Impact of government health coverage for ART: The results of a 5-year experience in Quebec.

An analysis of national registry data for 5 years of in-vitro fertilization (IVF) funding in Quebec, Canada was compared with the previous complete year of non-funded IVF cycles, as well as the first complete year following the end of funding. The number of cycles, livebirth rates, age group of patients treated, use of donor gametes, multiple pregnancy rates and cycle cancellation rates were assessed. The total number of IVF cycles performed increased dramatically during the funded period, averaging over 10,000 cycles per year. There was no change in the age group distribution of patients treated, but less egg donation was performed. Interestingly, funding was also associated with an increase in the IVF cycle cancellation rate (17.0% versus 34.4%, P < 0.001), a dramatic decline in the multiple pregnancy rate (25.6% versus 4.9%, P < 0.001), and a decline in the livebirth rate per fresh embryo transfer in stimulated IVF cycles (32.3% versus 25.5%, P < 0.001). Although the livebirth rate for stimulated IVF declined, over 9000 babies were born as a result of the coverage. Lessons learned from this experience could help develop a more fiscally responsible programme that still facilitates access to IVF care.

Can the rapid identification of mature spermatozoa during microdissection testicular sperm extraction guide operative planning?

The minimum sperm count and quality that must be identified during microdissection testicular sperm extraction (micro-TESE) to deem the procedure successful remains to be established. We conducted a retrospective study of 81 consecutive men with non-obstructive azoospermia who underwent a primary (first) micro-TESE between March 2007 and October 2013. Final assessment of sperm recovery [reported on the day of (intracytoplasmic sperm injection) ICSI] was recorded as (i) successful (available spermatozoa for ICSI) or (ii) unsuccessful (no spermatozoa for ICSI). The decision to perform a unilateral (with limited or complete microdissection) or bilateral micro-TESE was guided by the intra-operative identification of sperm recovery (≥5 motile or non-motile sperm) from the first testicle. Overall, sperm recovery was successful in 56% (45/81) of the men. A unilateral micro-TESE was performed in 47% (38/81) of the men (based on intra-operative identification of sperm) and in 100% (38/38) of these men, spermatozoa was found on final assessment. In 42% (16/38) of the unilateral cases, a limited microdissection was performed (owing to the rapid intra-operative identification of sperm). The remaining 43 men underwent a bilateral micro-TESE and 16% (7/43) of these men had sperm identified on final assessment. The cumulative ICSI pregnancy rates (per cycle started and per embryo transfer) were 47% (21/45) and 60% (21/35), respectively, with a mean (±SD) of 1.9 ± 1.0 embryos transferred. The data demonstrate that intra-operative assessment of sperm recovery can correctly identify those men that require a unilateral micro-TESE. Moreover, the rapid identification of sperm recovery can allow some men to undergo a limited unilateral micro-TESE and avoid the need for complete testicular microdissection.

Universal coverage of IVF pays off.

STUDY QUESTION: What was the clinical and economic impact of universal coverage of IVF in Quebec, Canada, during the first calendar year of implementation of the public IVF programme? SUMMARY ANSWER: Universal coverage of IVF increased access to IVF treatment, decreased the multiple pregnancy rate and decreased the cost per live birth, despite increased costs per cycle. WHAT IS KNOWN ALREADY: Public funding of IVF assures equality of access to IVF and decreases multiple pregnancies resulting from this treatment. Public IVF programmes usually mandate a predominant SET policy, the most effective approach for reducing the incidence of multiple pregnancies. STUDY DESIGN, SIZE, DURATION: This prospective comparative cohort study involved 7364 IVF cycles performed in Quebec during 2009 and 2011 and included an economic analysis. PARTICIPANTS/MATERIALS, SETTING, METHODS: IVF cycles performed in the five centres offering IVF treatment in Quebec during 2009, before implementation of the public IVF programme, were compared with cycles performed at the same centres during 2011, the first full calendar year following implementation of the programme. Data were obtained from the Canadian Assisted Reproductive Technologies Register (CARTR). Comparisons were made between the two periods in terms of utilization, pregnancy rates, multiple pregnancy rates and costs. MAIN RESULTS AND THE ROLE OF CHANCE: The number of IVF cycles performed in Quebec increased by 192% after the new policy was implemented. Elective single-embryo transfer was performed in 1.6% of the cycles during Period I (2009), and increased to 31.6% during Period II (2011) (P < 0.001). Although the clinical pregnancy rate per embryo transfer was lower in 2011 than in 2009 (24.9 versus 39.9%, P < 0.001), the multiple pregnancy rate was greatly reduced (6.4 versus 29.4%, P < 0.001). The public IVF programme increased government costs per IVF treatment cycle from CAD$3730 to CAD$4759. Despite increased costs per cycle, the efficiency defined by the cost per live birth, which factored in downstream health costs up to 1 year post delivery, decreased from CAD$49 517 to CAD$43 362 per baby conceived by either fresh and frozen cycles. LIMITATIONS, REASONS FOR CAUTION: The costs described in the economic model are likely an underestimate as they do not factor in many of the long-term costs that can occur after 1 year of age. The information collected in the Canadian ART register precludes the calculation of cumulative pregnancy rates. WIDER IMPLICATIONS OF THE FINDINGS: Our study confirms that the implementation of a public IVF programme favouring eSET not only sharply decreases the incidence of multiple pregnancy, but also reduces the cost per live birth. STUDY FUNDING/COMPETING INTEREST(S): M.P.V. holds a fellowship award from the Canadian Institutes of Health Research (CIHR). The economic analysis performed by M.P.C. was supported by an unrestricted grant from Ferring Pharmaceutical.

Rapid policy change to single-embryo transfer while maintaining pregnancy rates per initiated cycle.

Public financing of IVF aims at increasing access to treatment while decreasing the expenses associated with multiple pregnancies. Critics argue that it is associated with lower pregnancy rates. This study compared cycles performed during 2009 (before implementation of Quebec's public IVF programme; period I) to those performed in the year following implementation (period II) in a single IVF centre. First fresh cycles in period I (499 women) and first fresh cycles (815 women) along with their corresponding first vitrified-warmed transfer (271 women) in period II were evaluated. From period I to period II, single-embryo transfer increased from 17.3% to 85.0% (P<0.001), multiple ongoing pregnancy rate decreased from 25.8% to 1.6% (P<0.001) and ongoing pregnancy rate decreased from 31.9% to 23.3% (P=0.001). During period II, the ongoing pregnancy rate per vitrified-warmed embryo transfer was 19.2%, leading to a cumulative ongoing pregnancy rate per initiated cycle of 29.7%, which was not different to the pregnancy rate per fresh cycle during period I (31.9%). To conclude, Quebec's public IVF programme decreased multiple pregnancy rates while maintaining an acceptable cumulative ongoing pregnancy rate, a more precise outcome to evaluate the impact of public IVF programmes.

Working to eliminate multiple pregnancies: a success story in Québec.

In August 2010, the provincial government of Québec, Canada introduced funding of assisted reproduction treatment through the provincial health programme. Alongside this benefit, legislation was introduced to control assisted reproduction treatment activities in the province, including restrictions on the number of embryos that could be transferred in any one cycle. The aim of the programme was to transfer a single embryo in every cycle; multiple embryos could be transferred under suboptimal conditions but required physician justification. In the first 3 months of this programme, 1353 cycles of IVF were performed in five Québec assisted reproduction centres, with an overall clinical pregnancy rate of 32% per embryo transfer and 50% of transfers used elective single-embryo transfer (eSET). The multiple-pregnancy rate was only 3.7% per clinical pregnancy. In 2009, prior to the introduction of the programme, eSET was used in only 1.6% of embryo transfers, resulting in a multiple-pregnancy rate of 25.6%. These data demonstrate that providing provincially funded assisted reproduction treatment created an environment in which the aggressive use of eSET was not only possible, but also rapidly implemented. The result was a dramatic drop in multiple-pregnancy rates, approaching those for natural pregnancies.

In vitro oocyte maturation for the treatment of infertility associated with polycystic ovarian syndrome: the French experience.

BACKGROUND: In vitro oocyte maturation (IVM) permits the use of immature oocytes in IVF. IVM does not require ovarian stimulation and so can be offered to patients at risk of ovarian hyperstimulation syndrome. METHODS: For this indication, we carried out 45 cycles of IVM in 33 women with polycystic ovarian syndrome (PCOS). RESULTS: A total of 509 cumulus-oocyte complexes was obtained; 276 (54.2%) oocytes matured in 24 h and 45 (8.8%) in 48 h. The normal fertilization (2PN) rate of oocytes matured in 24 and 48 h was 69.5 and 73.3% respectively. Among the 214 embryos obtained, 103 were transferred and 30 were frozen. Forty transfers were performed (2.5 embryos/transfer). Eleven women had a positive beta-hCG test (26.2% of pregnancies/puncture, 27.5% of pregnancies/transfer) and nine women had a clinical pregnancy (20.0% of pregnancies/puncture, 22.5% of pregnancies/transfer). Five babies have been born and one pregnancy is ongoing. Results of the clinical examination carried out at birth were normal. CONCLUSIONS: Our results show that IVM may be offered as an alternative to conventional IVF and to ovarian drilling in women with PCOS. The role of IVM in the therapeutic armamentarium for this condition should be further clarified.

[Natural cycle IVF (nIVF) in women with implantation failure]. / Intérêt de la fécondation in vitro en cycle naturel (FIVn) dans les échecs de l'implantation.

Since the introduction of IVF treatments, natural cycle IVF (nIVF) has been largely replaced by IVF with ovarian stimulation to obtain multiple oocytes. Failure to anticipate the retrieval of more than two oocytes often results in cancellation of the cycle. However, nIVF has several advantages. It is associated with a close to zero multiple pregnancy rate, and a zero risk of ovarian hyperstimulation syndrome. Per cycle, nIVF is less time consuming, physically and emotionally less demanding for patients, and cheaper than stimulated IVF, but also less effective. GnRH antagonists have improved the outcome of nIVF cycles. They avoid unexpected ovulation and frequent cancellations. In selected cases, especially in women with implantation failure or with poor ovarian response, favorable results can be obtained from nIVF cycles, despite the replacement of a single embryo. Poor results are obtained in women over 38 years.

Perinatal outcome and developmental studies on children born after IVF.

Since the first birth after IVF, many scientific papers have been published on the technical aspects of the IVF procedure, but few studies have addressed the issue of the perinatal outcome of IVF pregnancies and of the children's development and well-being. A high rate of adverse outcome has been demonstrated in a large group of IVF pregnancies. Prematurity, low birth weight and perinatal mortality are higher than in the general population. The majority of these complications are related to multiple births, but they are also found in singleton pregnancies. An analysis of the multiple risk factors involved in these complications is needed. The infertile status of IVF patients clearly plays a role in the risk of adverse outcome. Age and parity may be important factors. The role of IVF itself has not been demonstrated convincingly. The effect of ovarian stimulation deserves further study. Most of the studies published on the follow-up of IVF children are reassuring, but it is clear that these studies are not sufficient to eliminate without doubt any adverse effects on the well-being of IVF children. All IVF pregnancies should be followed with great care, not because they are more precious than spontaneous pregnancies, but because they are exposed to an increased risk of complications. The main problem of IVF remains the high rate of multiple pregnancies, including twins.

[Functional results of the TVT procedure: a postal questionnaire on 144 patients with a median follow-up of 20 months]. / Chirurgie de l'incontinence urinaire d'effort par le TVT: le point de vue des patientes.

UNLABELLED: Introduction. The TVT procedure has been changed the surgical treatment of stress urinary incontinence (SUI). The aim of this study was to collect the patient's point of view. MATERIAL: and METHODS: The TVT procedure was performed to treat SUI on 144 consecutive women in our institution between May 1998 and December 2000. We have sent a postal questionnaire to all patients in order to determine subjective results on SUI and post-operative voiding difficulties. RESULTS: We have obtained 124 responses (86.1% of patients). The median follow-up was 20 months +/- 12 (range 8 to 38 months). The patients were "very satisfied" in 56.5% (n=70), "satisfied" in 34.6% (n=43) and "unsatisfied" in 8.9% of cases (n=11). The functional discomfort about SUI was, on a 0 to 10 visual analog scale, 7.5 +/- 2 preoperatively and 2.2 +/- 2.8 post-operatively. Only 13.7% of patients have SUI postoperatively, and then 86.3% are considered cured. Nevertheless, voiding difficulties are common after this procedure with 31.5% of patients complaining about dysuria. On 96 patients who had had mixed incontinence preoperatively, 45.8% (n=44) complaining about persistent urge symptoms. On 28 patients who had had pure SUI, 28.6% (n=8) complaining about de novo urge symptoms. CONCLUSION: The TVT procedure is an efficient treatment of stress urinary incontinence, but with numerous post-operative voiding difficulties. This conclusion justify a precise pre-operative information to the patients.