Factors influencing Assisted Reproductive Technology [ART] Outcome: possible implications for a private and public sector fertility clinic

Nel, Nicole Ashley (2016-12)

Thesis (MScMedSc)--Stellenbosch University, 2016.

Thesis

ENGLISH ABSTRACT: Infertility treatment, more specifically Assisted Reproductive Technology [ART], is available worldwide, but in many countries and public clinics, this service is not being offered, mostly due to limited resources and funds. Many factors can influence the outcome of ART and insufficient funds can have an effect on ovarian stimulation protocols, assisted reproduction procedures, laboratory procedures and equipment (i.e. CO₂ incubator). Strategies making ART as affordable and accessible as possible is of importance. The objective of the study was to investigate which factors in ART treatment might have the most significant effect on ART outcome in two ART laboratories – one in the public sector and one in the private sector. Two studies, one retrospective and one prospective were conducted. The retrospective study (2013 - 2014) investigated the effect of two different CO₂ incubators (MINC® benchtop incubator and large conventional Forma® incubator) used at a private fertility clinic, on ART outcome. Fertilization, embryo quality and development, and clinical pregnancy rate [CPR] outcomes were compared. A strict exclusion criteria was applied to eliminate other factors that could have an effect on the outcomes and patients were well paired for the study. Three hundred and eighty five (385) cycles were included. No statistical significant difference was observed between the two incubators for embryo quality on culture days 2 and 5. For day 3, the MINC® incubator showed a significant superiority over the Forma® incubator for the proportion of good quality embryos [GQE]/number of ova aspirated (44.58% vs. 39.31%; p < 0.05). There was no statistical significant difference in CPR between the incubators (45.43% vs 47.17%; p =0.81). The prospective study aimed at determining (by means of regression analyses) the possible negative or positive impact of female patient profile (specifically number of oocytes, age, body mass index [BMI], Anti-Mullerian Hormone [AMH] and female diagnosis - tubal factor and endometriosis) in two different ART clinics (public and private fertility clinic) on ART outcome with regard to CPR. Eight hundred and twenty (820) cycles (572 in the private clinic; 248 in the public clinic) were included. Patient profiles in the two clinics were very different. The most common female diagnosis at the private clinic was Advanced Maternal Age compared to Tubal Factor Infertility [TFI] at the public clinic. Patients with a high BMI was also much more prevalent in the public clinic. No statistically significant association, in both clinics (with pooled and separate data), was observed between BMI, AMH, endometriosis or TFI and CPR. The only significant association with CPR in the final regression analysis (pooled data) was the Site (clinic) and the number of metaphase II oocytes available. Data analysis for the two clinics separately,considering all confounding factors investigated, indicated that the number of metaphase II oocytes available was the only factor that showed a significant association with CPR - and only at the private clinic. For the public clinic, none of the factors had a significant association with CPR when all factors were included in the analysis. Various factors contribute to ART outcome, and these factors may differ in public and private clinics as shown in this study. Although the results did not show marked differences in outcome between the incubator types, all outcomes were better in the MINC® and its use should be encouraged. The result of an independent, significant association between number of MII oocytes and CPR is linked to specific ovarian stimulation protocols and potential alternative strategies should be investigated to optimize outcome without increasing costs.

AFRIKAANSE OPSOMMING: Infertiliteit behandeling, meer spesifiek geassisteerde reproduktiewe tegnieke [GRT], word wêreldwyd toegepas, maar in baie ontwikkelende lande en staatsklinieke is hierdie diens nie beskikbaar nie. Die rede daarvoor is hoofsaaklik beperkte bronne en befondsing. Alhoewel daar baie faktore is wat die uitkoms van GRT kan beïnvloed kan ʼn gebrek aan fondse die ovulasie stimulasie protokolle, GRT prosedures en beskikbaarheid van apparaat (bv. CO₂ inkubator) affekteer. Strategieë wat GRT so bekostigbaar en toeganklik as moontlik maak is dus van uiterste belang. Die doel van hierdie studie was om te bepaal watter faktore moontlik ʼn effek kan hê op die uitkoms van GRT behandeling by twee verskillende GRT laboratoriums – een in die staat- en ʼn ander in die privaatsektor. Twee afsonderlike studies, een retrospektief en die ander prospektief, is gedoen. Die retrospektiewe studie (2013 – 2014) het beoog om te bepaal wat die effek van twee verkillende inkubators, (MINC® inkubator “benchtop” en ʼn groot konvensionele Forma® inkubator), op GRT uitkoms by ʼn privaat fertiliteitskliniek is. Bevrugting, embrio kwaliteit en ontwikkeling en die kliniese swangerskap uitkoms [KSU] is vergelyk. Om faktore wat moontlik die uitkoms van die studie kon beïnvloed te elimineer, is ʼn streng uitsluitingskriteria toegepas en paring van pasiënte was dus voldoende. Drie honderd vyf en tagtig (385) siklusse is ingesluit. Geen statisties beduidende verskil ten opsigte van embrio kwaliteit op kultuurdae 2 en 5 is gevind tussen die twee inkubators nie. Die MINC® inkubator het egter beter gevaar as die Forma® inkubator op kultuurdag 3, en statisties betekenisvol meer goeie kwaliteit embrio’s/aantal oösiete geaspireer is gevind (44.58% teen 39.31%; p < 0.05). Daar is ook geen statisties betekenisvolle verskil ten opsigte van kliniese swangerskap uitkoms tussen die twee inkubators waargeneem nie (45.43% teen 47.17%; p = 0.81). Die prospektiewe studie het beoog om te bepaal (d.m.v. ʼn regressie analise) watter faktore van die vroulike pasiëntprofiel (spesifiek die getal oösiete, ouderdom, liggaamsmassa-indeks, Anti- Mullerian hormoon en vroulike diagnose - buisfaktor infertiliteit en endometriose), moontlik ʼn positiewe of negatiewe effek kan hê op die GRT uitkomste, veral kliniese swangerskap [KSU], in twee verskillende fertiliteitsklinieke. Agthonderd en twintig (820) siklusse is ingesluit (572 in die privaatkliniek; 248 in die staatskliniek) in die studie. Die resultate het aangedui dat daar wel ʼn verskil was in die pasiëntprofiele tussen die twee klinieke. Die algemeenste vroulike diagnose in die privaatkliniek was gevorderde moederlike ouderdom en by die staatskliniek, buisfaktor infertiliteit. Die staatskliniek het ook ʼn hoër insidensie van pasiënte met ʼn hoë BMI getoon. Geen statisties beduidende assosiasie, in beide klinieke (met saamgevoegde en aparte data), is waargeneem tussen BMI, AMH , endometriose of buisfaktor infertiliteit en KSU nie. Die enigste statisties beduidende interaksie in die finale regressie model vir die saamgevoegde data met KSU, was die kliniek (“Site”) en die getal metafase II oösiete beskikbaar. Vir die twee klinieke apart, en wanneer al die faktore in ag geneem is, was net aantal metafase II oösiete betekenisvol geassosieer met KSU en ook net vir die privaatkliniek. Vir die staatskliniek het geen faktor wat ondersoek is, ʼn statistiese beduidende assosiasie met KSU getoon nie. Verskeie faktore beïnvloed die uitkomste van ʼn GRT siklus en hierdie faktore mag verskil in die staats- en privaatklinieke, soos bewys deur die studie. Alhoewel resultate nie betekenisvolle verskille in uitkomstes vir die twee inkubators gewys het nie, was alle uitkomstes beter in die MINC® en die gebruik daarvan moet aangemoedig word. Die resultaat van ʼn onafhanklike, beduidende assosiasie tussen die aantal metafase II oösiete en KSU is afhanklik van die spesifieke ovariale stimulasie protokol en potensiële alternatiewe strategieë moet ondersoek word om uitkomstes te optimaliseer sonder om die kostes te vermeerder.

Please refer to this item in SUNScholar by using the following persistent URL: http://hdl.handle.net/10019.1/100207
This item appears in the following collections: