section name header

Evidence summaries

Efficacy of in Vitro Fertilization and Embryo Transfer

In vitro fertilisation (IVF) and ovarian stimulation with intrauterine insemination appear to increase live birth rates in couples with poor prognosis compared with expectant management. Level of evidence: "B"

A Cochrane review [Abstract] 1 included 9 studies involving a total of 2191 subjects. Live-birth rates (LBR) per woman was higher with in vitro fertilisation (IVF) (45.8%) than expectant management (3.7%) (OR 22.00; 95% CI 2.56 to 189.37; 1 RCT, n=51). In studies comparing IVF versus ovarian stimulation plus intrauterine insemination (OS-IUI), LBR per woman did not differ significantly between the groups. Assuming 42% LBR with IUI + gonadotropins (1 IVF to 2 to 3 IUI cycles) and 26% LBR with IUI + gonadotropins (1 IVF to 1 IUI cycle), LBR would be 39% to 54% and 24% to 51% with IVF. There was no evidence of a significant difference in multiple pregnancy rate or ovarian hyperstimulation syndrome between the two treatments.

Another Cochrane review [Abstract] and a network meta-analysis 2 included 27 RCTs with 4 349 couples. Ten RCTs including 2 725 couples reported on live birth. For differences between OS, IUI, OS-IUI, or vitro fertilisation with or without intracytoplasmic (IVF/ICSI) versus expectant management see table (table T1). This suggests that if the chance of live birth following expectant management is assumed to be 17%, the chance following OS, IUI, OS-IUI, and IVF would be 9% to 28%, 11% to 33%, 15% to 37%, and 14% to 47%, respectively. When only including couples with poor prognosis of natural conception (3 trials, 725 couples) OS-IUI and IVF/ICSI increased LBR compared to expectant management (OR 4.48, 95% CI 2.00 to 10.1; moderate-certainty evidence; OR 4.99, 95 CI 2.07 to 12.04; moderate-certainty evidence), while there was insufficient evidence of a difference between IVF/ICSI and OS-IUI (OR 1.11, 95% CI 0.78 to 1.60; low-certainty evidence). Compared to expectant management, other treatments increased the odds of multiple pregnancy (11 RCTs, 2564 couples).

Expectant management vs other interventions for infertility

Outcome: Live birth rate or ongoing pregnancyAssumed riskwith comparatorExpectant managementRisk with interventionRelative effect(95% CI)Numbe of couples (Studies)Quality of evidence
166 per 1000OS 167 per 1000(92 to 282)OR 1.01(0.51 to 1.98)527 (2)Low
166 per 1000IUI 194 per 1000(108 to 325)OR 1.45(0.61 to 2.43)386 (1) Low
166 per 1000OS-IUI 242 per 1000(149 to 369)OR 1.61(0.88 to 2.94)454 (2) Low
166 per 1000IVF/ICSI272 per 1000(139 to 465)OR 1.88(0.81 to 4.38)only indirect evidence used hereLow

Comment: The certainty of the evidence is downgraded by risk of bias (no blinding).

    References

    • Sunkara SK, Kamath MS, Pandian Z et al. In vitro fertilisation for unexplained subfertility. Cochrane Database Syst Rev 2023;9(9):CD003357.[PubMed]
    • Wang R, Danhof NA, Tjon-Kon-Fat RI et al. Interventions for unexplained infertility: a systematic review and network meta-analysis. Cochrane Database Syst Rev 2023;(9):CD012692.[PubMed]

Primary/Secondary Keywords