Fertility Treatment, Use of in Vitro Fertilization, and Time to Live Birth Based on Initial Provider Type

Boltz MW, Sanders JN, Simonsen SE, Stanford JB

doi:10.3122/jabfm.2017.02.160184

Journal of the American Board of Family Medicine : JABFM, 30(2), 230-238, 2017

Fertility Treatment, Use of in Vitro Fertilization, and Time to Live Birth Based on Initial Provider Type

Jessica N Sanders , S E Simonsen , Joseph B Stanford

Author affiliations (2)

University of Utah ROR
University of Arizona ROR

DOI10.3122/jabfm.2017.02.160184 PMID28379830

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RRM Academy Synopsis

Starting Infertility Care With a Family Doctor Meant Less IVF

This retrospective cohort followed 867 Utah women with infertility. 84% saw a family doctor or OB-GYN first, 8% an IVF doctor. Starting with a family doctor meant about half as much IVF. About half of each group was pregnant within five years.

Key Findings

Of the 867 women, 732 (84%) saw a generalist provider first and 67 (8%) saw an IVF doctor first. Another 68 (8%) saw no provider about their fertility.
Women who started with a family doctor or OB-GYN were less likely to go through IVF. The adjusted odds ratio was 0.48 (95% CI, 0.28 to 0.82).
51.2% of women who started with a generalist got pregnant within the first 5 years of trying. For those who started with an IVF doctor it was 50.7%.
Among the 553 women who had a live birth, median time to that pregnancy was 35 months in the generalist group. It was 31 months in the IVF doctor group.
Live birth did not differ significantly by which provider a woman saw first.

Clinical Implications

The first door a couple walks through shapes what happens next. Eight in ten of these women brought the problem to a family doctor or OB-GYN, and those women ended up in IVF far less often. Their chance of a baby, and the months it took, looked much the same. The authors call this an association. The paper also names what IVF carries with it in the children: higher reported rates of birth defects, low birth weight, and preterm birth. This study asked only about the woman's care.

Study Notes

A retrospective cohort within the Fertility Experiences Study, run from April 2010 to September 2012. Researchers enrolled 867 Utah women with primary infertility. Half came from state records. Half came from the two clinics offering IVF in Utah then. Provider type was self-reported, so an OB-GYN with a fertility focus could be counted as an IVF doctor (a reproductive endocrinologist). 76% identified as Latter-Day Saint.

RRM Context

This study measured where couples start, not what a full workup would have found. It still matters. Most couples are already sitting in a generalist's office when the trouble begins, and that visit decides a great deal. Restorative reproductive medicine starts from a different question: what is causing this? Ovulation problems, thyroid and other hormone conditions, endometriosis, and male factor are nameable causes. IVF goes around them and leaves them in place. Unexplained infertility usually means undiagnosed.

Our editorial summary of this paper, not the article's abstract.

Abstract

Purpose

To explore the relationship between the type of clinician (generalist vs subspecialist) initially seen by infertile women, the treatment received, and the time to pregnancy.

Methods

We analyzed mixed-mode questionnaire data from 867 women with primary infertility enrolled into a retrospective cohort through population- and fertility clinic-based sampling. We compared women presenting first to generalist providers with women presenting first to fertility subspecialists, with the main outcomes of receiving in vitro fertilization (IVF), time to pregnancy, and live birth.

Results

The first contact for most (84%) women with infertility was a generalist provider. Only 8% of women sought care first from a fertility subspecialist, and these women were older and had been trying longer to conceive. Women who presented first to a generalist provider were less likely to receive IVF (adjusted odds ratio, 0.48; 95% confidence interval, 0.28-0.82), were equally likely to achieve pregnancy, and had similar times to pregnancy (adjusted hazard ratio, 1.11; 95% confidence interval, 0.80-1.53) compared with women who presented first to a subspecialist.

Conclusions

Generalist providers are frequently the first point of care for women with difficulty conceiving and are uniquely positioned to promote the balanced management of infertility.

Topics

Infertility

fertility treatment provider type outcomes, generalist vs subspecialist infertility care, IVF utilization primary care referral, time to pregnancy clinician type, infertility treatment pathways, reproductive endocrinologist referral patterns, family medicine fertility care, fertility subspecialist access, infertility treatment disparities provider, initial fertility consultation outcomes

PMID 28379830 28379830 DOI 10.3122/jabfm.2017.02.160184 10.3122/jabfm.2017.02.160184 Boltz et al. 2017, Boltz 2017

Cite this article

Boltz, M. W., Sanders, J. N., Simonsen, S. E., & Stanford, J. B. (2017). Fertility Treatment, Use of in Vitro Fertilization, and Time to Live Birth Based on Initial Provider Type. Journal of the American Board of Family Medicine : JABFM, 30(2), 230-238. https://doi.org/10.3122/jabfm.2017.02.160184

Keywords

Adult, Female, Fertilization in Vitro/statistics & Numerical Data, General Practitioners, Humans, Infertility, Female/therapy, Live Birth, Odds Ratio, Pregnancy, Retrospective Studies, Surveys and Questionnaires, Time-to-Pregnancy, Treatment Outcome, Female; Live Birth; Point-of-Care Systems; Pregnancy; Retrospective Studies; Surveys and Questionnaires; Time-to-Pregnancy, Fertilization; Fertilization in Vitro; Infertility

Endometriosis Infertility Open Access

Endometriosis, Oocyte, and Embryo Quality

Latif S et al., 2023 J Clin Med

Endometriosis is a common finding among women with infertility, and women who are diagnosed with endometriosis are almost twice as likely to experience infertility. Mechanisms by which endometriosis causes infertility remain poorly understood. In this review, we evaluate the current literature on the impact of endometriosis on oocyte and embryo quality. The presence of endometriosis evidently reduces ovarian reserve, oocyte quality, and embryo quality; however, this does not appear to translate to a clear clinical impact. Analysis of data from large assisted reproduction technology registries has shown that women with endometriosis have a lower oocyte yield but no reduction in reproductive outcomes. There is a need for future studies in the form of well-designed randomized controlled trials to further evaluate the role of surgical and medical treatment options in women with endometriosis undergoing assisted conception.

Infertility Reproductive Endocrinology Open Access

Intraovarian Platelet-Rich Plasma Injections: Safety and Thoughts on Efficacy Based on a Single Centre Experience With 469 Women

Fraidakis M et al., 2023 Cureus

Ovarian rejuvenation is an innovative procedure intended to restore ovarian fertility and development during the climacteric and has been used to enhance fertility in women with premature ovarian insufficiency (POI). This retrospective study was conducted to determine the effects of an intraovarian platelet-rich plasma (PRP) injection on ovarian stimulation outcomes in women referred to an in vitro fertilisation centre. This was a retrospective observational study, and the inclusion criteria included women of reproductive age with at least one ovary with a history of infertility, hormonal abnormalities, an absence of a menstrual cycle, and premature ovarian failure. During the patient's first consultation, a detailed reproductive history was recorded, a pelvic scan for ovarian size was conducted, and hormonal analysis for follicle-stimulating hormone (FSH), anti-Müllerian hormone (AMH), estradiol (E2), and luteinizing hormone (LH) was conducted. In the study, 469 women with a history of infertility, hormonal abnormalities, an absence of a menstrual cycle, and premature ovarian failure had hormonal levels recorded up to four months after treatment, and these were included in the study. The volume of peripheral blood required to prepare 6-8 mL of PRP for administration was 40-60 mL. The initial concentration of platelets in the peripheral blood sample was about 25000/µL, whereas the prepared PRP had a concentration of 900.000/µL. A volume of approximately 2-4 mL per ovary, depending on the ovarian volume, was used for the intraovarian injection. PRP intervention had significant effects on FSH concentration at the α = 0.05 level. Statistically significant increases in normal values of FSH and E2were observed for months three and four after the PRP intervention for all age groups. The results of our observational study revealed that a PRP intraovarian injection is associated with improved ovarian tissue and function. Future randomised clinical trials are needed to shed light on the use of PRP in ovarian rejuvenation before offering it routinely in clinical practice.

Fertility Awareness Infertility

A randomized trial of web-based fertility-tracking software and fecundability

Wise LA et al., 2023 Fertil Steril

To assess the effect of randomization to FertilityFriend.com, a mobile computing fertility-tracking app, on fecundability. Parallel non-blinded randomized controlled trial nested within the Pregnancy Study Online (PRESTO), a North American preconception cohort. PATIENT(S): Female participants aged 21 to 45 years attempting conception for ≤6 menstrual cycles at enrolment (2013-2019). Randomization (1:1) of 5532 participants to receive a premium Fertility Friend (FF) subscription. MAIN OUTCOME MEASURE(S): Fecundability (per-cycle probability of conception). Participants completed bimonthly follow-up questionnaires until pregnancy or a censoring event, whichever came first. We first performed an intent-to-treat analysis of the effect of FF randomization on fecundability. In secondary analyses, we used a per-protocol approach that accounted for adherence in each trial arm. In both analyses, we used proportional probabilities regression models to estimate fecundability ratios (FR) and 95% confidence intervals (CI) comparing those randomized vs. not randomized and applied inverse probability weights to account for loss-to-follow-up (intent-to-treat and per-protocol analyses) and adherence (per-protocol analyses only). Using life-table methods, 64% of the 2775 participants randomized to FF and 63% of the 2767 participants not randomized to FF conceived during 12 cycles; these respective percentages were each 70% among those with 0-1 cycles of attempt time at enrolment. Of those randomized to FF, 72% were defined as adherent (68% of observed menstrual cycles). In intent-to-treat analyses, there was no appreciable association overall (FR = 0.97; 95% CI, 0.90-1.04) or within strata of pregnancy attempt time at enrolment, age, education, or other characteristics. In per-protocol analyses, we observed little association overall (FR = 1.06; 95% CI, 0.99-1.14), but weak-to-moderate positive associations among participants who had longer attempt times at enrolment (FR = 1.15; 95% CI, 0.98-1.35 for 3-4 cycles; FR = 1.14; 95% CI, 0.87-1.48 for 5-6 cycles), were aged <25 years (FR = 1.29; 95% CI, 1.01-1.66), had ≤12 years of education (FR = 1.32; 95% CI, 0.92-1.89), or were non-users of hormonal contraception within 3 months before enrolment (FR = 1.10; 95% CI, 1.02-1.19). No appreciable associations were observed in intent-to-treat analyses. In secondary per-protocol analyses that accounted for adherence, randomization to FF was associated with slightly greater fecundability among selected subgroups of participants; however, these results are susceptible to unmeasured confounding.

Pregnancy Infertility Open Access

Validation of a Brief Measure for Complicated Grief Specific to Reproductive Loss

Buskmiller C et al., 2023 Cureus

Objective Complicated grief reactions follow some pregnancy outcomes, like miscarriage, stillbirth, neonatal death, infant death, selective reduction, or termination of pregnancy. Stigma can delay treatment and worsen outcomes. Screening tools such as the Edinburgh Postnatal Depression Scale detect complicated grief poorly, and specific tools for prolonged or complicated grief after a reproductive loss are cumbersome. In this study, a five-item questionnaire to detect complicated grief after reproductive loss of any type was designed and preliminary validated. Methods A questionnaire patterned after the extensively validated Brief Grief Questionnaire (BGQ) was created by a group of physicians and lay advocates to employ non-traumatic but specific language related to grief after miscarriage, stillbirth, neonatal death, infant death, selective reduction, or termination of pregnancy. One hundred and forty women at a large academic center were recruited in person and via social media to validate the questionnaire with well-studied instruments for anxiety (7-item Panic Disorder Severity Scale, PDSS), trauma (22-item Impact of Events Scale), and reproductive grief and depressive symptoms (33-item Perinatal Grief Scale [PGS]). Results The response rate was 74.9%. Of the 140 participants, 18 (12.8%) experienced their loss during high-risk pregnancies, and 65 (46.4%) were recruited via social media. Seventy-one (51%) respondents had a score > 4, a positive screen for the BGQ. On average, women experienced their loss 2 years prior to participation (IQR 1-5 years). Cronbach's alpha was 0.77 (95% CI: 0.69-0.83). The goodness of fit indices of the model met Fornell and Larker criteria (RMSEA = 0.167, CFI = 0.89, SRMR = 0.06). The AVE was 0.42 and the CR 0.78. Conclusions This investigator-created screening tool is internally consistent and meets preliminary criteria for discriminant validity. This tool can be refined prior to testing for sensitivity and specificity in screening for complicated grief after a reproductive loss.

Fertility Treatment, Use of in Vitro Fertilization, and Time to Live Birth Based on Initial Provider Type

Starting Infertility Care With a Family Doctor Meant Less IVF

Key Findings

Clinical Implications

Study Notes

RRM Context

Abstract

Topics

Cite this article

Keywords

Related articles

Endometriosis, Oocyte, and Embryo Quality

Intraovarian Platelet-Rich Plasma Injections: Safety and Thoughts on Efficacy Based on a Single Centre Experience With 469 Women

A randomized trial of web-based fertility-tracking software and fecundability

Validation of a Brief Measure for Complicated Grief Specific to Reproductive Loss