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• W2023658912 abstract "As president of the Society for Assisted Reproductive Technology (SART), I initiated the first clinic-specific reporting of success rates, responding to federal legislation requiring that patients have access to actual reported outcomes to aid their choice of provider. In vitro fertilization (IVF) programs promptly realized that their patient volume would be influenced by their success rates relative to their competitors. Initially, low implantation rates required transfer of multiple embryos to achieve a reasonable rate of success. However, as laboratory and clinical techniques improved, a high rate of multiple pregnancies rapidly became IVF's most serious complication. Besides patients' perceptions that multiples are a positive outcome and because most often the costs of multiples are borne by medical insurance whereas the costs of IVF treatment are shouldered by the infertile couple, competition among programs has been a major obstacle to reducing the number of embryos transferred. When the first national results were reported, seven clinical pregnancies had resulted from frozen embryo transfer (FET). In 2011 the number of births following FET approached 10,000, and birth rates were only modestly lower than with fresh transfer, despite most embryos having been slow-frozen and remaining after the best were transferred fresh. In a randomized study where all embryos were frozen, pregnancy success was found to be greater with delayed transfer, even with a slow freezing protocol (1Shapiro B.S. Daneshmand S.T. Garner F.C. Aguirre M. Hudson C. Thomas S. Evidence of impaired endometrial receptivity after ovarian stimulation for in vitro fertilization: a prospective randomized trial comparing fresh and frozen-thawed embryo transfer in normal responders.Fertil Steril. 2011; 96: 344-348Abstract Full Text Full Text PDF PubMed Scopus (508) Google Scholar). In meta-analyses comparing fresh and frozen transfers, pregnancy complications (the most prominent being preterm delivery, preeclampsia, and low birth weight) were significantly less frequent with FET (2Maheshwari A. Pandey S. Shetty A. Hamilton M. Bhattacharva S. Obstetric and perinatal outcomes in singleton pregnancies resulting in the transfer of frozen thawed versus fresh embryos generated through in vitro fertilization treatment: a systematic review and meta-analysis.Fertil Steril. 2012; 98: 368-377Abstract Full Text Full Text PDF PubMed Scopus (374) Google Scholar). Most recently, the application to embryo cryopreservation of vitrification, which has minimal impact on embryos, is rapidly leading to a freeze-all approach for a substantial proportion of IVF cycles. The advent of embryo vitrification has also led to innovative approaches for poor responders (3Cabo A. Garrido N. Crespo J. Remohi J. Pellicer A. Accumulation of oocytes: a new strategy for managing low-responder patients.Reprod Biomed Online. 2012; 24: 424-432Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar), which may also apply to patients with poor embryo quality. Inability to cope with repeated failures has a profound effect on ultimate success and is magnified in such patients. High doses of gonadotropins in nonhuman models reduce oocyte quality. With the use of a moderate level of stimulation and accumulating oocytes using vitrification, the authors achieved higher cumulative success by avoiding a high dropout rate in the control group (3Cabo A. Garrido N. Crespo J. Remohi J. Pellicer A. Accumulation of oocytes: a new strategy for managing low-responder patients.Reprod Biomed Online. 2012; 24: 424-432Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar). A further sea change in IVF today is the advent of preimplantation genetic screening (PGS) with comprehensive chromosome screening (CCS), allowing good responders over age 35 years to have single-embryo transfer (SET) with a high rate of success (4Schoolcraft W.B. Comprehensive chromosome screening of trophectoderm provides eSET for infertile women with advanced maternal age.Fertil Steril. 2013; 100: 615-619Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar). Because of the more favorable outcomes with delayed transfer, this technique is resulting in a major shift of good-prognosis patients away from fresh embryo transfer (ET). A new registry structure should align the incentives of the IVF program with not only pregnancy success, but also improved maternal and perinatal outcomes. It should promote a responsible approach to utilization of medical resources by reducing the high costs of multiple pregnancies. It should not stifle new approaches aimed at providing improved care through CCS in good-prognosis patients and reduced stimulation and accumulation of better-quality embryos for poor-prognosis couples. I propose that results of fresh and frozen ET should be combined, yielding rates of clinical pregnancy and delivery per ET. That should remove all considerations regarding the decision to perform fresh transfer or freeze all, except for what is ideal for the patient, her pregnancy, and her offspring. I also propose increasing the emphasis on implantation rate (as well as delivery rate) per ET. The capability of each individual embryo to result in a viable delivery is the single best index of program quality, including all aspects of patient preparation, ovarian stimulation, oocyte retrieval, laboratory procedures (including CCS), ET, and provision of a receptive endometrium. Those results should occupy the top two lines of the clinic-specific report, thereby emphasizing that there are no better indices through which individual programs can be compared. This would have the further advantage of promoting the transfer of fewer embryos, because even transfer of a second embryo of lesser quality would reduce those numbers. The temptation to transfer a further low-quality embryo, which has been associated with more perinatal complications, would also be discouraged. It would promote the use of CCS, which increases those rates by selecting chromosomally normal embryos, but also reduces miscarriage to low levels, avoiding the profound discouragement, emotional toll, cost, and time lost from a couple's attempts at conception. It would also encourage milder and therefore more patient-friendly stimulation regimens, allowing selection of the most favorable cohort of follicles. It would promote adoption of other embryo selection techniques, avoiding some futile transfers. Combining fresh and frozen transfer results and highlighting results per ET would also mitigate effects of conscious or unconscious manipulation of fresh transfer results by shifting poorer-prognosis patients to FET reporting through embryo banking (5Kushnir VA, Vidali A, Barad DH, Gleicher N. The status of public reporting of clinical outcomes in assisted reproductive technology. Fertil Steril. 2013 June 8. doi: 10.1016/j.fertnstert.2013.05.012.Google Scholar). If the first four lines would be clinical pregnancy rate per embryo transferred, delivery rate per embryo transferred, clinical pregnancy rate per ET, and delivery rate per ET. What other information would be important for couples to have? Cancellation rate from cycle initiation to oocyte retrieval and from oocyte retrieval to creation of an embryo gives information regarding the efficiency of stimulation regimen planning and execution and of oocyte insemination. The proportion of pregnancies that result in twin and triplet deliveries must also be included. Tremendous progress has been made over the more than two decades since clinic-specific results were first reported. Competition among IVF programs for the best results has contributed to that progress. Thanks to strong leadership by SART and the American Society for Reproductive Medicine (ASRM) and their guidelines regarding the maximum number of embryos that should be transferred, triplet births reported to SART decreased from over 4% to just over 1% over the years 2000 through 2011. Unfortunately, patient desires and competition have stymied attempts to make further progress and to substantially increase the number of SETs. Herein I have suggested changes in the structure of clinic-specific reporting that would not only recognize the realities of recent advances, but would align incentives for IVF programs toward achieving ideal outcomes for the couple, for the resulting pregnancy, for the offspring, and for utilization of health care resources. I hope to broaden the discussion so that reporting provides a more valid comparison among programs while also helping to achieve these broader goals. Consumer-friendly reporting of in vitro fertilization outcomesFertility and SterilityVol. 101Issue 1PreviewDr. David Meldrum proposes a revision of the clinic-specific Society for Assisted Reproductive Technology (SART)/Centers for Disease Control and Prevention (CDC) reporting format to better reflect the current practice of in vitro fertilization (IVF) by combining the outcomes of fresh and frozen embryo transfers in the numerator and making transfer procedure the denominator of choice (1). I concur with the first but disagree with the second part of his proposal, making transfer the preferred denominator without regard to the number of retrievals contributing embryos to the transfer. Full-Text PDF Defining assisted reproductive technology successFertility and SterilityVol. 100Issue 4PreviewWe are very pleased to note Dr. Meldrum's Conceptions piece (1), following our recent report (2), reaffirming our main conclusion that the current in vitro fertilization (IVF) outcome reporting system requires a major overhaul. Dr. Meldrum, furthermore, emphasizes other points raised in our article, including the need for ART reports to incorporate maternal and perinatal outcomes rather than just pregnancy rates in defining assisted reproductive technology (ART) success, to better align reports with patient interests (3). Full-Text PDF" @default.
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