“Should we be trying expectant management or IVF treatment?”
INTRODUCTION: The clinical indications for IVF, initially started from bilateral tubal blockage and now has extended to unexplained subfertility in which there is no identifiable cause or barrier to conception. There is little evidence from randomized controlled trials that IVF is effective in these couples.Which couples with unexplained subfertility can expect increased chances of ongoing pregnancy with IVF compared to expectant management ?
SUMMARY: Eekelen et al1 recently compared outcomes in couples with unexplained subfertility undergoing IVF (n = 40921) from registry data to couples with the same type of subfertility on expectant management. Those couples on expectant management (only intercourse) comprised a prospective nation wide Dutch cohort (n = 4875) and a retrospective regional cohort from Aberdeen, Scotland (n =975). They excluded couples who had tried for less than 1 year to conceive, cases of anovulation, tubal occlusion, mild or severe endometriosis or male subfertility. Matching of couples who received IVF and couples on expectant management based on their characteristics to control for confounding were done. They fitted a Cox proportional hazards model including patient characteristics, IVF treatment and their interactions to estimate the individualized chance of conception over 1 year, either following IVF or expectant management for all combinations of patient characteristics. The endpoint was conception leading to ongoing pregnancy, defined as a foetus reaching a gestational age of at least 12 weeks. The adjusted 1year chance of conception was 47.9% (95% CI: 45.0–50.9) after IVF and 26.1% (95% CI: 24.2–28.0) after expectant management. The absolute difference in the average adjusted 1 year chances of conception was 21.8% (95%CI: 18.3–25.3) in favour of IVF. The effectiveness of IVF was influenced by female age, duration of subfertility and previous pregnancy. IVF was effective in women under 40 years, but the 1 year chance of an IVF conception declined sharply in women over 34 years. In contrast, in woman over 40 years of age, IVF was less effective, with an absolute difference in chance compared to expectant management of 10% or lower. Regardless of female age, IVF was also less effective in couples with a short period of secondary subfertility (1 year) who had chances of natural conception of 30% or above.
CONCLUSION: For couples in which the woman is under 40 years of age, IVF is associated with higher chances of conception than expectant management in unexplained subfertile couples. IVF should be used selectively based on judgements on gain compared to continuing expectant management for a given couple.
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