Re: Are we overusing IVF?
Kamphuis and colleagues analysed the overuse of IVF treatment focusing on the newer indications such as unexplained subfertility where evidence is sparse.1There is no doubt of an increase in the incidence of unexplained subfertility as an indication for IVF, but it would be pertinent to ask the question “why is this so”? With the cited incidences being especially based on registries from Western countries, one of the most likely reason for the increase in unexplained causes is the increase in female childbearing age2&3 and ovarian senescence in these older women presenting as unexplained subfertility.4
Since the beginning of IVF registries there has been a gradual increase in the mean age of women seeking IVF treatment.5&6 There has been a parallel increase in the proportion of older women seeking IVF treatment5&6 and in the proportion of IVF cycles being offered for unexplained subfertility as correctly pointed out by the authors.1
Human biology dictates conception which has a negative correlation with advancing female age. Epidemiological studies have shown natural conception rates in women aged 40 years or over to be 13.9 conceptions per thousand women.7 Although the success with IVF has seen major increases over the years, IVF success in women aged ≥ 40 years has not much changed despite advances in the technology, with live birth rates being less than 14%.5 However, many women and couples view IVF as a "fix all" for their voluntary postponement of childbearing.8
Is IVF a cure for ovarian senescence which is very often diagnosed as unexplained infertility in older women? What is the management pathway for fertility in these women? The studies cited by Kamphius and colleagues on natural conception rates among women with unexplained infertility involve younger women 9,10 and would be incorrect to extrapolate this evidence to older women. Paucity of evidence to guide management of the ever increasing “older woman” seeking fertility is perhaps leading to IVF being overused. As the authors have rightly pointed out randomised controlled trials of effectiveness on new indications for IVF are needed to inform both clinicians and couples. IVF should not be viewed as a blanket treatment for various causes of subfertility unless substantiated by strong evidence.
We would like to conclude this correspondence by posing a key question on primary prevention. Could the epidemic of ovarian ageing and subfertility be tackled by promoting fertility awareness among women and society? Education would certainly go a long way in health economics and perhaps a remedy for “too much medicine”.
1. Kamphuis E, Bhattacharya S, der Veen Fvan, Mol BWJ, Templeton A, BMJ 2014;348:g252.
2. Bushnick T, Garner R. The children of older first-time mothers in Canada: their health and development. Ottawa (ON): Statistics Canada. Sept 2008. Available at: http://www.statcan.gc.ca/pub/89–599-m/ 89–599-m2008005-eng.htm.
3. Royal College of Obstetricians and Gynaecologists. RCOG statement on later maternal age. Available at: http://www.rcog.org.uk/what-we-do/ campaigning-and-opinions
4. Maheshwari A, Hamilton M, Bhattacharya A. Effect of female age on the diagnostic categories of infertility. Hum Reprod 2008; 23: 538-542.
7. http://www.ons.gov.uk/ons/dcp171778_301080.pdf (Office for national statistics)
8. Maheshwari A, Bhattacharya S, Johnson NP. Predicting fertility. Hum Fertil 2008; 11(2):109-17.
9. 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.
10. 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.
11. Reindollar RH, Regan MM, Neumann PJ, Levine BS, Thornton KL, Alper MM, et al. A randomised clinical trial to evaluate optimal treatment for unexplained infertility: the fast track and standard treatment (FASTT) trial. Fertil Steril 2010; 94:888-99.
Competing interests: No competing interests