Action 10: ART Services


Refer for ART Services

10. ART Services: If IVF is accessible, it should be used as indicated. ICSI can be used selectively to treat male factor infertility. Preimplantation genetic diagnosis may be used in selected patients with genetically-based medical conditions. Adopt protocols to avoid ovarian hyperstimulation syndrome (OHSS) and multiple births. The use in ART of donor gametes and embryos and surrogates/gestational carriers can be selectively applied when available, appropriate and consistent with patient and society values and laws. (ASRM and SART, 2012a; ASRM and SART, 2012b; ASRM and SART, 2012c)

In vitro fertilization (IVF)

In vitro fertilization (IVF) is indicated in tubal disease, severe endometriosis and with ICSI, in cases of severe male infertility. The majority of cycles worldwide, however, involve use of IVF or ICSI as an empiric treatment for a wide range of diagnoses either initially or after other treatment has failed. The live birth rates per cycle in most diagnostic groups are similar to those in couples with tubal disease or male infertility. Centers for Disease Control and Prevention. Assisted Reproductive Technology 2012. Accessed March 1, 2015.

Live birth rates average 20% to 30% per started IVF cycle (International Committee for Monitoring Assisted Reproductive Technologies, 2014). In couples with tubal obstruction or severe male infertility, this is a dramatic improvement over the expected rates without treatment, and RCTs are not necessary to demonstrate effectiveness. In other diagnoses, however, even after three years’ duration of infertility there remains a small but real chance of pregnancy without treatment. In a trial of immediate IVF versus a 90 day delay before IVF in 139 infertile couples with fallopian tube patency, the likelihood of delivery was 21-fold higher in the treated group (95% CI 2.8, 155) (Hughes, 2004). The delivery rates were 29% and 1% in the IVF and delay groups, respectively. For every four women, there was one more birth in the IVF group than in the delayed group. In the FASTT management trial, the pregnancy rates averaged 31% in the two IVF groups (Reindollar, 2010).

The methods for IVF and ICSI involve ovarian stimulation (usually while pituitary activity is suppressed to prevent premature ovulation), ultrasound-guided transvaginal oocyte retrieval and fertilization, achieved by surrounding oocytes with prepared sperm (IVF) or by injecting a single sperm into the oocyte cytoplasm (ICSI). Embryos are transferred to the endometrial cavity on the second to sixth day after retrieval, and progesterone or hCG are given to support the luteal phase (ASRM and SREI, 2008).

Adopt protocols to avoid OHSS and multiple births.

The risks of ovarian stimulation include multiple pregnancy and ovarian hyperstimulation syndrome (OHSS) (ASRM 2012b; ASRM, 2008i). Multiple pregnancy, with the attendant risks of preterm birth, should be avoided in all clinical settings, but especially in low-resource settings. Although ovarian stimulation in IVF cycles can be done with lower dosages of drugs and less monitoring than is standard in developed countries, a protocol that achieves good pregnancy rates without multiple birth rates has not yet been found. (Allersma, 2013)

Of course, multiple pregnancy rates would not be increased above normal if only one embryo were transferred in an IVF or ICSI cycle. The average number of embryos transferred in the IVF trials cited above was 2.0 (Hughes, 2004) and 2.3 (Reindollar, 2010). Single-embryo transfer generally results in lower pregnancy rates unless the women and men come from the group with a good prognosis (Min, 2010). Good prognosis usually involves female age less than 37 years and a sufficient ovarian response, fertilization and embryo development, and that at least two high quality embryos are available for transfer. None of the relevant single embryo trials pertain to low-resource countries. Nevertheless, it would be prudent in all low-resource settings to adopt mild ovarian stimulation protocols and elective single-embryo transfer policies in good prognosis patients.

Refer when possible.

When an advanced centre does not provide the services required by a patient, such as IVF/ICSI, donor insemination or tubal surgery, it should be prepared to refer the patient where possible to a centre where the necessary service is available.

Other specialized services such as the use of donor oocytes, donor embryos, surrogates/gestational carriers and unconventional parenting create novel and challenging clinical situations for the infertility specialist. Referral to other centres, including those across borders and jurisdictional boundaries, are extremely complex and often unique. Providers and their teams have to determine for themselves how they can best meet their professional obligations to their patients while remaining true to their own values as well as the values and laws of their society. (ASRM and SART, 2008a)