The burden of infertility in New Zealand: A baseline survey of prevalence and service use.

BACKGROUND: Studies in southern New Zealand indicate that up to a quarter of women experienced infertility, likely due to delay in childbearing. However, these findings may not be generalisable to the whole population. AIMS: To assess the lifetime prevalence of infertility and evidence for disparities for New Zealand men and women in a nationally representative sample. MATERIALS AND METHODS: In 2014/15 a general health survey with a module on sexual and reproductive health was conducted among New Zealand residents aged 16-74 years; 3792 men and 5222 women provided information on infertility. RESULT(S): There were 8.2% (95% CI 7.1-9.4%) of men and 12.5% (11.3-13.8%) of women who had experienced infertility; among fertility-tested women this was 15.4% (14.0-16.9%). Prevalence peaked in the 35-44 year age group (14.3% for men, 19.1% for women and 20.8% for fertility-tested women). Estimates for European, Maori and Asian ethnicities were similar. Pacific men and women had higher relative risks: 2.37 (95% CI 1.51-3.71) and 1.76 (1.27-2.44), respectively, compared with Europeans. Medical help was sought by 69.3% (95% CI 62.4-75.5%) of infertile men and 68.2% (63.1-72.9%) of women; this was significantly lower for Maori and Pacific. CONCLUSIONS: Infertility levels for those of European ethnicity were similar to studies in southern New Zealand, and in other high-income countries. However, infertility levels were just as high for Maori, and higher for Pacific people, despite experiencing fertility at younger ages. Focusing on reducing causes of infertility other than delayed childbearing would likely contribute to addressing this health disparity.

Ovulation monitoring and fertility knowledge: Their relationship to fertility experience in a cross-sectional study.

BACKGROUND: Various aspects of fertility knowledge, including the timing of the fertile window, have consistently been found to be poor. Limited evidence also suggests ovulation monitoring to time intercourse could be common. However, there have been no studies that compare these two aspects of fertility and women's fertility/infertility experiences. AIM: To examine the frequency of ovulation monitoring and its relationship with fertility knowledge and experience. METHOD: A cross-sectional study of women aged 25-50 years resident in southern New Zealand was undertaken in 2011. Randomly selected women were asked to complete a fertility questionnaire. Outcome prevalence measures were calculated with 95% confidence intervals (CI) and associations investigated using χ2 tests and Poisson regression. RESULTS: Ovulation monitoring was common, having ever been undertaken by 31.4% (95% CI: 28.5-34.3%) of the 1034 participants. However, knowledge was poor, particularly regarding the fertile window. More women who had ever monitored ovulation correctly identified the fertile window, although the proportion was still very low (18.4 vs 13.1% in those who had not, P = 0.027). Regression modelling showed ovulation monitoring was independently associated with seeking medical help to conceive, education and fertility experience, but not with knowledge. CONCLUSION: This study confirms ovulation monitoring was commonly undertaken. However, many women, including those who had monitored their ovulation, had poor fertility knowledge and failed to identify the fertile window. Poor fertility knowledge needs to be addressed, especially among women intending to conceive.

Infertility and outcomes for infertile women in Otago and Southland.

AIM: To establish the burden of infertility in women residing in Otago and Southland. METHODS: A survey of women aged 25-50 years residing in Otago and Southland was conducted to determine the proportions that experienced infertility, sought medical help and resolved their infertility, and to assess the determinants of these outcomes. RESULTS: Of the 1,125 participants, 21.7% (95% CI 19.1-24.4%) had experienced infertility, defined as ever having tried unsuccessfully to conceive for at least 12 months, increasing to 25.3% (22.6-28.1%) when seeking medical help was included in this measure. Seeking medical help to conceive among those having difficulties was very common and most women resolved their first episode of infertility with a live birth. Infertility was more common with extremes of body mass index, higher education and not being in a heterosexual relationship. Infertility resolution was less likely for those over 35 years at onset of infertility and with increasing social deprivation. DISCUSSION: Infertility was common in women residing in Otago and Southland. Despite high levels of infertility resolution overall, those with higher deprivation appeared disadvantaged. Further research is needed to provide national estimates and investigate factors influencing infertility outcomes.

Development of clinical priority access criteria for assisted reproduction and its evaluation on 1386 infertile couples in New Zealand.

BACKGROUND: In New Zealand ranking patients for elective, publicly funded procedures uses clinical priority access criteria (CPAC). A CPAC to prioritize patients seeking assisted reproductive technology (ART) was developed in 1997 and implemented nationwide in 2000. This study describes the development of the ART CPAC tool and its evaluation on 1386 couples referred to a single tertiary service from 1998 to 2005. METHODS: A total of 48 health professionals and consumers assisted in criteria development. A score between 0 and 100 points was calculated for each couple and those who reached ≥65 points were eligible for publicly funded ART. Couples beneath the treatment threshold were placed on active review; the review being the date the score was calculated to reach the treatment threshold. Couples who would never be eligible or who were on active review were offered private treatment. Treatments and outcomes (spontaneous and treatment dependent live birth pregnancies) were used to evaluate the criteria. RESULTS: Three social criteria (duration infertility, number of children and sterilization status) and two objective criteria (diagnosis and female age) formed the priority score. Of the evaluated couples, 643 (46%) were eligible within 1 year of referral (Group 1), 451 (33%) >1-5 years from referral (Group 2) and 292 (21%) couples were never eligible (Group 3). The predominant ART was IVF. A total of 480 couples had at least one IVF treatment with 404 (84%) having publicly funded treatment. A total of 762 (55%) women gave birth, 473 from treatment and 289 spontaneously. Group 1 had more pregnancies from treatment while Group 2 had most pregnancies overall being mainly from spontaneous pregnancies. Compared with Group 3 cases the hazard ratio using time to spontaneous live birth pregnancy for Group 1 couples was significantly lower, 0.51 (95% confidence interval 0.36-0.74) and for Group 2 cases significantly higher, 1.86, (1.35-2.58). Treatments using ART were evaluated for the three eligibility groups, with the never eligible divided into women age <40 (Group 3a) and woman age ≥40 at referral (Group 3b). Compared with Group 1 cases the hazard ratio to treatment dependent live birth pregnancy was similar for Groups 2 and 3a but significantly lower for Group 3b (0.37, 0.14-0.90). CONCLUSIONS: The clinical priority access score was able to discriminate between the chance of pregnancy with and without treatment and those offered and not offered treatment. The CPAC is a useful model for informing the allocation of public funding for ART in other countries.

Sample-size calculations for trials that inform individual treatment decisions: a 'true-choice' approach.

BACKGROUND: Sample size decisions for clinical trials should be taken in such a way as to maximize informed choice by reducing scientific uncertainty about the consequences of an intervention. PURPOSE: Recent approaches to trial design have focused on the potential decision impact of the trial when deciding whether the trial should be undertaken, and how large it ought to be. For the most part these approaches are concerned with the impact of trials either on clinical opinion or on collective reimbursement recommendations. Our purpose is to model the contribution of clinical trials to patient-level decision-making and to propose a way of assessing this contribution at the design stage. METHODS: The model is developed within the framework of Bayesian decision theory. It is presumed that some patients make choices that they would not have made in the presence of perfect information about the likely consequences. These 'false' choices would be reversed in response to a fully informative (ie, very large) trial of the competing interventions. By contrast, choices that would not change in response to a fully informative trial are termed 'true' choices since they accurately reflect patient preferences. RESULTS: An impact plot is proposed which maps how the expected numbers of 'true' and 'false' choices change in response to a trial of any given size. The approach is illustrated with reference to the choice of delivery mode for term breech presentation, using data obtained before the recent term breech trial. Applications in other contexts are indicated. LIMITATIONS: No account is taken of the magnitude of expressed patient preferences for one treatment over another. The upside is that the need for detailed utility-elicitation is obviated. CONCLUSIONS: The approach is a pragmatic aid to trial design in settings where patient preference drives the choice between alternative treatments.

Survey of Australasian clinicians' prior beliefs concerning lipiodol flushing as a treatment for infertility: a Bayesian study.

OBJECTIVE: To evaluate clinicians' beliefs concerning the effectiveness of lipiodol flushing as a treatment for unexplained infertility, and to integrate these prior beliefs with evidence from randomised trials. DESIGN: Survey. SETTING: Specialists in Australasian in vitro fertilisation (IVF) clinics in 2001. METHODS: One of two types of structured survey was used to gather information from fertility specialists in Australasian IVF clinics. Prior beliefs were captured graphically and textually from responses. RESULTS: Nineteen specialists returned questionnaires. Eighteen of the 19 specialists believed that lipiodol flushing was more likely to be beneficial than harmful. The most widely held prior belief, reflected in both textual and numerical responses, was that lipiodol was likely to produce a small beneficial response. The credible limits of this belief were compatible with a reasonable fertility benefit, as more than 50% believed that a 1.5-fold increase in pregnancy rate was plausible. The two surveys found that a 1.2-fold or 1.4-fold increase in pregnancy rate was the median expected level of benefit at which clinicians would have been inclined to recommend lipiodol flushing to their patients (combined range 1.1- to 2.3-fold) - new evidence suggests that for women with endometriosis but otherwise unexplained infertility, these levels of benefit are exceeded. CONCLUSIONS: Among Australasian fertility specialists there is variation in prior beliefs concerning the effectiveness of lipiodol flushing as a treatment for unexplained infertility and in the expected level of benefit at which clinicians are inclined to recommend this treatment. Generalisability of these beliefs remains uncertain owing to a low study response rate.