnancy and live birth rates like
those patients who had their first IVF/ICSI cycle attempt (27.3%
versus 27.3%, p=0.99). Conclusions: Our results showed, for the first time, evidence that this therapeutic
protocol (PRIMER) could be used as a feasible treatment based on biological
rationale for patients with RIF, considering its promising outcomes, it is a
simple procedure and not associated with patient complications.
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Affiliation(s)
- Felipe Dieamant
- Center for Human Reproduction Prof Franco Jr. Ribeirão Preto, Brazil.,Paulista Center for Diagnosis Research and Training. Ribeirão Preto, Brazil
| | - Laura D Vagnini
- Paulista Center for Diagnosis Research and Training. Ribeirão Preto, Brazil
| | - Claudia G Petersen
- Center for Human Reproduction Prof Franco Jr. Ribeirão Preto, Brazil.,Paulista Center for Diagnosis Research and Training. Ribeirão Preto, Brazil
| | - Ana L Mauri
- Center for Human Reproduction Prof Franco Jr. Ribeirão Preto, Brazil.,Paulista Center for Diagnosis Research and Training. Ribeirão Preto, Brazil
| | - Adriana Renzi
- Paulista Center for Diagnosis Research and Training. Ribeirão Preto, Brazil
| | - Bruna Petersen
- Center for Human Reproduction Prof Franco Jr. Ribeirão Preto, Brazil.,Paulista Center for Diagnosis Research and Training. Ribeirão Preto, Brazil
| | - Mariana C Mattila
- Center for Human Reproduction Prof Franco Jr. Ribeirão Preto, Brazil
| | - Andreia Nicoletti
- Center for Human Reproduction Prof Franco Jr. Ribeirão Preto, Brazil.,Paulista Center for Diagnosis Research and Training. Ribeirão Preto, Brazil
| | - Joao Batista A Oliveira
- Center for Human Reproduction Prof Franco Jr. Ribeirão Preto, Brazil.,Paulista Center for Diagnosis Research and Training. Ribeirão Preto, Brazil
| | - Ricardo Baruffi
- Center for Human Reproduction Prof Franco Jr. Ribeirão Preto, Brazil.,Paulista Center for Diagnosis Research and Training. Ribeirão Preto, Brazil
| | - Jose G Franco
- Center for Human Reproduction Prof Franco Jr. Ribeirão Preto, Brazil.,Paulista Center for Diagnosis Research and Training. Ribeirão Preto, Brazil
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31
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Bhattacharya S, Evers JLH, Gameiro S, Negri E, Somigliana E, Vercellini P, Wellings K, Baird DT, Crosignani P, Glasier A, La Vecchia C. Towards a more pragmatic and wiser approach to infertility care. Hum Reprod 2019; 34:1165-1172. [DOI: 10.1093/humrep/dez101] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 05/13/2019] [Accepted: 05/17/2019] [Indexed: 12/25/2022] Open
Abstract
Abstract
Infertility represents a very peculiar area of medicine. Contrary to other areas, where signs and symptoms lead to a diagnosis, which in turn leads to a specific treatment, in reproduction the lack of signs and symptoms for more than 12 months suggests the diagnosis of ‘unexplained subfertility’, and if this condition has lasted for some years, couples qualify for IVF. Diagnosis and treatments can extend over long periods of time (even years) and the accuracy of the diagnostic armamentarium is not optimal. Uncertainty about diagnosis and the need for significant perseverance is demanding on both couples and physicians, and actually constitute a very favourable situation for overdiagnosis (‘unexplained subfertility’) and overtreatment (IVF) on one hand, and, on the other, it may also affect compliance with treatments. To improve our capacity to properly handle this challenging situation, increased attention should be given to the duration of pregnancy seeking. Initiating treatments earlier in older women is unwise because this population has a lower fecundity and, therefore, duration of pregnancy seeking is even more important to achieve a reliable diagnosis of infertility. Moreover, if the infertility work-up is unremarkable, duration of pregnancy seeking should be extended up to more than 2 years prior to making a diagnosis of unexplained infertility regardless of age. An adequate period of pregnancy seeking is also required for couples who are diagnosed with conditions that can interfere with fertility to avoid overdiagnosis and overtreatment. Indeed, most causes of infertility will reduce but not impair natural conception. Within this sometimes long-term management, physicians should also pay attention to detrimental life habits in order to optimize the chances of both natural and assisted reproduction technology -mediated pregnancy. Even if interventional studies are not conclusive, it is advisable to address the problems of obesity and smoking. Focussing on frequency of sexual intercourse may be also beneficial for natural conception. Finally, there is the need for improving our capacity to handle compliance. Providing information on the importance of persevering at the start of treatment, promoting shared decision-making and tackling patient, clinic and treatment causes of drop-out can all improve the overall chances of parenthood. Thus, we plead for a wiser and more pragmatic approach to infertility, paying more attention to these neglected, but in our opinion essential, aspects of infertility care.
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33
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Zemyarska MS. Is it ethical to provide IVF add-ons when there is no evidence of a benefit if the patient requests it? JOURNAL OF MEDICAL ETHICS 2019; 45:346-350. [PMID: 30745435 DOI: 10.1136/medethics-2018-104983] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 12/25/2018] [Accepted: 01/10/2019] [Indexed: 06/09/2023]
Abstract
In vitro fertilisation (IVF) 'add-ons' are therapeutic or diagnostic tools developed in an endeavour to improve the success rate of infertility treatment. However, there is no conclusive evidence that these interventions are a beneficial or effective adjunct of assisted reproductive technologies. Additionally, IVF add-ons are often implemented in clinical practice before their safety can be thoroughly ascertained. Yet, patients continue to request and pay large sums for such additional IVF tools. Hence, this essay set out to examine if it is ethical to provide IVF add-ons when there is no evidence of a benefit if the patient requests it. In order to determine what is ethical-namely, morally good and righteous, the question was considered in relation to three key values of medical ethics-autonomy, beneficence and non-maleficence. It was determined that providing IVF add-ons might be morally acceptable in specific circumstances, if true informed consent can be given, there is a potential of cost-effective physiological or psychological benefit and the risk of harm is minimal, particularly with regard to the unborn child.
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34
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Affiliation(s)
- Sjoerd Repping
- Center for Reproductive Medicine, Amsterdam Reproduction & Development Institute, Amsterdam University Medical Centers, Amsterdam 1105-AZ, Netherlands.
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35
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Sharpe RM. Of mice and men: long-term safety of assisted reproduction treatments. Hum Reprod 2019; 33:793-796. [PMID: 29635456 DOI: 10.1093/humrep/dey071] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 03/09/2018] [Indexed: 12/16/2022] Open
Affiliation(s)
- Richard M Sharpe
- MRC Centre for Reproductive Health, The Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK
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36
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Andersen CY, Kristensen SG, Mamsen LS, Barratt CLR. Education, education, education-now more than ever? Mol Hum Reprod 2018; 24:426-429. [PMID: 29939362 DOI: 10.1093/molehr/gay028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 06/23/2018] [Indexed: 11/13/2022] Open
Abstract
The generation of scientists and physicians that took part in starting the whole era of modern-assisted reproduction is currently close to retirement or has already left research. A new generation is about to take over and the profession is facing a massive transgenerational transition. Since current treatments have reached a plateau in success rates and costs, new research and development is required to further advance the field. Today, multi-disciplinary platforms including numerous research areas, not previously integrated in our field, are fundamental to achieve new clinical approaches. Structured, broader and purposeful education of young researchers should be intensified and prioritized, and innovative educational initiatives are needed to facilitate 'thinkers' and advance developments in the field of assisted reproduction.
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Affiliation(s)
- Claus Yding Andersen
- Laboratory of Reproductive Biology, The Juliane Marie Centre for Women, Children and Reproduction, Copenhagen University Hospital and Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 9, Rigshospitalet, Copenhagen, Denmark
| | - Stine G Kristensen
- Laboratory of Reproductive Biology, The Juliane Marie Centre for Women, Children and Reproduction, Copenhagen University Hospital and Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 9, Rigshospitalet, Copenhagen, Denmark
| | - Linn Salto Mamsen
- Laboratory of Reproductive Biology, The Juliane Marie Centre for Women, Children and Reproduction, Copenhagen University Hospital and Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 9, Rigshospitalet, Copenhagen, Denmark
| | - Christopher L R Barratt
- Reproductive and Developmental Biology, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
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37
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Barratt CLR. A Dolce & Gabbana model in every ART clinic? ACTA ACUST UNITED AC 2018; 24:431-432. [DOI: 10.1093/molehr/gay030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 07/23/2018] [Indexed: 12/15/2022]
Affiliation(s)
- Christopher L R Barratt
- Reproductive and Developmental Biology, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
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38
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Lemmens L, Kos S, Beijer C, Braat DDM, Nelen WLDM, Wetzels AMM. Techniques used for IUI: is it time for a change? Hum Reprod 2018; 32:1835-1845. [PMID: 28854719 DOI: 10.1093/humrep/dex223] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 06/04/2017] [Indexed: 12/29/2022] Open
Abstract
STUDY QUESTION Are the guidelines for the technical aspects of IUI (WHO, 2010) still in accordance with the current literature? SUMMARY ANSWER In general, the laboratory guidelines of the World Health Organization (WHO) are a suitable protocol, although the evidence is not always conclusive and some changes are advisable. WHAT IS KNOWN ALREADY Lack of standardization of the technical procedures required for IUI might result in inter-laboratory variation in pregnancy rates. Most centers still use their own materials and methods even though some guidelines are available. STUDY DESIGN, SIZE, DURATION A structural review focusing on the association between pregnancy rates and the procedures of semen collection (e.g. ejaculatory abstinence, collection place), semen processing (e.g. preparation method, temperature during centrifugation/storage), insemination (e.g. timing of IUI, bed rest after IUI) and the equipment used. PARTICIPANTS/MATERIALS, SETTING, METHODS A literature search was performed in Medline and the Cochrane library. When no adequate studies of the impact of a parameter on pregnancy results were found, its association with sperm parameters was reviewed. MAIN RESULTS AND THE ROLE OF CHANCE For most variables, the literature review revealed a low level of evidence, a limited number of studies and/or an inadequate outcome measure. Moreover, the comparison of procedures (i.e. semen preparation technique, time interval between semen, collection, processing and IUI) revealed no consensus about their results. It was not possible to develop an evidence-based, optimal IUI treatment protocol. LIMITATIONS, REASONS FOR CAUTION The included studies exhibited a lack of standardization in inclusion criteria and methods used. WIDER IMPLICATIONS OF THE FINDINGS This review emphasizes the need for more knowledge about and standardization of assisted reproduction technologies. Our literature search indicates that some of the recommendations in the laboratory guidelines could be adapted to improve standardization, comfort, quality control and to cut costs. STUDY FUNDING/COMPETING INTEREST(S) The Dutch Foundation for Quality Assessment in Medical Laboratories (SKML), Nijmegen, The Netherlands. S.K. and W.N. have no conflicts of interest to disclose. C.B. and A.W. are members of the board of the SKML. With a grant from SKML, L.L. was paid for her time to perform the research and write the publication. D.B. received grants from Merck Serono, Ferring and MSD, outside the submitted work. REGISTRATION NUMBER N/A.
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Affiliation(s)
- L Lemmens
- Fertility Laboratory, Department of Obstetrics and Gynaecology, Radboud University Medical Center Nijmegen, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - S Kos
- Department of Clinical Chemistry, Maasstad Hospital Rotterdam, PO Box 9100, 3007 AC Rotterdam, The Netherlands
| | - C Beijer
- Department of Clinical Chemistry, Atalmedial, Medical Diagnostic Centre, PO Box 69641, 1060 CR Amsterdam, The Netherlands
| | - D D M Braat
- Department of Obstetrics and Gynaecology, Radboud University Medical Center Nijmegen, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - W L D M Nelen
- Department of Obstetrics and Gynaecology, Radboud University Medical Center Nijmegen, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - A M M Wetzels
- Fertility Laboratory, Department of Obstetrics and Gynaecology, Radboud University Medical Center Nijmegen, PO Box 9101, 6500 HB Nijmegen, The Netherlands
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39
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Pye C, Chatters R, Cohen J, Brian K, Cheong YC, Laird S, Mohiyiddeen L, Skull J, Walters S, Young T, Metwally M. Induced endometrial trauma (endometrial scratch) in the mid-luteal menstrual cycle phase preceding first cycle IVF/ICSI versus usual IVF/ICSI therapy: study protocol for a randomised controlled trial. BMJ Open 2018; 8:e020755. [PMID: 29780028 PMCID: PMC5961587 DOI: 10.1136/bmjopen-2017-020755] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Endometrial trauma commonly known as endometrial scratch (ES) has been shown to improve pregnancy rates in women with a history of repeated implantation failure undergoing in vitro fertilisation (IVF), with or without intracytoplasmic sperm injection (ICSI). However, the procedure has not yet been fully explored in women having IVF/ICSI for the first time. This study aims to examine the effect of performing an ES in the mid-luteal phase prior to a first-time IVF/ICSI cycle on the chances of achieving a clinical pregnancy and live birth. If ES can influence this success rate, there would be a significant cost saving to the National Health Service through decreasing the number of IVF/ICSI cycles necessary to achieve a pregnancy, increase the practice of single embryo transfer and consequently have a large impact on risks and costs associated with multiple pregnancies. METHODS AND ANALYSIS This 30-month, UK, multicentre, parallel group, randomised controlled trial includes a 9-month internal pilot and health economic analysis recruiting 1044 women from 16 fertility units. It will follow up participants to identify if IVF/ICSI has been successful and live birth has occurred up to 6 weeks post partum. Primary analysis will be on an intention-to-treat basis. A substudy of endometrial samples obtained during the ES will assess the role of immune factors in embryo implantation. Main trial recruitment commenced on January 2017 and is ongoing.Participants randomised to the intervention group will receive the ES procedure in the mid-luteal phase of the preceding cycle prior to first-time IVF/ICSI treatment versus usual IVF/ICSI treatment in the control group, with 1:1 randomisation. The primary outcome is live birth rate after completed 24 weeks gestation. ETHICS AND DISSEMINATION South Central-Berkshire Research Ethics Committee approved the protocol. Findings will be submitted to peer-reviewed journals and abstracts to relevant national and international conferences. TRIAL REGISTRATION NUMBER ISRCTN23800982; Pre-results.
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Affiliation(s)
- Clare Pye
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Robin Chatters
- Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Judith Cohen
- Hull Health Trials Unit, University of Hull, Hull
| | - Kate Brian
- Patient and Public Involvement (PPI), Fertility Network UK, London, UK
| | - Ying C Cheong
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Susan Laird
- Biomolecular Sciences Research Centre, Sheffield Hallam University, Sheffield, UK
| | - Lamiya Mohiyiddeen
- Saint Mary's Hospital - Central Manchester University Hospitals, Manchester, UK
| | - Jonathan Skull
- Fertility Unit - Jessop Wing, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Stephen Walters
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Tracey Young
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Mostafa Metwally
- Fertility Unit - Jessop Wing, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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40
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Barratt CLR, De Jonge CJ, Sharpe RM. 'Man Up': the importance and strategy for placing male reproductive health centre stage in the political and research agenda. Hum Reprod 2018; 33:541-545. [PMID: 29425298 PMCID: PMC5989613 DOI: 10.1093/humrep/dey020] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 01/18/2018] [Indexed: 12/20/2022] Open
Abstract
Approximately 1 in 20 young men today have sperm counts low enough to impair fertility, whereas this may not have been the case historically. The cause(s) of such a decline in male reproductive health is unknown, despite it being a global health issue. Concomitantly, little progress has been made in answering fundamental questions in andrology or in developing new diagnostic tools or alternative management strategies to ICSI in infertile men. We advocate formulation of a detailed roadmap for male reproductive health to facilitate development of a research agenda that highlights the present unmet needs and key unanswered questions, and seeks to deliver effective funding and investment to address them. This vision we term 'a Male Reproductive Health Ecosystem'.
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Affiliation(s)
- Christopher L R Barratt
- Reproductive and Developmental Biology, Medical School, Ninewells Hospital, University of Dundee, Dundee DD1 9SY, UK
| | | | - Richard M Sharpe
- MRC Centre for Reproductive Health, The Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, UK
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41
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Barratt CLR, Björndahl L, De Jonge CJ, Lamb DJ, Osorio Martini F, McLachlan R, Oates RD, van der Poel S, St John B, Sigman M, Sokol R, Tournaye H. The diagnosis of male infertility: an analysis of the evidence to support the development of global WHO guidance-challenges and future research opportunities. Hum Reprod Update 2017; 23:660-680. [PMID: 28981651 PMCID: PMC5850791 DOI: 10.1093/humupd/dmx021] [Citation(s) in RCA: 252] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 04/12/2017] [Accepted: 07/12/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Herein, we describe the consensus guideline methodology, summarize the evidence-based recommendations we provided to the World Health Organization (WHO) for their consideration in the development of global guidance and present a narrative review of the diagnosis of male infertility as related to the eight prioritized (problem or population (P), intervention (I), comparison (C) and outcome(s) (O) (PICO)) questions. Additionally, we discuss the challenges and research gaps identified during the synthesis of this evidence. OBJECTIVE AND RATIONALE The aim of this paper is to present an evidence-based approach for the diagnosis of male infertility as related to the eight prioritized PICO questions. SEARCH METHODS Collating the evidence to support providing recommendations involved a collaborative process as developed by WHO, namely: identification of priority questions and critical outcomes; retrieval of up-to-date evidence and existing guidelines; assessment and synthesis of the evidence; and the formulation of draft recommendations to be used for reaching consensus with a wide range of global stakeholders. For each draft recommendation the quality of the supporting evidence was then graded and assessed for consideration during a WHO consensus. OUTCOMES Evidence was synthesized and recommendations were drafted to address the diagnosis of male infertility specifically encompassing the following: What is the prevalence of male infertility and what proportion of infertility is attributable to the male? Is it necessary for all infertile men to undergo a thorough evaluation? What is the clinical (ART/non ART) value of traditional semen parameters? What key male lifestyle factors impact on fertility (focusing on obesity, heat and tobacco smoking)? Do supplementary oral antioxidants or herbal therapies significantly influence fertility outcomes for infertile men? What are the evidence-based criteria for genetic screening of infertile men? How does a history of neoplasia and related treatments in the male impact on (his and his partner's) reproductive health and fertility options? And lastly, what is the impact of varicocele on male fertility and does correction of varicocele improve semen parameters and/or fertility? WIDER IMPLICATIONS This evidence synthesis analysis has been conducted in a manner to be considered for global applicability for the diagnosis of male infertility.
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Affiliation(s)
- Christopher L R Barratt
- Department of Reproductive and Developmental Biology, Medical School, Ninewells Hospital, University of Dundee, Dundee, DD1 9SY, Scotland
| | - Lars Björndahl
- Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | | | | | | | | | - Robert D Oates
- Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Sheryl van der Poel
- Department of Reproductive Health and Research, Human Reproduction Programme, (HRP, The UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction), WHO, Geneva, Switzerland
- Population Council, New York, NY, USA
| | - Bianca St John
- Hudson Institute of Medical Research, Clayton, Australia
| | - Mark Sigman
- Warren Alpert Medical School of Brown University, RI, USA
| | - Rebecca Sokol
- Department of Obstetrics and Gynaecology and Medicine, Keck School of Medicine, University of Southern California, CA, USA
| | - Herman Tournaye
- Centre for Reproductive Medicine, Vrije Universiteit Brussel, Brussels, Belgium
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Harper J, Jackson E, Sermon K, Aitken RJ, Harbottle S, Mocanu E, Hardarson T, Mathur R, Viville S, Vail A, Lundin K. Adjuncts in the IVF laboratory: where is the evidence for 'add-on' interventions? Hum Reprod 2017; 32:485-491. [PMID: 28158511 DOI: 10.1093/humrep/dex004] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 01/05/2017] [Indexed: 01/20/2023] Open
Abstract
Globally, IVF patients are routinely offered and charged for a selection of adjunct treatments and tests or 'add-ons' that they are told may improve their chance of a live birth, despite there being no clinical evidence supporting the efficacy of the add-on. Any new IVF technology claiming to improve live birth rates (LBR) should, in most cases, first be tested in an appropriate animal model, then in clinical trials, to ensure safety, and finally in a randomized controlled trial (RCT) to provide high-quality evidence that the procedure is safe and effective. Only then should the technique be considered as 'routine' and only when applied to the similar patient population as those studied in the RCT. Even then, further pediatric and long-term follow-up studies will need to be undertaken to examine the long-term safety of the procedure. Alarmingly, there are currently numerous examples where adjunct treatments are used in the absence of evidence-based medicine and often at an additional fee. In some cases, when RCTs have shown the technique to be ineffective, it is eventually withdrawn from the clinic. In this paper, we discuss some of the adjunct treatments currently being offered globally in IVF laboratories, including embryo glue and adherence compounds, sperm DNA fragmentation, time-lapse imaging, preimplantation genetic screening, mitochondria DNA load measurement and assisted hatching. We examine the evidence for their safety and efficacy in increasing LBRs. We conclude that robust studies are needed to confirm the safety and efficacy of any adjunct treatment or test before they are offered routinely to IVF patients.
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Affiliation(s)
- Joyce Harper
- Embryology, IVF and Reproductive Genetics, Institute for Women's Health, University College London, London, UK
| | - Emily Jackson
- Law Department, London School of Economics and Political Science, London, UK
| | - Karen Sermon
- Research Group Reproduction and Genetics, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Robert John Aitken
- Priority Research Centre for Reproductive Science, University of Newcastle, NSW, Australia
| | - Stephen Harbottle
- Cambridge IVF, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Edgar Mocanu
- Rotunda Hospital and RCSI, Parnell Square, Dublin 1, Ireland
| | - Thorir Hardarson
- Fertilitetscentrum, Carlanders Hospital, 402 29Gothenburg, Sweden
| | - Raj Mathur
- Department of Reproductive Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9WL, UK
| | - Stephane Viville
- Institut de Parasitologie et Pathologie Tropicale, EA 7292, three rue Koeberlé, 67000 Strasbourg, France and Laboratoire de diagnostic génétique, UF3472-génétique de l'infertilité, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
| | - Andy Vail
- Centre for Biostatistics, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK
| | - Kersti Lundin
- Reproductive Medicine, Sahlgrenska University Hospital, Goteborg, Sweden
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Hviid MM, Macklon N. Immune modulation treatments—where is the evidence? Fertil Steril 2017; 107:1284-1293. [DOI: 10.1016/j.fertnstert.2017.04.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Accepted: 04/18/2017] [Indexed: 12/11/2022]
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44
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Bhide P, Maheshwari A, Cutting R, Seenan S, Patel A, Khan K, Homburg R. Time lapse imaging: is it time to incorporate this technology into routine clinical practice? HUM FERTIL 2017; 20:74-79. [DOI: 10.1080/14647273.2017.1283068] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Priya Bhide
- Homerton Fertility Centre, Homerton University Hospital NHS foundation Trust, London, United Kingdom
| | - Abha Maheshwari
- NHS Grampian, Aberdeen Fertility Centre, Aberdeen, United Kingdom
| | - Rachel Cutting
- Jessop Fertility, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Susan Seenan
- Fertility Network UK, East Sussex, United Kingdom
| | - Anita Patel
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Khalid Khan
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Roy Homburg
- Homerton Fertility Centre, Homerton University Hospital NHS foundation Trust, London, United Kingdom
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