The cost-effectiveness of using a prognosis-tailored strategy model to triage couples with idiopathic infertility for assisted reproduction technology.

OBJECTIVES: To evaluate whether a prognosis-tailored triage of ART for couples with idiopathic infertility by using the Hunault prognostic model can decrease the cost of treatment without compromising the chance of live birth. STUDY DESIGN: This is a retrospective study conducted in an Australian fertility clinic. Couples seeking infertility consultation who were subsequently found to have idiopathic infertility after evaluation were included. We compared the costs per conception leading to live birth of the prognosis-tailored strategy with the immediate ART strategy, which generally reflects the current practice in Australian fertility clinics, over a 24-month period. In the prognosis-tailored strategy, for each couple, the prognosis for natural conception was assessed using the well-established Hunault model. Total cost of treatments were calculated as the sum of typical out-of-pocket and Australian Medicare cost (Australian national insurance scheme). RESULTS: We studied 261 couples. In the prognosis-tailored strategy, the total cost was $2,766,781 and the live birth rate was 63.9%. In contrast, the immediate ART strategy yielded a live birth rate of 64.4% with a total cost of $3,176,845. Implementing the prognosis-tailored strategy using the Hunault model saved $410,064 in total and $1,571 per couple. The incremental cost-effectiveness ratio (ICER) was $341,720 per live birth. CONCLUSION: In couples with idiopathic infertility, assessment of prognosis for natural conception using the Hunault model and delaying ART for 12 months in couples with favourable prognoses can considerably reduce costs without significantly compromising live birth rates.

Anti-Müllerian hormone is a predictor of medium-term cumulative live birth following in vitro fertilization/intracytoplasmic sperm injection: A retrospective study.

OBJECTIVES: This study aims to examine the capacity of anti-Müllerian hormone (AMH) to predict cumulative live birth rate (CLBR) following IVF/ICSI within 36 months since start of treatment. STUDY DESIGN: This is a cohort study of women seeking IVF/ICSI fertility treatment in a private Australian IVF clinic in a single calendar year. Live births were monitored over three years following start date of IVF/ICSI. The impact of serum AMH level on the CLBR was assessed using Cox's proportional hazard models, and its incremental values in the prediction of CLBR were evaluated. RESULTS: The CLBRs were significantly higher in women with AMH levels in the highest (>44.5 pmol/L; 87.0%, 95% CI 79.2% - 95.1%) and in the middle two quartiles (between 11.5 and 44.5 pmol/L; 81.0%, 95% CI 74.2% - 87.6%), compared with AMH levels below the 25th percentile (≤11.5 pmol/L; 63.2%, 95% CI 53.2% - 74.5%). Approximately half of the women with AMH in the lowest quartile conceived a live birth within 12 months of starting IVF compared with two-thirds of the women in the upper three quartiles. After adjusting for confounders, AMH remained a significant, albeit slight predictor of CLBR with a fall of 3 pmol/L equating to an 1% decrease in CLBR. The AMH's added values into the prediction of live birth were slight, indicated by a net reclassification improvement of 13.8%. The value is lower than that of maternal age (35.1%). CONCLUSIONS: Serum AMH level was a significant slight predictor of CLBR following IVF/ICSI. AMH should not be used to exclude women from IVF/ICSI however, women with low AMH should be counselled on the likelihood of taking longer to achieve a live birth than individuals with normal AMH levels.

The predictive value of anti-Müllerian hormone for natural conception leading to live birth in subfertile couples.

RESEARCH QUESTION: What is the predictive value of serum anti-Müllerian hormone (AMH) level for natural conception and its clinical effect on subfertile couples? DESIGN: A retrospective cohort of ovulatory women seeking fertility consultation in a private fertility clinic. Couples who had an immediate indication for IVF were excluded. All natural conceptions leading to live birth before the start of assisted reproductive technology were followed within 12 months of the initial consultation. A prediction model was developed by updating the Hunault model with serum AMH to predict the probabilities of achieving a natural conception leading to live birth. RESULTS: A total of 325 couples were included in the final analysis. The estimated cumulative proability of achieving natural conception leading to live birth within 12 months was 20.9% (95% CI 12.9% to 28.2%). The categorical net reclassification improvement of AMH is 7.6%. For couples with a predicted chance of natural conception changed from poor (<30%) by the reference model to good (≥30%) by the updated model, the cumulative natural conception rate leading to live birth was 52.0%. For couples who had predicted chance of natural conception changed from good to poor by the updated model, the rate was 18.9%. CONCLUSIONS: The addition of serum AMH to the routine fertility work-up may improve prognosis-based treatment policy and help to prevent unnecessary costs and stress for couples. Prospective validation of the updated model with AMH is required before clinical application.

Can the use of diagnostic and prognostic categorisation tailor the need for assisted reproductive technology in infertile couples?

BACKGROUND: The complications associated with in vitro fertilisation (IVF) for both the offspring and mother, and its high cost make it essential to tailor the technology to those infertile couples who truly benefit from it. AIMS: To determine whether a simple prognostic algorithm could discriminate between couples who require immediate fertility treatments and couples in whom less invasive strategies should be offered first. MATERIALS AND METHODS: In this retrospective cohort study, couples were classified into six groups based on the medical necessity of IVF and their prognosis for natural conception: (i) tubal/severe semen factor mandating immediate IVF due to the very low chance of natural conception; (ii) pure anovulation infertility; (iii) female age ≥39 years; and (iv) unexplained/mild male infertility (no indication for immediate treatment) with (4A) good, (4B) moderate or (4C) poor prognosis of natural conception, as per an existing, validated prognostic model. For each group, we constructed Kaplan-Meier curves to measure natural conception and the effect of fertility treatment. RESULTS: The 12 months cumulative live birth rate for couples with unexplained or mild male infertility and poor prognosis increased from 1% without treatment to 35% after treatment (P < 0.001). In contrast, couples with good prognosis experienced a statistically insignificant increase in their cumulative live birth rate from 40% to 56% (P = 0.07). This demonstrates that a prognostic model could predict a couple's chances of natural conception and the benefit they derive from treatment. CONCLUSIONS: This prognostic mode allows fertility treatment to be individually tailored to reduce unnecessary IVF without compromising fertility chances.

Human growth hormone for poor responders: a randomized placebo-controlled trial provides no evidence for improved live birth rate.

RESEARCH QUESTION: Does the addition of human growth hormone (HGH) to an IVF cycle improve the live birth rate in previously documented poor responders to FSH? DESIGN: Double-blind, placebo-controlled, randomized clinical trial comparing HGH to placebo in maximal stimulation in an IVF cycle. The study was stopped after 4 years. Women receiving ovarian stimulation in one IVF cycle, having failed to produce more than 5 eggs in a previous cycle with more than 250 IU/day of FSH were included. Basal FSH was ≤15 IU/l, body mass index <33 kg/m2, age <41 years. HGH or placebo were added from the start of the cycle in a double-blinded manner. The primary outcome was live birth rate. MAIN RESULTS: The live birth rates following an IVF cycle were 9/62 (14.5%) for growth hormone and 7/51 (13.7%) for the placebo group (risk difference 0.8%, 95% confidence interval [CI] -12.1 to 13.7%; odds ratio [OR] 1.07, 95% CI 0.37-3.10). There was a greater odds of oocyte retrieval with growth hormone (OR 5.67, 95% CI 1.54-20.80) but no better chance of embryo transfer (OR 1.42, 95% CI 0.50-4.00). Birth weights were comparable. CONCLUSIONS: Planned participant numbers were not reached. It was not possible to demonstrate an increase in live birth rate from the addition of growth hormone in women with a previous poor ovarian response to IVF.

The use of complementary medicine and therapies by patients attending a reproductive medicine unit in South Australia: a prospective survey.

BACKGROUND: There is limited research describing the use of complementary medicines (CM) and therapies among patients with infertility. OBJECTIVE: (i) To examine the use of CM by subjects attending an infertility clinic at their first consultation and six months later; (ii) to examine men's and women's views on the effectiveness and safety of these practices; and (iii) to examine the documentation of the use of CMs and therapies in clinical notes. DESIGN: A prospective survey of 100 consecutive new patients presenting to an infertility clinic. Subjects were requested to complete a self-administered questionnaire at their first visit and six months later. A retrospective audit of 200 patient records. RESULTS: A response rate of 72% was obtained. Sixty-six percent of patients attending the infertility clinic in South Australia used CMs. Six months following the initial consultation the use of CMs had declined. The most commonly used CMs included multivitamins, herbs, and mineral supplements, and subjects consulted most frequently with naturopaths, chiropractors and acupuncturists. The use of CMs and therapies was poorly documented by clinical staff. CONCLUSION: Complementary medicines and therapies are widely used by patients with infertility. Health-care practitioners and fertility specialists need to be proactive in acquiring and documenting the use of these practices. There is a need to provide further information to patients on the use of CMs and therapies. Further research examining the reasons for use of CMs and therapies is needed.