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E-mail: vansteirteghama{at}humanreproduction.co.uk
In an Opinion paper published this month, nine clinicians from different countries enumerate why they believe ovarian hyperstimulation with GnRH antagonists may have advantages over GnRH agonists: reduction of treatment duration, lower risk for ovarian hyperstimulation and no hypo-estrogenic adverse events since pituitary down-regulation is avoided. Probability of achieving a live birth is similar in both protocols. The authors recommend the GnRH antagonist protocol for predicted normal responders and enumerate different aspects of the protocol where further data are still required, including implications on cost, psychological parameters and patient preference (p. 764).
A critical feature in clinical embryology is the type of protein that will be used in ART culture media. A good-sized single-center randomized controlled trial was carried out with embryos cultured in medium with serum albumin with or without serum substitute supplement. Both primary endpoints of the study, embryo implantation rate and live birth rate, were higher when embryo culture was done with the addition of serum substitute supplement. In view of the requirements for ultra-rigorous quality control measures when human-derived blood products are used, the authors question that these culture conditions can be applied in every IVF laboratory (p. 782).
Failure of strategies that increased use of emergency contraception to reduce unintended pregnancy is an issue that requires further analysis and research. Multivariable logistic regression was used on data from a recent randomized controlled trial of 1490 sexually active women assigned to either increased access or standard access to emergency contraception. Predictive modeling was used to estimate pregnancy risk scores for each participant. The contraception use of women with low or high risk of pregnancy was also examined. Three baseline variables were significantly predictive of unintended pregnancy: number of previous pregnancies, history of recent unprotected sex and the psychosocial factor ‘aversion to pregnancy’. Increased access to emergency contraception had a greater impact on women who were at lower baseline risk for pregnancy (p. 815).
Three properly controlled studies examining outcome parameters of ART are reported in this issue, two of them examine whether low-dose aspirin has an impact on the outcome of IVF/ICSI. There are several meta-analyses on the use of aspirin in ART, but the results are conflicting which justify additional randomized controlled trials. Clinical pregnancy rates were similar in a placebo-controlled trial where 100 mg aspirin or placebo was administered (p. 856). Aspirin may decrease uterine artery vascular impedance, which has been hypothesized as beneficial for ART. The placebo-controlled trial compared vascular impedance of the uterine artery on the day of embryo transfer when low-dose aspirin or placebo was administered daily from the start of ovarian stimulation. There was no difference in vascular impedance of the uterine artery on the day of transfer between the two groups (p. 861). The embryo transfer procedure is considered a crucial step in ART. Several studies have compared success rates of different types of catheters. A new randomized controlled trial compared two different catheters and three different operators, and concluded that the success of an embryo transfer catheter is for the most part operator-dependent (p. 880).
In the course of ART treatments, patients often have to make decisions on what to do with their supernumerary embryos. Sometimes patients may have to indicate their preferences at the start of treatment. An observational study reports on the considerations, motives and emotions that parents have with regard to future or current embryo disposition. Such studies increase our understanding on how patients think about human embryos and how they will decide on their fate and the meanings attributed to them. The way patients conceptualize embryos influences the decision they will make regarding their embryos (p. 896).
A prospective cohort study reports on 1338 couples starting publicly funded infertility treatment in four large tertiary referral centers. Opportunity to link to birth records provides almost complete ascertainment of births over a 5-year follow-up period. An additional questionnaire was sent to obtain data about spontaneous conceptions. Registry data indicated that nearly 70% of couples had at least one delivery during the 5-year follow-up period. From the questionnaire data, it was suggested that during the follow-up period nearly 20% had at least one delivery from spontaneous conception and 6% adopted a child (p. 991).
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