Factors Affecting Pregnancy Rates in IVF Russian Association of Human Reproductive Health St. Petersburg. September 9, 2011 G. David Adamson, MD,FRCSC,FACOG,FACS Director, Fertility Physicians of Northern California Adjunct Clinical Professor, Stanford University Associate Clinical Professor, UCSF
48
Embed
Factors Affecting Pregnancy Rates in IVF - rahr.ru · Factors Affecting Pregnancy Rates in IVF ... – No decline in ongoing pregnancy rate overall ... • Known factors affecting
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Factors Affecting Pregnancy Rates in IVF
Russian Association ofHuman Reproductive Health
St. Petersburg. September 9, 2011G. David Adamson, MD,FRCSC,FACOG,FACS
Director, Fertility Physicians of Northern CaliforniaAdjunct Clinical Professor, Stanford University
Associate Clinical Professor, UCSF
Disclosures• Advanced Reproductive Care (ARC)
– Founder and CEO• Professional Organizations
– ASRM: Past President– FIGO: Chair, Reproductive Medicine Committee– ICMART: Int’l Committee Monitoring ART– IFFS: Executive Committee– WERF: Chair
• Patients– “This glossary does not include specific
measures of “success” which would take into consideration the well-being of babies as well as of their mothers, fathers, surrogates and/or gamete donors.” (1)
• Other Society Stakeholders– Appropriate cost to broader society– Minimized social or ethical issues– Appropriate number of babies for that society
• A healthy singleton baby1. ICMART WHO Glossary 2009. Fertil Steril 2009;92:1520–4.
Patient SelectionFor IVF
Informed Consent and Guidelines For Care*
• Evidence based medicine• Effective consulting and counseling• Informed consent guidelines• Guidelines for providing infertility
services• Practice guidelines• Ethical guidelines
* Significant influence on patient’s decision
Major Categories of Factors That Affect IVF Success
• Patient population• Quality of medical treatment• Quality of gamete/embryology laboratory• Measurement & reporting of outcomes• Resources available for treatment
– Financial– Patient support services
• Values and ethics– Patients– Physicians– Community– Society
PatientPopulation
Pregnancy Rates Following Treatment (Per Cycle)
LIVE BIRTHS PER TRANSFER FOR ART CYCLES USING FRESH EMBRYOS FROM OWN AND DONOR EGGS, BY PATIENT AGE
ASRM Practice Committee. Fertil Steril Nov 2008;90(Suppl 3):S66-7.
Normal Uterus and Endometrium
Uterine Factors andAge-Related Infertility• Polyps increase with age (1)• Myomas increase with age (2,3)• No significant age-related decline in
delivery rates with egg donation
1. Nagele F. Am J Obstet Gynecol. 1996; 88:9002. Baird et al. Am J Obstet Gynecol 2003;188:100-7.3. Peddada et al. PNAS 2008 Dec 16;105(50):19887-92.
Submucous Myoma
Meta-analysis ofMyoma Studies
• Fertility outcomes– decreased in women with submucosal fibroids– removal seems to confer benefit
• Intramural fibroids– appear to decrease fertility– results of therapy are unclear
• More high-quality studies need to be directed toward the value of myomectomy for intramural fibroids, focusing– size– number– proximity to the endometrium
Pritts. Fertil Steril. 2009 Apr; 91(4):1215-23. Epub 2008 Mar 12.
Effects Of Male Age On Fertility
• Many studies confounded by age of female partner
• In studies controlling for female age, MEN age > 50 create pregnancies at a rate 23-38% lower than MEN age <30
• In some studies, male factor is associated with lower IVF pregnancy rates
Patient characteristics vary among programs; therefore, these data
should not be used for comparingclinics.
Quality ofMedical Treatment
1-5 weeks
Sample IVF Cycle Average 2 Month Process
CONTRACEPTION
GnRHa/ant INJECTIONS
FSH INJECTIONS
hCG
Ultrasound and Estradiol
Monitoring
Baseline Ultrasound/ SHG
PROGESTERONE SUPPLEMENTATION
35 hrs
Retrieval forIVF or GIFT
EmbryoTransfer
menses menses
Day1
3-5 days
10-15 days ~ 10 days 9-11 days
PregnancyTest
Current Mandatory Regulation of ARTMandatory for SART Programs
• SART– Personnel requirements: Program, Medical and Lab Directors– On-site accreditation of laboratory by CAP/ASRM, JCAHO or
NY state– Reporting of results to SART/CDC– On-site validation of reported results by SART/CDC– On-site review of adherence to SART Practice, Laboratory,
Advertising and Ethics Guidelines– Mandatory participation in SART quality assurance program
• CDC (“Mandatory”, but not enforceable, for all ART programs)– Reporting of results to SART/CDC– On-site validation of reported results by SART/CDC– Listing of non-responder clinics by CDC
• FEDERAL TRADE COMMISSION (FTC)– Truth-in-advertising
Multiple Birth: ASRM/SART GuidelinesNumber of Embryos to Transfer (2008)
3322All Others
3221Favorable*
Day 5
5432All Others
5321-2Favorable*
>4038-4035-37<35Day 3
* 1st cycle, good embryos, # to * 1st cycle, good embryos, # to cryocryo, or prior IVF success, or prior IVF success
Key Steps in IVFEmbryo Transfer
•Technique•? Ultrasound guidance•Number and quality of embryos transferred
Embryo Transfer Catheter
Clinical Pregnancy Rate per Embryo Transfer
by Age and Cycle Number
Silberstein. Fertil Steril 2005;84(4):1043-5.
All PatientsNumber = 1,177Cycles = 1,788
Age < 35
Age 35-38 Age > 38*1 2 3 4 5
1 2 3 4 51 2 3 4 5
* *20%
*
*
1 2 3 4 5
20%
20% 20%
40% 40%
40%40%
*
Quality ofLaboratory
FPNC Gamete Laboratory
Key Steps in IVFFertilization
• Conventional Insemination
• Intracytoplasmic Sperm Injection (ICSI)
What Can Urologists Do For Severe Male Factor Infertility?
TOTAL 291 8.3%Serour. Fertil Steril 1998;70(4):638-42.
Elective Single Embryo Transfer (eSET): An American Perspective
• Decrease in number of embryos transferred from two to one– Reasonable option in one-third of patients– Reduces twin incidence to half its original– No decline in ongoing pregnancy rate overall
• The proportion of patients for whom this is appropriate will vary from program to program, depending on individual patient characteristics.
• Implement the program gradually– Distinct clinical phases– Judicious patient selection
• Cryopreservation
PatientResources
Patient Drop-out Rates Are 37 – 68%:What is Impact on Cumulative eSET?
• A major unknown confounding variableon the overall success of eSET (1,2)– Cost– Physician-recommended– 65% not pregnant did not pursue covered
treatment in Sweden (3)• Psychological –26%• Poor Prognosis – 25%• Spontaneous pregnancy – 19%• Physical burden – 6%• Serious disease – 2%• Other –7% (1) Fertil Steril 2004;81:258-78.
• Oral gonadotropins• More efficient utilization of cryopreserved
embryos• Genetics
– Diagnosis of selected genes associated with causes of infertility
– Treatment of selected genes associated with causes of infertility
– Prevention of genetically identifiable causes of infertility
“Far Future” Factors That Might Affect IVF Success Rates
• Societal recognition of IVF as a disease
• Societal financial support of infertility services, including IVF
• Widespread application of “affordable ART” in low resource environments
• Complete integration of reproductive medicine treatment into comprehensive women’s health prevention and treatment programs
CONCLUSION:Factors That Affect IVF Success
• Define Success: Healthy singleton baby• Infertility is a complex disease
– 2 patients plus child(ren)– Many causes– Some treatments simple, many complex– Multiple treatments simultaneously– Significant scientific and technological advances– Both known and unknown factors affect success
• Known factors affecting success– Types of patients– Quality of care– Quality of laboratory– Complexity and interpretation of outcome assessment– Socioeconomic factors– Patient and physician values and ethics