1. Agenda
• Looking at Success of IVF/ICSI treatment
• Success according to who??
• Changes in approach
– Patient selection
– Stimulation
– Laboratory
– Embryo transfer
– Follow up
• Conclusions

2. Assessment of success
Out of every 100
couples starting
IVF...
..only 50 will
achieve an
ongoing
pregnancy within
a 1-year
treatment
period…
Lintsen, HR 2007
Forgot drop outs
Included non ART Pregn
Produced many triplets

3. Risk of ovarian hyperstimulation syndrome (OHSS)
• Characterized by a sudden increase in vascular
permeability and accumulation of fluid in the abdomen
• Vasoconcentration with risk of venous and arterial
thrombosis
• OHSS is potentially fatal, but can be avoided by cautious
use of gonadotropins and careful monitoring of stimulation
regimens
• Prevalence of OHSS in Europe: ~1.2%1
• Estimate of death due to OHSS in stimulated cycles:
1:400,000–1:500,0002,3
1. Andersen et al. Hum Reprod 2008;23:756
2. Brinsden et al. Br J Obstet Gynaecol 1995;102:767
3. Balen 2005 Available at www.hfea.gov.uk. Accessed 23 July 2008

4. The patient’s success
IVF/ICSI can be
• Complex
• Time-consuming
• Expensive
• Stressful
• Associated with risks such as OHSS
Fauser et al. Lancet 2005;365:1807
Macklon et al. Endocr Rev 2006;27:170
What can we do to improve the patient’s
experience?

5. ‘Recognition of increased fetal risk
significantly reduces desire for multiples’
‘Important to involve affected staff,
patients saw no need for a trial
and found randomization unacceptable’
‘Essential to develop a single ET strategy that
does not negatively affect pregnancy rates’
Twisk, FS 2007
HR 2004
HR 2005
FS 2004
HR 2005
The patient’s wish – information,
information, information...

6. Singleton
Twins
Tri-Quadruplets
$ 9,845
$ 37,947
$109,765
Costs…can be reduced
IVF and obstetrical cost per
pregnancy
2%
35%
77%
Proportion associated with
ART
Callahan, N Engl J Med 1994

8. In vitro fertilization − the true balance
Substitute outcome parameters
Oocyte number
Follicle number
Embryo number
Implantation rate
Pregnancy rate/cyle
risks / complications
patient discomfort
costs
Healthy term live birth
per treatment period
Heijnen, HR 04

9. No difference in clinical pregnancy rates

10. Cumulative effects of adding frozen−thaw
cycles to SET OR series of cycles SET or DET
Pregnancy rates
similar
Reduction of
multiples
Need for more
cycles fresh or cryo