Clinical prediction models to inform individualized decision-making in subfertile couples : a stratified medicine approach

Funding This work was supported by a Chief Scientist Office Postdoctoral Training Fellowship in Health Services Research and Health of the Public Research (Ref PDF/12/06). The views expressed in this paper represent the views of the authors and not necessarily the views of the funding body.Peer reviewedPostprin

Managing infertility in primary care

Couples may be reluctant to disclose they are experiencing infertility. Helen Allan and Ginny Mounce provide a discussion on the anxiety couples experience and how to care for these patient

Harbin Consensus Conference Workshop Group. (2014) Improving the Reporting of Clinical Trials of Infertility Treatments (IMPRINT): modifying the CONSORT statement

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Sperm chromatin dispersion test before sperm preparation is predictive of clinical pregnancy in cases of unexplained infertility treated with intrauterine insemination and induction with clomiphene citrate

Background/aims: A large proportion of men with normal sperm results as analyzed using conventional techniques have fragmented DNA in their spermatozoa. We performed a prospective study to examine the incidence of DNA fragmentation in sperm in cases of couples with previously unexplained infertility and treated with intrauterine insemination. We evaluated whether there was any predictive value of DNA fragmentation for pregnancy outcome in such couples. Methods: The percentage of DNA fragmentation and all classical variables to evaluate sperm before and after sperm treatment were determined. We studied the probable association between these results and pregnancy outcome in terms of clinical and ongoing pregnancy rate per started first cycle. We also assessed the optimal threshold level to diagnose DNA fragmentation in our center. Results: When using threshold levels of 20, 25, and 30%, the occurrence of DNA fragmentation was 42.9, 33.3, and 28.6%, respectively. Receiver operating characteristic (ROC) analysis of all cases revealed an area under the curve of 80% to predict the clinical pregnancy rate per cycle from testing the sperm motility (a + b) before treatment. We failed to generate an ROC curve to estimate pregnancy outcome from the amount of DNA fragmentation before treatment. However, when selecting only those men with a pretreatment DNA fragmentation of at least 20%, the pretreatment result was statistically different between couples who achieved a clinical pregnancy and those who did not. Conclusion: DNA fragmentation is often diagnosed in couples with unexplained infertility. Each center should evaluate the type of test it uses to detect DNA fragmentation in sperm and determine its own threshold values

Intracytoplasmic morphologically selected sperm injection versus conventional intracytoplasmic sperm injection: A randomized controlled trial

Background: Intracytoplasmic morphologically selected sperm injection (IMSI) is still proposed and employed in the clinical practice to improve the reproductive outcome in infertile couples scheduled for conventional intracytoplasmic sperm injection (cICSI). The aim of the current randomized controlled trial (RCT) was to test the hypothesis that IMSI gives a better live birth delivery rate than cICSI. Methods: Infertile couples scheduled for their first cICSI cycle for male factor were allocated using a simple randomization procedure. All available biological and clinical data were recorded and analyzed in a triple-blind fashion. Results: Our final analysis involved the first 121 patients (48 and 73 subjects for IMSI and cICSI arm, respectively) because the trial was stopped prematurely on the advice of the data safety and monitoring Committee because of concerns about IMSI efficacy at the first interim analysis. No significant difference between arms was detected in rates of clinical pregnancy per embryo transferred [11/34 (32.3 %) vs. 15/64 (23.4 %); odds ratio (OR) 1.56, 95 % (confidence interval) CI 0.62–3.93, P = 0.343] and of live birth delivery [9/48 (18.8 %) vs. 11/73 (15.1 %); OR 1.30, 95%CI 0.49–3.42, P = 0.594). Conclusion: Current data did not support the routine use of IMSI in the clinical practice for improving cICSI results in unselected infertile couples with male factor

Women's autonomy and reproductive responsibilities during the course of assisted reproductive technology : an analysis using three hypothetical scenarios that have resulted in the birth of a disabled child

University of Technology Sydney. Faculty of Law.This thesis examines, whether it is appropriate to hold a woman ethically or legally responsible for decisions made by her during assisted reproductive technology (ART) treatment that result in disability in the child born subsequently. This question is explored through three hypothetical scenarios that are fictional narrations of potentially real-life clinical situations that could occur within an ART procedure. They are used to illustrate the ethical and legal issues that may arise and involve the following different circumstances: The first scenario involves a single woman using donor sperm in New South Wales (NSW). The second scenario concerns a couple using their own gametes in Victoria (VIC), where the woman has an undisclosed genetic condition. In the third scenario, a NSW couple uses their own gametes and, after the birth, they discover that the woman and the child have a genetic condition. As a non-lawyer, my aim is to apply a feminist bioethical lens to selected laws that regulate this area, rather than to provide a comprehensive account and critique of those laws. Prior to undertaking this thesis I completed a Master of Science at the University of Geneva, focusing on how medical responsibility was assigned to the health professionals involved in six Swiss court cases where there was an unwanted birth (including both an able bodied and a disabled child). In this project I build on my previous Master’s research along with my professional expertise as a midwife, to develop a thesis which focuses on the legal and ethical rights and responsibilities of women. I draw on feminist, disability and bioethics scholarship and examine selected points of ART legislation and regulation in Australia. This thesis establishes that the new challenges posed by ART, the increased opportunities for decision-making throughout ART processes, and the involvement of multiple decision-makers, have raised novel considerations about health risks and ethical responsibilities that have a major impact on a woman’s reproductive autonomy. The majority of the legislation, regulations and guidelines I analyse are silent about the woman and her legal rights and responsibilities, instead focussing on the responsibilities of the clinics. I argue that, though it is sometimes beneficial for women to be absent from the law, ultimately the law should directly address a woman’s rights and responsibilities in order to grant her the rightful place she deserves as central to reproduction and also to protect and guarantee her rights and interests. In the documents consulted here, the woman, who is a key player and decision-maker in the reproduction process, is conspicuously absent. The thesis demonstrates that holding a woman ethically responsible at every decision-making point in ART will result in an unfair, onerous increase in her responsibility and transgress her reproductive autonomy. The thesis argues that a complex balance is needed between the interests and rights of the woman, the interests of the future child, concerns based on the rights and interests of people living with a disability and the more general values of non-discrimination and diversity of life. All these factors are essential considerations as they have an impact on a woman’s decision-making processes within ART

Factors associated with successful outcome of infertility threatment at Hospital Raja Perempuan Zainab II

Infertility is defined as the inability to conceive after a year of regular unprotected intercourse. Different treatment modalities are available to treat infertility ranging from simple, non-invasive oral agent such as clomiphene citrate to invasive procedure such as assisted reproductive technology (ART). The objective of this cross-sectional study was to determine the factors associated with the successful outcome of infertility treatment at Hospital Raja Perempuan Zainab II. Out of 429 cases, only 117 cases that fulfilled the inclusion creiteria were included. A retrospective record review was done using a checklist proforma consisting of sociodemography (age, ethnicity, education level and employment status), female variables (menstrual history, infertility history, sexual history, medical and surgical history, investigations, causes and treatment), male variables (smoking status, medical and surgical history, seminal fluid analysis, the last treatment method and its outcome ( success or failure). The successful outcome of treatment was categorised into intrauterine pregnancy, abortion or extrauterine pregnancy. The end outcome for intrauterine pregnancy was assessed in terms of mode of delivery (SVD or LSCS) and the fetal outcome (singleton or multiple births and gestational age). The descriptive methods and multiple logistic regression were applied to answer the objectives and hypotheses of this study. The overall successful rate post infertility treatment was 20.5% (95% CI: 16.8%, 24.2%) which resulted in thirteen intrauterine pregnancies, ten abortions and one extrauterine pregnancy. All thirteen pregnancies resulted in singleton babies, seven were delivered via SVD and six delivered via LSCS for precious pregnancy (two cases), fetal distress (2 cases) and one case of placenta praevia. Two of the babies were prematured, and the rest were delivered at term. Analysis from logistic regression showed that age of menarche (adj OR= 1.59,95% CI: 1.05, 2.42, p-value= 0.030) was the only significant factor affecting the successful outcome of infertility treatment when adjusted for age of men and women, BMI, duration of infertility, smoking, sperm characteristics (sperm count, percentage of progressive motility and normal morphology) and treatment options. The proportion of women with successful outcome post infertility treatment was almost similar to other studies and the odds of having a successful outcome are much higher in women with late age of menarche. Keywords: Infertility, intrauterine pregnancy, extrauterine pregnancy, abortion, age of menarche

Cumulative live birth rates after one or more complete cycles of IVF : a population-based study of linked cycle data from 178 898 women

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The value of automated follicle volume measurements in IVF/ICSI

Background/Aims: The objective of this literature study is to investigate the place of recent software technology sonography-based automated volume count (SonoAVC) for the automatic measurement of follicular volumes in IVF/ICSI. Its advantages and disadvantages and potential future developments are evaluated. Methods: A total of 74 articles were read via a PubMed literature study.The literature study included 53 articles, 32 of which for the systematic review. Results: The SonoAVC software shows excellent accuracy. Comparing the technology with the “golden standard” two-dimensional (2D) manual follicle measurements, SonoAVC leads to a significantly lower intra- and inter-observer variability. However, there is no significant difference in clinical outcome (pregnancy rate).We noted a significant advantage in the time gained, both for doctor and patient. By storing the images, the technology offers the possibility of including a quality control and continuous training and further standardization of follicular monitoring can be expected. Ovarian reserve testing by measuring the antral follicle count with SonoAVC is highly reliable. Conclusion: This overview of previously published literature shows how SonoAVC offers advantages for clinical practice, without losing any accuracy or reliability. Doctors should be motivated to the general use of follicular volumes instead of follicular diameters