Prevalence of Infertility in the US and Overview of In Vitro Fertilization (IVF)

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EP: 1.Prevalence of Infertility in the US and Overview of In Vitro Fertilization (IVF)

EP: 2.Role of GnRH Agonists and Antagonists in Controlled Ovarian Stimulation (COS) in IVF

EP: 3.Using GnRH Agonists and GnRH Antagonists in Clinical Practice

Steven J. Ory, MD: Estimating the prevalence of infertility in any country is a very challenging problem demographically because it depends on the group that’s being studied, and the data vary quite a bit. The best estimates in the United States suggest that 12% to 15% of the reproductive-age population of women have difficulty conceiving at some point in their lives. This number, we believe, has been fairly stable over the past few decades. However, there has been a change in the birth rate. In most other developed countries, there’s been a progressive decline in the birth rate. The United States has continued to see that as well. Much of that relates to pushing the time of initial childbirth to later in life. Women are deferring their choice to have a child, often into their late 30s. The group that’s had the largest increase in firstborn children have been women in their 40s. This demographic trend has been underway for a good 20 years or more.

The first step in an infertility evaluation is seeing the couple, taking the relevant history, and doing some basic infertility tests. That’s going to give some insight into the underlying problem and what options might be most effective for them. This typically includes an assessment of ovulation, often done with a serum progesterone determination; an anatomical assessment of hysterosalpingogram and a saline sonogram; a semen analysis; and of increasing importance, an assessment of the ovarian reserve.

Following those tests, there’s usually a meeting with the couple to interpret the tests. If there’s a specific explanation, uncovered treatment is sometimes directed to that particular problem but often the couple have unexplained infertility. They may also have what we call subfertility, where they don’t meet the definition of infertility: a 12 months of unprotected intercourse without success. The couple may be older and have a shorter interval of time, but from the testing and their age, we might predict that they may have difficulty conceiving or it may take a longer period of time.

The comments I’m going to make at this point, are really going to pertain to in vitro fertilization [IVF], one of the assisted reproductive technologies. Although there are many alternatives short of IVF, it’s increasingly used as a first option. Initially, it was used for couples with tubal factor infertility, but it’s been expanded to many options with the development of intracytoplasmic sperm injection, or ICSI. It became the treatment of choice for male factor infertility and subsequently for endometriosis and unexplained infertility couples that have failed other therapies. As it’s currently practiced, it has a significantly higher success rate than any of the other treatment options. It’s increasingly chosen as a first option for the efficiency and the economy of the treatment.

I mentioned the assessment of the ovarian reserve testing. This is critical as a prelude to IVF. The tests that are commonly used to look at ovarian reserve—the anti-Müllerian hormone, or AMH; the antral follicle count, or AFC; traditionally FSH [follicle-stimulating hormone]; and sometimes estradiol—all have a predictive value less than 70%. Usually in aggregate you can get a sense of where the woman’s ovarian reserved lies. You can determine whether she has an average ovarian reserve or a high ovarian reserve, which might be reflected by high antral follicle count or a high AMH. This is typical of a woman with polycystic ovarian syndrome. She may also have a diminished ovarian reserve. Those particular categories will determine their prognosis for success and also the best treatment modality to choose for them.

Transcript edited for clarity