The paper by Kamphuis and colleagues requests that we reopen the debate on the indications and provision of IVF1. Given the risk of iatrogenic complications and potentially limited cost-effectiveness, the authors suggest that conservative treatment should be reconsidered as a viable alternative for couples with a good prognosis1. This position is based on the premise that the primary motivation to seek IVF treatment is to achieve a pregnancy which would otherwise be unlikely to occur at all. In such a case, it may indeed be reasonable to expect couples to wait in excess of three years before embarking on treatment2,3,4. However, national census data indicates that for many this potentially reflects the ideal time frame for completion of their entire family5. ‘Family planning’ is therefore increasingly focused on achieving the family wished for in a desired time. Social demographic trends increasingly require women to conceive their families in a shorter window. The potentially detrimental psychological impact of trying to conceive over a relatively prolonged time may further alter any individual couples analysis of cost-effectiveness6. While we agree that continued development of novel strategies to reduce adverse maternal and perinatal complications are required, at present stratification of ovarian stimulation7, milder stimulation regimens8, use of GnRH agonist triggers and segmentation of the IVF cycle9 are serving to reduce the risk of complications such as ovarian hyperstimulation syndrome while improving success rates. Limiting the number of embryos transferred has also been associated with improved short and long-term maternal, perinatal and offspring outcomes10,11. While we commend the authors on questioning the efficacy of IVF intervention versus time to treat subfertility, we suggest that the premise of this debate is no longer the key issue. Patients now appreciate that IVF can be utilised for family planning in the context of their lifecourse and for many is an effective and efficient strategy for reducing their time to completion of family.
Scott M Nelson1
Paul Devroey2
Ernesto Bosch3
Nicholas S Macklon4
Affiliations:
1. School of Medicine, University of Glasgow, G12 8QQ Glasgow, UK.
2 Center for Reproductive Medicine, Dutch-speaking Free University Brussels, Brussels and AZ Jan Palfijn Hospital, Gent, Belgium.
3. IVI Valencia, Valencia, Spain.
4. Academic Unit of Human Development and Health, University of Southampton, Southampton SO16 5YA UK.
References:
1. Kamphuis EI, Bhattacharya S, van der Veen F, Mol BW, Templeton A; Evidence
Based IVF Group. Are we overusing IVF? BMJ. 2014 Jan 28;348:g252. doi:
10.1136/bmj.g252. PubMed PMID: 24472708.
2. Brandes M, Hamilton CJ, van der Steen JO, de Bruin JP, Bots RS, Nelen WL, et al. Unexplained infertility: overall ongoing pregnancy rate and mode of conception. Hum Reprod 2011;26:360-8.
3.Troude P, Bailly E, Guibert J, Bouyer J, de la Rochebrochard E, DAIFI Group. Spontaneous pregnancies among couples previously treated by in vitro fertilization. Fertil Steril 2012;98:63-8.
4. Steures P, van der Steeg JW, Hompes PG, Habbema JD, Eijkemans MJ, Broekmans FJ, et al. Intrauterine insemination with controlled ovarian hyperstimulation versus expectant management for couples with unexplained subfertility and an intermediate prognosis: a randomised clinical trial. Lancet 2006; 368:216-21.
5. http://www.ons.gov.uk/ons/rel/vsob1/characteristics-of-mother-2--england...
6. Schmidt L. Psychological burden of infertility and assisted reproduction. Lancet 2006;367:379-380
7. Macklon NS, Stouffer RL, Giudice LC, Fauser BC. The science behind 25 years of
ovarian stimulation for in vitro fertilization. Endocr Rev. 2006 Apr;27(2):170-207.
8. La Marca A, Sunkara SK. Individualization of controlled ovarian stimulation in
IVF using ovarian reserve markers: from theory to practice. Hum Reprod Update.
2014 Jan-Feb;20(1):124-40.
9. Devroey P, Polyzos NP, Blockeel C. An OHSS-Free Clinic by segmentation of IVF
treatment. Hum Reprod. 2011 Oct;26(10):2593-7.
10. Fauser BC, Devroey P, Macklon NS. Multiple birth resulting from ovarian
stimulation for subfertility treatment. Lancet. 2005 May 21-27;365(9473):1807-16.
11. Lawlor DA, Nelson SM. Effect of age on decisions about the numbers of embryos to transfer in assisted conception: a prospective study. Lancet. 2012 Feb 11;379(9815):521-7.
Rapid Response:
Re: Are we overusing IVF?
The paper by Kamphuis and colleagues requests that we reopen the debate on the indications and provision of IVF1. Given the risk of iatrogenic complications and potentially limited cost-effectiveness, the authors suggest that conservative treatment should be reconsidered as a viable alternative for couples with a good prognosis1. This position is based on the premise that the primary motivation to seek IVF treatment is to achieve a pregnancy which would otherwise be unlikely to occur at all. In such a case, it may indeed be reasonable to expect couples to wait in excess of three years before embarking on treatment2,3,4. However, national census data indicates that for many this potentially reflects the ideal time frame for completion of their entire family5. ‘Family planning’ is therefore increasingly focused on achieving the family wished for in a desired time. Social demographic trends increasingly require women to conceive their families in a shorter window. The potentially detrimental psychological impact of trying to conceive over a relatively prolonged time may further alter any individual couples analysis of cost-effectiveness6. While we agree that continued development of novel strategies to reduce adverse maternal and perinatal complications are required, at present stratification of ovarian stimulation7, milder stimulation regimens8, use of GnRH agonist triggers and segmentation of the IVF cycle9 are serving to reduce the risk of complications such as ovarian hyperstimulation syndrome while improving success rates. Limiting the number of embryos transferred has also been associated with improved short and long-term maternal, perinatal and offspring outcomes10,11. While we commend the authors on questioning the efficacy of IVF intervention versus time to treat subfertility, we suggest that the premise of this debate is no longer the key issue. Patients now appreciate that IVF can be utilised for family planning in the context of their lifecourse and for many is an effective and efficient strategy for reducing their time to completion of family.
Scott M Nelson1
Paul Devroey2
Ernesto Bosch3
Nicholas S Macklon4
Affiliations:
1. School of Medicine, University of Glasgow, G12 8QQ Glasgow, UK.
2 Center for Reproductive Medicine, Dutch-speaking Free University Brussels, Brussels and AZ Jan Palfijn Hospital, Gent, Belgium.
3. IVI Valencia, Valencia, Spain.
4. Academic Unit of Human Development and Health, University of Southampton, Southampton SO16 5YA UK.
References:
1. Kamphuis EI, Bhattacharya S, van der Veen F, Mol BW, Templeton A; Evidence
Based IVF Group. Are we overusing IVF? BMJ. 2014 Jan 28;348:g252. doi:
10.1136/bmj.g252. PubMed PMID: 24472708.
2. Brandes M, Hamilton CJ, van der Steen JO, de Bruin JP, Bots RS, Nelen WL, et al. Unexplained infertility: overall ongoing pregnancy rate and mode of conception. Hum Reprod 2011;26:360-8.
3.Troude P, Bailly E, Guibert J, Bouyer J, de la Rochebrochard E, DAIFI Group. Spontaneous pregnancies among couples previously treated by in vitro fertilization. Fertil Steril 2012;98:63-8.
4. Steures P, van der Steeg JW, Hompes PG, Habbema JD, Eijkemans MJ, Broekmans FJ, et al. Intrauterine insemination with controlled ovarian hyperstimulation versus expectant management for couples with unexplained subfertility and an intermediate prognosis: a randomised clinical trial. Lancet 2006; 368:216-21.
5. http://www.ons.gov.uk/ons/rel/vsob1/characteristics-of-mother-2--england...
6. Schmidt L. Psychological burden of infertility and assisted reproduction. Lancet 2006;367:379-380
7. Macklon NS, Stouffer RL, Giudice LC, Fauser BC. The science behind 25 years of
ovarian stimulation for in vitro fertilization. Endocr Rev. 2006 Apr;27(2):170-207.
8. La Marca A, Sunkara SK. Individualization of controlled ovarian stimulation in
IVF using ovarian reserve markers: from theory to practice. Hum Reprod Update.
2014 Jan-Feb;20(1):124-40.
9. Devroey P, Polyzos NP, Blockeel C. An OHSS-Free Clinic by segmentation of IVF
treatment. Hum Reprod. 2011 Oct;26(10):2593-7.
10. Fauser BC, Devroey P, Macklon NS. Multiple birth resulting from ovarian
stimulation for subfertility treatment. Lancet. 2005 May 21-27;365(9473):1807-16.
11. Lawlor DA, Nelson SM. Effect of age on decisions about the numbers of embryos to transfer in assisted conception: a prospective study. Lancet. 2012 Feb 11;379(9815):521-7.
Competing interests: No competing interests