Assisted reproductive technology: an overview of Cochrane Reviews New search for studies and content updated (conclusions changed)

Abstract

Abstract Background

As many as one in six couples will encounter problems with fertility, defined as failure to achieve a clinical pregnancy after regular intercourse for 12 months. Increasingly, couples are turning to assisted reproductive technology (ART) for help with conceiving and ultimately giving birth to a healthy live baby of their own. Fertility treatments are complex, and each ART cycle consists of several steps. If one of these steps is incorrectly applied, the stakes are high as conception may not occur. With this in mind, it is important that each step of the ART cycle is supported by good evidence from well‐designed studies.

Objectives

To summarise the evidence from Cochrane systematic reviews on procedures and treatment options available to couples with subfertility undergoing assisted reproductive technology (ART) procedures.

Methods

Published Cochrane systematic reviews of couples undergoing ART procedures (in vitro fertilisation or intracytoplasmic sperm injection) were eligible for inclusion in the overview. We also identified Cochrane reviews in preparation, for future inclusion.

The primary outcome of the overview was live birth or the composite outcome live birth or ongoing pregnancy, as reported by the included reviews. Our secondary outcomes were clinical pregnancy, multiple pregnancy, miscarriage, and ovarian hyperstimulation syndrome. We excluded studies of intrauterine insemination and ovulation induction.

We undertook selection of systematic reviews, data extraction, and quality assessment in duplicate. We assessed review quality by using the AMSTAR tool. We organised reviews by their relevance to specific stages in the ART cycle. We summarised their findings in the text and reported data for each outcome in 'Additional tables'.

Main results

We included 68 systematic reviews published in the Cochrane Library up to May 2018. All were of high quality. These reviews identified 38 interventions that were effective (n = 23) or promising (n = 15), and they identified 19 interventions that were ineffective (n = 2) or possibly ineffective (n = 17). For 15 interventions, review authors were unable to draw conclusions owing to lack of evidence.

We identified an additional 11 protocols and four titles for future inclusion in this overview.

Authors' conclusions

This overview provides the most up‐to‐date evidence on ART cycles from systematic reviews of randomised controlled trials. Fertility treatments are costly, and the stakes are high. Using the best available evidence to optimise outcomes is best practice. Evidence from this overview could be used to develop clinical practice guidelines and protocols that can be applied in daily clinical practice to improve live birth rates and reduce rates of multiple pregnancy, cycle cancellation, and ovarian hyperstimulation syndrome.

Author(s)

Cindy Farquhar, Jane Marjoribanks

Abstract

Plain language summary

Assisted reproductive technology: an overview of Cochrane Reviews

Review question

What is the evidence on effectiveness and safety of procedures and treatment options available to couples with subfertility undergoing assisted reproductive technology (ART) procedures.

Background

As many as one in six couples encounter problems with fertility, defined as failure to achieve a clinical pregnancy after regular intercourse for 12 months. Increasingly, couples are turning to assisted reproductive technology (ART) for help with conceiving and ultimately giving birth to a healthy live baby of their own. Fertility treatments are complex and costly, and each assisted reproduction cycle consists of several steps. If one of the steps is incorrectly applied, the stakes are high as conception may not occur. With this in mind, it is important that each step involved in ART is supported by good evidence from well‐designed studies. Cochrane reviewers examined the evidence from Cochrane systematic reviews on ART published in the Cochrane Library.

Study characteristics

We included 68 Cochrane systematic reviews on various stages of the ART cycle. All were of high quality. We included in the overview reviews of in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI). We did not include reviews of intrauterine insemination (placing sperm inside a woman's uterus to facilitate fertilisation) or ovulation induction (stimulation of ovulation by medication). This overview provides the most up‐to‐date evidence from randomised controlled trials on ART cycles. The overview is up‐to‐date to May 2018.

Key results

The reviews identified 38 interventions that were effective (n = 23) or promising (n = 15), and they identified 19 interventions that were ineffective (n = 2) or possibly ineffective (n = 17). For 15 interventions, the reviews were unable to draw conclusions owing to lack of evidence. Use of evidence from this overview to guide clinical practice should help to improve live birth rates and reduce rates of multiple pregnancy, cycle cancellation, and ovarian hyperstimulation syndrome.

Quality of the evidence

All included reviews were of high quality. The quality of the evidence for specific comparisons ranged from very low to high.

Author(s)

Cindy Farquhar, Jane Marjoribanks

Reviewer's Conclusions

Authors' conclusions

Implications for practice

This overview provides the most up‐to‐date evidence on ART cycles from systematic reviews of randomised controlled trials. Fertility treatments are costly and the stakes are high. Best practice requires using the best available evidence to optimise outcomes. Evidence from this overview could be used to develop clinical practice guidelines and protocols for use in daily clinical practice, to improve live birth rates, and to reduce rates of multiple pregnancy, cycle cancellation, and ovarian hyperstimulation syndrome.

Implications for research

This overview highlights areas for which evidence is insufficient because of lack of primary research or lack of reporting of important outcomes, and it can be used to generate research questions. The most important outcomes are live birth, cumulative live birth, multiple pregnancy, cycle cancellation, and ovarian hyperstimulation syndrome.

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