Cohort follow-up of couples with primary infertility in an ART programme using frozen donor semen

Fabrice Guerif1, Florence Fourquet2, Henri Marret1, Marie-Helene Saussereau1, Claire Barthelemy1, Claire Lecomte1, Pierre Lecomte1, Jacques Lansac1 and Dominique Royere1,3

1 CECOS, Biologie de la Reproduction, Département de Gynécologie-Obstétrique et Reproduction Humaine, Centre Hospitalier Universitaire Bretonneau, 37044 Tours, and 2 Service d'Information Médicale et d'Hygiène, Centre Hospitalier Universitaire Bretonneau, 37044 Tours, France


    Abstract
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
BACKGROUND: This study was designed to determine the crude cumulative live-birth rates in a cohort initiating frozen donor semen treatment until completion. METHODS: This cohort study included 588 couples with primary infertility in one University Hospital centre. The treatment sequence involved first artificial insemination (AID) followed by IVF if necessary (IVF-D). Live birth, drop-out for personal or medical reasons and recourse to IVF-D were recorded for all patients. Live births and drop-out were expressed both as rates per cycle and crude cumulative rates. RESULTS: At the completion of AID and IVF-D cycles, 406 couples in the cohort (69%) achieved a live-birth and 182 couples (31%) discontinued treatment. In most cases, couples stopped treatment for personal reasons (74%) whereas fewer couples were denied further treatment for medical reasons (26%). CONCLUSIONS: This is the first report on the crude cumulative live-birth rate in a cohort after AID and IVF-D cycles. Although calculation based on crude cumulative live-birth rate shows lower results in comparison with life table analysis, this method allows patients to obtain an insight into their actual chances of achieving a successful pregnancy.

Key words: artificial insemination/crude cumulative live-birth rate/drop-out/frozen donor semen/IVF


    Introduction
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
The use of donor semen has for a long time been the only way to obtain a successful pregnancy for couples in whom infertility was related to severe male factors. For the past ten years the frequency of artificial insemination with donor sperm (AID) has been considerably reduced as the use of intracytoplasmic sperm injection (ICSI) has become widespread. However AID remains an alternative way of obtaining a successful pregnancy for couples infertile for several reasons, e.g. lack of full spermatogenesis in non-obstructive azoospermia, previous failed ICSI attempts, genetic or viral risk related to male partner, and fear of unknown genetic risks during ICSI procedure. As acquired immunodeficiency syndrome emerged and increased in frequency, use of frozen donor semen which was cryopreserved for at least 6 months was substituted for fresh semen (American Fertility Society, 1988Go). This practice was initiated in France before 1980 by the French Federation CECOS (Centre d'Etude et de Conservation des OElig;ufs et du Sperme). Frozen donor semen may be used for artificial insemination (Trounson et al., 1981Go; Byrd et al., 1990Go; Patton et al., 1992Go; Wainer et al., 1995Go; Botchan et al., 2001Go) or alternatively for IVF with donor sperm (IVF-D) (Mahadevan et al., 1983Go; Cohen et al., 1985Go; Vekemans et al., 1987Go; Morshedi et al., 1990Go; Robinson et al., 1993Go).

On initiating an assisted reproductive technology (ART) programme, patients need precise information on the chances of achieving successful pregnancy. This information is usually based on the ongoing clinical pregnancy or the live-birth rate per started cycle. However, the success rate of a single cycle does not answer the question of how high the cumulative chances of achieving successful pregnancy are after a given number of cycles. Various methods allow expression of cumulative pregnancy rate (CPR): (i) crude CPR without any assumption about patients discontinuing further treatment and (ii) CPR using life-table analysis. In the latter case, it is assumed that discontinuing patients have the same probability of a successful pregnancy as patients proceeding to a further cycle after previous failed treatments (Guzick et al., 1986Go; Haan et al., 1991Go; Roest et al., 1998Go; De Vries et al., 1999Go). However, it should be kept in mind that, from a patient's point of view, the live-birth rate is the most important endpoint. Thus the probability of a live birth after a given number of insemination or IVF cycles remains the key issue that needs to be addressed for infertile couples. Although the use of donor semen is well established and widely used, it may be psychologically stressful for patients (Owens et al., 1993Go). Physicians involved in AID need therefore to counsel their patients by providing them with a realistic prognosis in terms of the duration and outcome of treatment.

To our knowledge, the crude cumulative live-birth rate in a cohort of patients having embarked upon a frozen donor semen programme including AID and IVF-D cycles has not yet been reported. This monocentre cohort study (CECOS, Tours) was therefore designed to assess the crude cumulative live-birth rate in couples with primary infertility on initiating an ART programme with frozen donor semen. All patients were followed until the birth of a live baby or the end of treatment for medical or personal reasons.


    Materials and methods
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Patients
A cohort of 588 consecutive couples with primary infertility due to severe male infertility was referred to CECOS at Tours between January 1991 and December 1997 for frozen donor semen insemination. During this period of 7 years, 3119 AID cycles were performed. Among the 588 couples, 124 couples turned to IVF-D after previously failed AID cycles and undertook 236 IVF-D cycles. The cohort study excluded patients who directly initiated IVF-D for any reason, in order to investigate the benefit of AID prior to IVF-D cycles. During this study, patients were not charged in France for all AID cycles and for four IVF-D cycles. The general procedure for donor recruitment, donor selection and semen cryopreservation has been described elsewhere (Federation CECOS et al., 1989Go).

Reasons for infertility in patients who initiated AID treatment comprized non-obstructive azoospermia (59.6%), severe (<1x106 sperm/ml) or moderate (1–10x106 sperm/ml) oligozoospermia (27.6%), obstructive azoospermia (7.3%), previous failure of ICSI (3.1%) and severe (total sperm motility <5%) asthenozoospermia (2.4%). It should be mentioned that from 1991 until 1997, there was a decrease in the percentage of patients with severe or moderate oligozoospermia or asthenozoospermia with the increasing use of ICSI. Only women who had never conceived before (delivery, abortion or ectopic pregnancy) were included in the cohort. Female infertility factors that could affect the outcome of treatment were detected before the initiation of AID cycles. This involved recording of medical history, current physical examination, basal body temperature charts, serum hormone assessment, transvaginal ultrasonographic examination and evaluation of cervical mucus. Tubal patency was confirmed by hysterosalpingography or laparoscopy. In addition, all couples attended an interview to discuss the psychological aspects of artificial procreation with donor semen prior to being included on the waiting list. The mean age (±) of the women in the cohort was 29.8 ± 3.4 years (range 21–40 years). The duration of infertility of these couples ranged from 1–17 years (5.3 ± 2.7 years).

AID cycles
All AID cycles were performed using intracervical insemination with a cervical cap or cupule, depending on the opening of the cervix. One insemination was performed per cycle with at least 2.0x106 motile sperm per straw. For women with normal ovulatory cycles (46% of women), the appropriate time for insemination was estimated on the basis of basal body temperature charts, transvaginal ultrasonographic evaluation and examination of cervical mucus. The use of ovarian stimulation (54% of women) was indicated either for ovulatory disorder (including luteal defect and cervical mucus anomalies) or for irregular cycles in order to reduce the number of consultations. Ovarian stimulation used clomiphene citrate (Clomid®; Marion Merell SA, Puteaux, France) or HMG (Neopergonal®; Metrodine® Serono Laboratories, Paris, France; Humegon®; Organon Pharmaceuticals, Saint-Denis, France) or recombinant FSH (Follitropine alpha, Gonal F®; Serono Laboratories or Follitropine beta, Puregon®; Organon Pharmaceuticals). Except for cervical anomalies where low doses of gonadotrophins were preferred, antiestrogens were first used, then gonadotrophins, then possibly a combination of antiestrogens and gonadotrophins in severe ovulatory disorders. Monitoring involved serum estradiol assessment and transvaginal ultrasonographic evaluation of follicular growth. The criterion for timing the administration of HCG was the presence of one or two preovulatory follicles. The cancellation rate was 15%, with a similar distribution between multifollicular growth (>=3 preovulatory follicles) and insufficient follicular growth or cervical mucus quality. Intracervical insemination was performed on the day of HCG administration (5000 IU, i.m. Gonadotrophine Chorionique Endo®; Organon Pharmaceuticals). An average of 5.0 ± 3.4 AID cycles per couple was performed (range 1–14) in the cohort studied. After six and again after 12 AID cycles, previously failed AID cycles were assessed in order to decide whether to continue AID cycles, to proceed to IVF-D cycles or to stop all further treatment. Proceeding to IVF-D between the first and the sixth AID cycles was mainly decided when a poor or unsatisfactory response was observed in previous AID cycle(s). Poor response was defined by follicular growth defect despite increasing doses of gonadotrophins. Unsatisfactory response was mainly observed in patients with polycystic ovaries, when it was impossible to hinder multiple ovulations.

IVF-D cycles
The ovarian stimulation protocol in IVF-D cycles involved desensitization with GnRH agonist (0.1 mg triptorelin, Decapeptyl®; Ipsen-Biotech Laboratories, Paris, France; 0.3 mg buserelin, Suprefact®; Hoechst-Aventis Laboratories, Paris, France). Once desensitization was confirmed by serum estradiol assessment (<50 pg/ml) and transvaginal ultrasonography (absence of follicle with a diameter >10 mm), treatment with HMG or recombinant FSH was initiated. Monitoring involved serum estradiol assessment and transvaginal ultrasonographic evaluation of follicular growth. HCG (10 000 IU, i.m.) was administered when at least three follicles reached a mean diameter of 18 mm with adequate estradiol concentrations (>300 pg/ml per mature follicle). Transvaginal oocyte retrieval was performed 34–36 h following HCG injection. Fertilization was checked 16–18 h post-insemination. At day 2, one to three embryos were transferred. All single embryo transfers in this series were compulsory. Two embryos were transferred more often than three embryos depending on the female age, the quality of the embryos and the rank of the IVF-D cycle (e.g. 67 versus 23% during the first cycle, 50 versus 50% during the fourth cycle for two and three embryos, respectively). An average of 1.9 ± 0.9 IVF-D cycles per couple was performed (range 1–4) in the cohort.

Only live births were taken into account. Spontaneous abortions, ectopic pregnancies and pregnancies lost beyond 12 weeks were considered as failed cycles. The end-point of patients' follow-up was either live birth or withdrawal from the programme. Discontinuing patients were divided into two groups: medical or personal reasons. Some patients were denied further treatment for medical reasons involving poor prognosis [poor response to hormonal stimulation and/or age >40 years and/or failure and/or weak (<20%) fertilization rate in IVF-D]. Other patients discontinued further treatment for personal reasons (lost to follow-up, decision to postpone further treatment, move, adoption, divorce, changing to ICSI). Patients were considered as lost to follow-up when they failed to return to follow-up appointments for >12 months. For each couple, live-birth rate, changing to IVF-D and drop-out for medical or personal reasons were recorded. When IVF-D cycles were subsequently performed for some couples, live-birth rate (including results of frozen–thawed embryo transfers) and reasons for drop-out were also recorded.

Statistical methods
The results are given as mean values ± SD and were analysed using Staview 4.1 (Abacus Concepts, Berkeley, USA). ANOVA followed by post hoc comparisons or contingency tables were used, depending on the parameter being evaluated, with P < 0.05 as the threshold of statistical significance.


    Results
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
From 1991 until 1997, 588 couples started their first AID cycle in the CECOS at Tours and had a total of 3119 AID cycles. One hundred and twenty four couples who failed to achieve a live birth in AID cycles underwent a total of 236 IVF-D cycles.

Outcome of AID cycles
The outcome of 3119 AID cycles is shown in Table IGo. The mean live-birth rate per AID cycle in this cohort was 10.9%, with the highest rate during the first AID cycle (14.3%). From the second to the seventh AID cycle, the live-birth rate per cycle was similar (range 10.1–12.1%) and decreased progressively thereafter (from 8.1 to 5.4%). Finally, the crude cumulative live-birth rate reached 49 and 58% after six and twelve or more AID cycles respectively. Among the couples who did not achieve a pregnancy with live birth, 21.1% turned to IVF-D and 20.9% dropped out. Couples stopped further treatment mainly for personal reasons and rarely for medical reasons (83.7 versus 16.3% respectively; P < 0.05). The frequency of couples who dropped out or turned to IVF-D was higher after the sixth and twelfth AID cycles. Beyond six AID cycles, the proportion of couples who stopped any further treatment or turned to IVF-D was similar (11.2 and 12.3% respectively). In contrast, after twelve or more AID cycles, a higher proportion of couples turned to IVF-D cycles compared with couples who dropped out (47.3 versus 21.6% respectively; P < 0.05).


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Table I. Outcome of 3119 AID cycles in a cohort of 588 couples
 
The pregnancy outcome following AID cycles is shown in Table IIGo. After 3119 AID cycles, 341 couples achieved parenthood with the birth of 359 babies. The sex ratio was 1.36 among the 323 singleton births. The rate of multiple deliveries (twins only) was 5.3%. Loss of pregnancy included 37 (9.7%) spontaneous abortions, 2 (0.3%) ectopic pregnancies and three (0.5%) pregnancies terminated following diagnosis of chromosomal or ultrasonographic abnormalities. Among patients obtaining pregnancy without achieving a live birth, 52% of couples did achieve a live birth during later AID cycles, 19% turned to IVF-D (IVF-Dt) and 29% dropped out after failed AID cycles.


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Table II. Pregnancy outcome following AID and IVF-Dt cycles
 
The crude cumulative live-birth rate did not differ between the two main male infertility factors leading couples to choose frozen semen donor insemination (58.6 versus 56.4% for azoospermic and oligozoospermic patients respectively). Similarly, the mean number of AID cycles necessary to achieve a live birth did not differ between azoospermic and oligozoospermic patients (3.5 ± 2.5 versus 3.7 ± 2.5 respectively).

Couples were allocated to four groups, depending on the outcome of AID cycles [live birth (LB), stopping for personal reasons (SPR), stopping for medical reasons (SMR) and IVF-Dt]. The characteristics of these four groups of patients are shown in Table IIIGo. The mean age of women who dropped out for medical reasons (SMR) was significantly higher than for other situations (LB, SPR and IVF-Dt). The duration of infertility was also higher in the SMR group when compared with the LB group.


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Table III. Characteristics of couples in relation to the outcome of AID cycles
 
Outcome of IVF-D cycles following failed AID cycles
Among the 247 couples who did not achieve a live birth after AID cycles, 124 turned to IVF-D (IVF-Dt). The outcome of 236 IVF-Dt cycles following previously failed AID cycles is shown in Table IVGo. In this group of patients, the mean live-birth rate per IVF-Dt cycle was 27.6%. The live-birth rate per cycle was stable for the two first cycles (28–31%) and then decreased progressively to 21 and 14% for the third and fourth cycles, respectively. The crude cumulative live-birth rate after four IVF-Dt cycles reached 52.4%. In those couples who failed to achieve a live birth despite additional IVF-Dt cycles (47.6%), the reasons for drop-out were almost equally distributed between stopping for medical and personal reasons (47.5 versus 52.5% respectively). However, medical reasons were more frequently involved in treatment discontinuation for the two first IVF-D cycles and vice-versa for the two last cycles.


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Table IV. Outcome of 236 IVF-D cycles in 124 couples who failed to conceive during previous AID cycles
 
The outcome of pregnancies after IVF-D cycles is shown in Table IIGo. After 236 IVF-Dt cycles, 65 couples achieved parenthood with the birth of 84 babies. It may be noticed that nine couples among these 65 couples achieved parenthood after transfer of frozen–thawed embryos, which means a 14% increase in live births following this procedure. Among the 48 singleton births, the sex ratio was 1.0. A mean number of 2.2 ± 0.6 embryos were transferred, resulting in 26% multiple pregnancies (15 twins and two triplets). Eight spontaneous abortions (11%) were recorded, but there were no ectopic or terminated pregnancies. In this miscarriage group, 38% of couples were afterwards able to achieve a live birth after the subsequent IVF-Dt cycles and 62% dropped out.

The crude cumulative live birth rate per IVF-Dt cycle did not differ between the two main male infertility factors leading couples to frozen semen donor insemination (57.3 versus 45% for azoospermic and oligozoospermic patients respectively). Similarly, the mean number of IVF-Dt cycles necessary to achieve a live birth was similar in azoospermic and oligozoospermic patients (1.7 ± 0.8 versus 1.5 ± 0.7 respectively).

Couples were allocated to three groups depending on the outcome of IVF-Dt cycles (live birth, stopping for personal reasons and stopping for medical reasons). The characteristics of these groups at the end of IVF-Dt cycles are shown in Table VGo. Mean age of women and duration of infertility were similar in all groups. In contrast, the decision to stop further treatment for personal reasons was taken after a higher number of cycles compared to other groups (P < 0.05). Poor quality oocytes were observed among all couples who stopped further treatment for medical reasons, e.g. 29% couples with fertilization failure, 64% couples with poor fertilization, 7% couples with female age >40 years.


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Table V. Characteristics of couples in relation to the issue of IVF-D cycles
 
Final outcome of the whole cohort
The outcome for 588 couples with primary infertility initiating an ART programme with frozen donor semen, including AID cycles and IVF-D cycles, is summarized in Figure 1Go. Following all AID and IVF-D cycles, 406 couples of the whole cohort studied [69% (CI95: 66.9–72.8)] achieved a live birth whereas 182 couples (31%) stopped further treatment. The majority of the latter couples decided to discontinue treatment for personal reasons (74%) and treatment was discontinued for the other couples for medical reasons (26%). Personal reasons for discontinuing treatment were loss to follow-up (30%), decision to postpone further treatment (29%), move (13%), adoption (12%), divorce (9%) and choice of ICSI (7%). The distribution of personal reasons was similar for patients who dropped out after failed AID cycles and for patients who dropped out after unsuccessful additional IVF-D cycles.



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Figure 1. Overview of the outcome of 588 couples with primary infertility who entered an ART programme with frozen donor semen..

 

    Discussion
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
A cohort study was undertaken in our unit to determine the crude cumulative live birth rate in an ART programme with frozen donor semen (including AID and IVF-D cycles). Primary infertility was diagnosed in all couples included in the cohort when they started AID. The follow-up involved both live births and stopping treatment (for medical or personal reasons). The study included two successive steps. First, all patients initiated AID cycles with different outcomes (live births for 58% of couples, end of treatment for 20.9% of couples and turning to IVF-D for 21.1% of couples) and secondly 52.4% of couples who turned to IVF-D achieved a live birth. Altogether, the majority of couples (69%) completed parenthood with the birth of a live child using one or both treatments. The remaining couples (31%) discontinued treatment, mostly for personal reasons (74%) rather than for medical reasons (26%).

The first part of the study concerned AID cycles. The crude cumulative live-birth rate increased progressively and reached a plateau after the seventh cycle. This is in agreement with a previous study reporting a decrease from a mean of 10.3% per cycle during the first six cycles to 2.3% after 24 cycles (Federation CECOS et al., 1989Go). However the cycle number at which the decline is reported to start remains a matter of debate. Indeed a pregnancy rate of >10% until the 15th cycle was recently reported (Botchan et al., 2001Go). However, it is now commonly accepted that a decreasing probability of achieving pregnancy after a given number of unsuccessful cycles may be due to low female fertility (Hershlag et al., 1991Go).

In order to keep the fertility status of the couples homogeneous, only couples with primary infertility were included in the cohort. The crude cumulative live-birth rate reached 30.6% after three cycles, 49% after six cycles and 58% after >=12 AID cycles in our series, which is similar to a previously reported cumulative conception rate of 19% after three cycles, 33% after six cycles and 54% after 12 cycles for couples in the first course of treatment with cryopreserved donor semen (Shenfield et al., 1993Go). Interestingly, higher cumulative conception rates were reported in the same study for couples having achieved a full pregnancy during an earlier course of treatment (40% after three cycles, 67% after six cycles and 79% after 12 cycles). Similarly, the mean success rate was reported to be lower in women who initiated insemination for a first pregnancy (7.2%) than for a second or third pregnancy (11.2%) (Federation CECOS et al., 1989Go). Other authors also reported a higher probability to conceive in those couples who had already conceived (Tan et al., 1994Go; Croucher et al., 1998Go; Williams and Alderman, 2001Go). In contrast, other authors found that the pregnancy rate per cycle was similar in women with primary versus secondary infertility (Robinson et al., 1993Go). Better results in a first as opposed to a second course of treatment was reported only once (Botchan et al., 2001Go). Two factors have been evoked that may explain these contradictory results. The first is that women previously treated by fresh donor sperm insemination returned later for frozen donor sperm insemination, which is expected to give lower results. Alternatively, increased age might explain lower fertility in women initiating AID for a second pregnancy. Thus, in view of the heterogeneity of couples with respect to female fertility status, we decided to include only patients with primary infertility in our cohort.

Various factors may influence the success rate in AID cycles, e.g. female age, male factor, the quality of the inseminated sperm, the timing of the insemination, ovarian stimulation protocols and insemination technique. In this cohort study, we only evaluated the influence of the male factor that led couples to choose donor insemination on the outcome of AID cycles. Pregnancy rates following AID cycles have been reported earlier to be higher in women with an azoospermic partner when compared with women with an oligozoospermic partner (Emperaire et al., 1982Go; Ecochard et al., 1999Go; Williams and Alderman, 2001Go). The rationale for this is that women with an azoospermic partner more frequently have normal fertility whereas women with an oligozoospermic partner represent a hypofertile subgroup from which the highly fertile women have been eliminated by achieving a spontaneous conception. In contrast, we did not observe any difference between azoospermic and oligozoospermic patients in terms of cumulative live-birth rate per couple, as reported in some other studies (Robinson et al., 1993Go; Shenfield et al., 1993Go). Half of the oligozoospermic patients in our cohort had severe oligozoospermia (<1x106 sperm/ml). Therefore, the heterogeneity of sperm characteristics in oligozoospermic patients may explain in part this discrepancy in the literature.

The second part of the study involved patients who turned to IVF-D after previously failed AID cycles. In our cohort, turning to IVF-D achieved a crude cumulative live-birth rate of 52%. Overall IVF-D allowed the cohort to achieve 65 additional live births after failed AID cycles. The overall percentage of multiple pregnancies was 26%, with the higher value being observed after the first IVF-Dt cycle (38 versus 14%, 14 and 0% after the second, third and fourth cycle respectively). The high frequency of multiple pregnancies after IVF-D is a serious iatrogenic complication that should be prevented to a considerable extent. Elective transfer of a single embryo should be considered, particularly during the first two cycles, whenever at least one good quality embryo is available (Van Royen et al., 1999Go; Vilska et al., 1999Go; Gerris and Van Royen, 2000Go). Finally, the total crude cumulative live birth rate reached 69% in the whole cohort after this 19% increase in live IVF-Dt births. Taken together these results argue for switching to IVF-Dt, after failure at the seventh cycle, since the chance of obtaining a live birth drastically decreases beyond the seventh cycle.

Before starting infertility treatment, patients need to be clearly informed about their chances of a successful pregnancy according to each available ART technique. Among all variables that express the success rate of an ART programme, live birth is undoubtedly the most meaningful. Additionally, a success rate can be expressed per cycle or per couple, taking into account, in the latter case, the results of consecutive cycles (Wilcox et al., 1993Go). The chances of achieving a live birth after a specified number of cycles remains the best information for a couple. Cumulative pregnancy rate may therefore be expressed as the crude cumulative pregnancy rate or calculated according to life-table analysis. The cumulative pregnancy rate after a large number of cycles was reported to be overestimated by the life-table method (Stolwijk et al., 1996Go; Land et al., 1997Go). If the chances of a successful pregnancy are assumed to be the same for patients who dropped out as for patients who continue treatment, the cumulative live-birth rate by life-table analysis considerably exceeds the crude cumulative live birth rate after AID and IVF-D cycles [87.6% (CI95: 84.1–90.5) versus 69% (CI95: 66.9–72.8) respectively]. Additionally, it may be expected that couples who discontinue treatment for personal reasons should have a better chance of achieving a pregnancy than patients who discontinue treatment for medical reasons (Doody, 1993Go; Walters, 1994Go; Stolwijk et al., 1996Go; Land et al., 1997Go). If it is assumed that the chance of a successful pregnancy is the same for patients who drop out for personal reasons as for patients who continue treatment, whereas patients who drop out for medical reasons would have no chance of a successful pregnancy, the whole cohort results remain slightly overestimated compared to crude cumulative live-birth rate [79.9% (CI95: 78.1–81.6) versus 69% (CI95: 66.9–72.8) for corrected and crude cumulative live-birth rates, respectively].

In conclusion, we decided to include only couples with primary infertility and to use live-birth rate and crude cumulative live-birth rate in our cohort study in order to avoid confounding variables, which may hinder interpretation of the results. Thus, although results may appear to be lowered by using such a strategy, it may be assumed that it gives a more realistic assessment of these ART procedures. This study is the first to follow up both AID and IVF-D cycles in the same cohort using live-birth rate as the end-point. At the end of both procedures, 69% couples achieved parenthood, whereas 31% were denied further treatment at various stages of treatment, mainly for personal reasons. Bearing in mind that these results need to be adjusted for each centre, we conclude that, while encouraging medical staff to select the best treatment strategy, such findings may actually help patients to accept or refuse a frozen donor semen programme.


    Notes
 
3 E-mail: royere{at}med.univ-tours.fr Back


    References
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
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Submitted on December 3, 2001; accepted on February 4, 2002.