1 Division of Reproductive Medicine, Department of Obstetrics and Gynaecology, Erasmus Medical Centre, Rotterdam and 2 Department of Reproductive Medicine, University Medical Centre, Utrecht, The Netherlands
3 To whom correspondence should be addressed at: Department of Obstetrics and Gynaecology, Erasmus Medical Center, Dr Molewaterplein 40, 3015GD Rotterdam, The Netherlands. Email: e.heijnen{at}azu.nl
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Abstract |
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Key words: health economics/IVF/live birth rate/singleton birth/treatment outcome
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Introduction |
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Focusing on the whole treatment: consequences for clinical practice |
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The introduction of GnRH antagonists into clinical practice has enabled shorter treatment protocols to be applied, since, in contrast to GnRH agonists, treatment can be limited to the days in the mid-to-late follicular phase truly at risk of a premature LH rise (Bouchard and Fauser, 2000). Moreover, since this approach enables the endogenous inter-cycle FSH rise to be utilized rather than suppressed, it has opened the way to the development of mild stimulation protocols in which exogenous FSH administration is limited to the mid-late follicular phase (Fauser et al., 1999
; Macklon and Fauser, 2000
; de Jong et al., 2001
; Hohmann et al., 2003
).
Mild stimulation protocols may reduce drop-outs from IVF and therefore increase the overall number of cycles per patient, resulting in increased overall birth rates per started treatment. Shorter, patient-friendly stimulation protocols may increase efficiency, enabling more cycles to be carried out in a given period than is possible with conventional stimulation protocols. Increasing exposure to chances of becoming pregnant while reducing exposure to the complications of conventional ovarian stimulation also offers a formula for reducing costs.
Single embryo transfer
In the present debate series, Land and Evers suggest adopting an outcome measurethe corrected singleton live birth rate per cycle startedthat rewards efficacy (many healthy singleton babies) and penalizes unsafety (multiple pregnancies) (Land and Evers, 2004). We would agree that the ideal numerator for determining IVF outcome is a term singleton baby. However, Dickey et al. (2004)
proposed that multiple outcome measures are necessary when evaluating IVF success, and that twin as well as singleton births should be counted as IVF successes. While healthy term twins may be perceived as a good outcome, twins in general are at higher risk of neonatal morbidity and mortality (Gardner et al., 1995
; Russell et al., 2003
), and the current consensus is that multiple pregnancies should be prevented. One approach to the problem of reporting IVF results may be the implementation of a scoring system where singletons count higher than twins (score 1 versus 0.5), but both are recognized as preferable to no pregnancy and higher order multiple pregnancies (score 0). In this way twin pregnancies contribute to the pregnancy rate per treatment, but are also relatively penalized (Hunault et al., 2002
).
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Healthy baby |
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The integrated picture |
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We postulate that the combination of mild stimulation and single embryo transfer would reduce the overall costs of treatment, both to couples and society, partly by reducing the indirect costs related to pregnancy complications. This could be achieved despite an increased number of cycles compared with conventional IVF hyperstimulation and double embryo transfer (Collins, 2002; De Sutter et al., 2002
; Gerris et al., 2004
). We consider that the optimal numerator and denominator for defining outcome from IVF are the term singleton birth rate per started IVF treatment (or per given period). Widespread adoption of this definition would be an important step towards achieving these goals.
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References |
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Submitted on April 28, 2004; accepted on May 20, 2004.