Simon Phillips

A comparison of in vitro maturation and in vitro fertilization for women with polycystic ovaries

OBJECTIVE To establish the relative success of treatment by unstimulated in vitro maturation (IVM) of oocytes or stimulated in vitro fertilization (IVF) in women with polycystic ovaries undergoing assisted conception treatment. METHODS The case‐control study included 107 IVM and 107 IVF cycles matched for age and cause of infertility. In vitro maturation patients underwent transvaginal recovery of immature oocytes during an unstimulated cycle, in vitro oocyte maturation, and fertilization. Those in the IVF group underwent ovarian stimulation after pituitary suppression. Embryos were transferred in the same cycle in both groups. Main outcome measures included numbers of mature oocytes and embryos produced, and rates of implantation, pregnancy, live birth, and complications. RESULTS In the IVM group after in vitro culture, 7.8 mature oocytes and 6.1 embryos were obtained per retrieval. With IVF, 12.0 mature oocytes (P < .01) and 9.3 embryos (P < .01) were obtained. The IVM pregnancy and live birth rates per retrieval were 26.2% and 15.9% compared with 38.3% and 26.2% for IVF (nonsignificant). The implantation rate of IVF‐derived embryos was higher (17.1% versus 9.5%) than that for IVM (P < .01). There were 12 cases (11.2%) of moderate or severe ovarian hyperstimulation syndrome in IVF patients, compared with none in the IVM group (P < .01). CONCLUSION Our results suggest that for women with polycystic ovaries who require assisted conception, IVM is a promising alternative to conventional IVF treatment.

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.

Sperm head morphology is related to high deoxyribonucleic acid stainability assessed by sperm chromatin structure assay

OBJECTIVE To examine the relationship between sperm strict morphology and sperm chromatin integrity. DESIGN Prospective study. SETTING Infertility clinic. PATIENT(S) Eighty-seven consecutive semen samples from non-azoospermic men presenting for infertility evaluation and 6 samples from fertile donors. INTERVENTION(S) Assessment of standard semen parameters and sperm chromatin structure assay (SCSA) parameters (%DFI [DNA fragmentation index] and %HDS [high DNA stainability]). Evaluation of %HDS and %DFI after treatment with dithiothreitol (a thiol-reducing agent used to decondense sperm nuclei) was also undertaken. MAIN OUTCOME MEASURE(S) Relationship between sperm strict morphology defects and SCSA parameters (%DFI and %HDS). RESULT(S) We observed significant relationships between the percentage of normal sperm forms and both %HDS (r = -0.40) and sperm motility (r = 0.32). We also found significant relationships between sperm head defects and both %HDS (r = 0.40) and sperm concentration (r = -0.39). Sperm tail, midpiece, and neck defects were not significantly related to the SCSA parameters. Treatment of spermatozoa with dithiothreitol (to induce decondensation) resulted in a substantial increase in %HDS but no measurable change in %DFI. CONCLUSION(S) The observed relationship between sperm head defects and %HDS suggests that sperm head abnormalities may, in part, be due to incomplete sperm chromatin condensation.

Impact of reducing the number of embryos transferred from three to two in women under the age of 35 who produced three or more high-quality embryos

OBJECTIVE To investigate the effect of a reduction in the number of good-quality embryos transferred in patients <35 years of age on pregnancy and multiple pregnancy rate. DESIGN Prospective observational study with historical controls. SETTING Academic tertiary referral unit. PATIENT(S) Three hundred eight patients <35 years of age undergoing IVF-ET. INTERVENTION(S) For patients who had three or more good quality embryos available for transfer, those in group 1 were given the option to have either two or three embryos replaced, whereas those in group 2 were allowed a maximum of two embryos transferred. In both groups, patients who had less than three good-quality embryos had the option to have three embryos transferred. MAIN OUTCOME MEASURE(S) Pregnancy and multiple pregnancy rates. RESULT(S) Patients in group 1, compared with those in group 2, had significantly more embryos (3 vs. 2) of significantly higher cumulative embryo score (31 vs. 24) transferred. This resulted in significantly higher multiple (57.8% vs. 30.8%) and triplet (15.6% vs. 1.4%) pregnancy rates in group 1. However, no difference in overall clinical pregnancy rate (37.2% vs. 41.2%) or live birth rate (28.1% vs. 29.4%) was observed between group 1 and 2. CONCLUSION(S) In women <35 years of age, who have three or more good-quality embryos available for transfer, a maximum of two embryos should generally be transferred.

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

Spontaneous ovulation rate before oocyte retrieval in modified natural cycle IVF with and without indomethacin.

3730 to CAD

Reproductive performance of couples discordant for hepatitis B and C following IVF treatment.

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

Controlled natural cycle IVF: experience in a world of stimulation.

49 517 to CAD

Anti-sperm antibody levels are not related to fertilization or pregnancy rates after IVF or IVF/ICSI

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.

Consecutive Transfer of Day 3 Embryos and of Day 5–6 Blastocysts Increases Overall Pregnancy Rates Associated with Blastocyst Culture

The objective of this retrospective analysis was to evaluate the number of spontaneous ovulations occurring before oocyte retrieval in natural cycle IVF (nIVF) with and without the use of indomethacin. A total of 121 patients who underwent modified nIVF cycle between December 2003 and July 2006 were included in the study; 171 cycles without indomethacin and 84 cycles with indomethacin, started when the leading follicle reached 14 mm in size, were compared. The number of cycles with ovulation before oocyte retrieval and the number of cycles with no oocytes at retrieval were assessed with and without indomethacin. In addition, the pregnancy rates in the two groups of patients were analysed. There were 28 cycles (16%) in which ovulation occurred before oocyte retrieval in the group where no indomethacin was used and five cycles (6%) in which ovulation occurred before retrieval in the group where indomethacin was used. There was a statistically significant association between premature ovulation and indomethacin, with an odds ratio of 3.8 (95% confidence interval, 1.2-12.3). The oocyte retrieval per started cycle was 64% without indomethacin and 76% with indomethacin (P < 0.04). The clinical pregnancy rate per embryo transfer was 14% without indomethacin and 21% with indomethacin (not significant).