COMMENTARY

Assisted Reproductive Technology: The European Experience

Peter Kovacs, MD, PhD

Disclosures

March 13, 2018

Advances in the Management of Infertility

The first successful in vitro fertilization (IVF) treatment was performed in 1978.[1] Since then, it is estimated that more than 5 million newborns were conceived in vitro.[2,3] The primary indication for IVF was tubal infertility. The indications for IVF have since expanded beyond classic infertility problems (tubal, male factor, unexplained infertility, endometriosis), and IVF is now performed for genetic causes, to preserve fertility in oncology patients, or for elective purposes to maintain fertility.

Wider availability of assisted reproductive technology (ART) means that a small proportion of births in the developed world are conceived in vitro. Over the years, the regulations have changed to allow some procedures (eg, gamete donation, surrogacy) or ban others (eg, gender selection). Insurance coverage enabled many couples to participate in treatments that they otherwise could not afford, and made it possible to apply stricter regulations (eg, regarding the number of embryos transferred).

From time to time, it is important to assess how many and what type of cycles are performed to get a clear picture on the need for ART, and to understand its impact on national birth data. Clinicians, policymakers, and all those who influence insurance coverage could benefit from accessing accurate statistics.

European ART Statistics

For a recent study by Calhaz-Jorge and colleagues,[4] data were contributed by 38 of 51 European countries (85.4% of clinics). In total, 686,271 cycles (474.666 of which were fresh) were reported. The proportion of children conceived through IVF ranged from 0.7% to 6.2% of all births.

The pregnancy rate per retrieval was 29.6% for IVF and 27.8% for intracytoplasmic sperm injection (ICSI). The pregnancy rate in frozen embryo transfer cycles was 27% per thawing. The mean pregnancy rate in oocyte donation cycles was 49.8% per embryo transfer. In all, 31.4% of the cycles involved the transfer of a single embryo only, whereas in 56.3% of the cycles, two embryos were replaced and in 12.5% of the cycles, three or four embryos were transferred. There were significant differences in the number of embryos transferred among the countries, and 18% of the fresh IVF/ICSI cycles resulted in multifetal deliveries. Slightly more than 10,000 preimplantation genetic diagnosis/screening cycles were performed in 2013 and were associated with a 38.1% pregnancy rate per transfer.

Viewpoint

This report is the latest assessment of European IVF activity. The number of countries and clinics that report data varies annually, but the number of cycles performed increase each year. This may be due to wider availability of care, greater demand for IVF, and wider acceptance of ART in general.

The number of IVF cycles performed per 1 million population varies from as few as 235 to 2703. It is estimated that 1500 per 1 million population would meet the need in Europe.[5] The current average is 1.175 per 1 million population, so there is room for improvement.

Pregnancy rates have increased slightly every year despite the transfer of fewer embryos. In 87.7% of the cycles, one or two embryos were transferred and the multiple pregnancy rate was lower than in earlier years. The increased proportion of single or double embryo transfers is the result of stricter transfer policies, better tools for embryo selection, and improvements in cryopreservation technology. An increase in the number of cycles with elective single embryo transfer could further cut the number of multiple pregnancies, improve perinatal outcomes, and reduce costs related to these pregnancies.[6]

The increasing mean age of patients is a cause for concern. It is well established and shown in this analysis that pregnancy rates decline with age. If the current trends do not change, there will be an even greater need for oocyte donation and the regulations will need to change to accommodate this need.

Overall, a continued increase in the number of cycles performed, a slight improvement in pregnancy rates, and a decline in the number of multiple embryo transfers can be seen in Europe.

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