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Predicting the chances of a live birth after one or more complete cycles of in vitro fertilisation: population based study of linked cycle data from 113 873 women

BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i5735 (Published 16 November 2016) Cite this as: BMJ 2016;355:i5735

Overuse of ICSI compromises investigation treatment and improvement in male fertility.

Sir,
It is timely to look at how IVF procedures are conducted against the commercial interests (1, 2). Both in the UK and in most health economies in Europe and in North America, complex ART has been a first response to 'unexplained' male factor infertility. Very few, if any, fertility units seek to investigate and to treat these men, often telling the male patients that, diagnosis and treatment will not alter the outcome. As a result, the diagnosis for these men remains unexplained, and we have no opportunity to explore the male situation, prior to the hasty and inevitable offer of IVF and ICSI. In the UK, the figures for diagnosis of unexplained subfertility has tripled from 6204 to 19 552 cycles (3), while severe male infertility cases have increased 290% from 6771 to 19 643 from 2000 to 2011 (3). Severe male infertility can justify the use of IVF/ICSI procedures. None of these increases can be explained scientifically nor by evidence-based medicine making meaningful reassurance on health outcomes of children born using ICSI difficult to ascertain.
Urologists currently only see patients for whom ICSI is not available, which is usually due to absent funding (either because the couple do not fit the criteria, or because central or personal funds are exhausted). However, increasing numbers of men ‘diagnosed' with unexplained or male factor issues, are seeking advice and further investigation. Those of us who are fortunate enough to have had experience in investigating these men know that treatable conditions are detected, and that further investigation is likely to explain the unexplained.

It is now timely to treat men as equal partners, in terms of investigation and treatment; improvement in the male’s fertility, coupled with a measured and funded approach to IUI, is likely to reduce the number of IVF cycles, for an equivalent overall live birth rate. The inevitable consequence of such an approach would be increased opportunity to understand and treat an increasing number of men, for whom, apparently, no diagnosis exists. We suggest that no other medical or surgical specialty would willingly allow 50% of a condition to remain 'unexplained'.

Infertility is a debilitating condition, which requires equal input of both partners: the attempt to provide an increasingly expensive 'solution', without the sort of investigations now available, is no longer appropriate to modern, evidence-based, state funded medicine.

1. McLernon DJ, Steyerberg EW, Te Velde ER, Lee AJ, Bhattacharya Predicting the chances of a live birth after one or more complete cycles of in vitro fertilisation: population based study of linked cycle data from 113 873 women. BMJ. 2016 Nov 16;355:i5735. doi: 10.1136/bmj.i5735.
2. Bahadur G, Homburg R, Al-Habib A, Muneer A. Overuse of IVF risks public funding, BMJOnline, 20 December 2016 http://www.bmj.com/content/355/bmj.i5735/rapid-responses
3. Kamphuis EI, Bhattacharya S, van der Veen F, Mol BW, Templeton A. Evidence Based IVF Group. Are we overusing IVF? BMJ 2014;348:g252.

Jonathan Ramsay, Elizabeth Owen, Gulam Bahadur
Imperial College Healthcare NHS Trust, Male Fertility/Andrology, Hammersmith Hospital, Du Cane Road, London, W12 0HSUK
Chelsea and Westminster Hospital NHS Foundation Trust/West Middlesex University Hospital, Subfertility Unit, Twickenham Road, Isleworth, Middlesex TW7 6AF, UK

Competing interests: No competing interests

24 December 2016
Jonathan Ramsay
Consultant Urological Surgeon
Elizabeth Owen, Gulam Bahadur
Imperial College Healthcare NHS Trust, Male Fertility/Andrology, Hammersmith Hospital, Du Cane Road, London, W12 0HS UK; Chelsea and Westminster Hospital NHS Foundation Trust/West Middlesex University Hospital, Subfertility Unit, Twickenham Road, Isleworth, Middlesex TW7 6AF, UK