Comment on ‘A multicentre randomized controlled trial of expectant management versus IVF in women with Fallopian tube patency’
Städtische Kliniken Duesseldorf gGmbH, Frauenklinik Benrath, Department of Gynecological Endocrinology and Reproductive Medicine, Urdenbacher Allee 83, D-40593 Düsseldorf, Germany
Email: gnoth{at}uni-duesseldorf.de
Sir,
We read with great interest the study by Hughes et al. (2004)
which is an important contribution to the management of infertility. The authors discuss open and aboveboard concerns of their trial which are of general relevance for all (in future and urgently needed) randomized controlled trials comparing different treatment strategies in reproductive medicine.
In general, all treatment options in reproductive medicine have to be compared with spontaneous conception prospects to evaluate whether couples would benefit from interventions or not. In our opinion, a 3 month observation period is much too short to tap the spontaneous conception potential. We know from prospective studies that a least six cycles with intercourse in the fertile window and not just a few months are necessary to cover the period in which most of the conceptions (
80%) should occur (Gnoth et al., 2003). Snick et al. (1997) showed that after 12 months of subfertility, 54.5% of couples experienced a live birth in the following 36 months without any treatment. In couples with unexplained infertility, the rate reached nearly 61% and remained low for those with ovulation problems and endometriosis or male factor infertility. Snick's results are comparable with the results of Stolwijk et al. (2000) who found an ongoing pregnancy rate of 54.5% after five subsequent cycles of IVF or IVF/ICSI, meaning that interventions are not always superior to expectant management—especially in cases with unexplained infertility—if a sufficiently long observation period is acceptable.
Of course it is sometimes very difficult to get patients with infertility problems to wait unless they are informed in detail about their prognosis, the proposed pattern of investigation and treatment and also alternative ways of becoming parents (Schmidt, 1998) particularly as some are paying privately for reproductive treatment.
References
Gnoth C, Frank-Herrmann P, Freundl G, Godehardt D and Godehardt E (2003) Time to pregnancy: results of the German prospective study and impact on the management of infertility. Hum Reprod 18, 1959–1966.
Hughes EG, Beecroft ML, Wilkie V, Burville L, Claman P, Tummon I, Greenblatt E, Fluker M and Thorpe K (2004) A multicentre randomized controlled trial of expectant management versus IVF in women with Fallopian tube patency. Hum Reprod 19, 1105–1109.
Schmidt L (1998) Infertile couples' assessment of infertility treatment. Acta Obstet Gynecol Scand 77, 649–653.[CrossRef][Web of Science][Medline]
Snick HK, Snick TS, Evers JL and Collins JA (1997) The spontaneous pregnancy prognosis in untreated subfertile couples: the Walcheren primary care study. Hum Reprod 12, 1582–1588.
Stolwijk AM, Wetzels AM and Braat DD (2000) Cumulative probability of achieving an ongoing pregnancy after in-vitro fertilization and intracytoplasmic sperm injection according to a woman's age, subfertility diagnosis and primary or secondary subfertility. Hum Reprod 15, 203–209.
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