Fertilitet , infertilitet og assisteret reproduktion i et overordnet perspektiv. Anders Nyboe Andersen Professor dr med, Fertilitetsklinikken , Rigshospitalet U- kursus i Infertilitet , Odense 2014. Infertilitet Ikke et nyt problem – men nye behandlinger.
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Anders Nyboe Andersen
Professor dr med, Fertilitetsklinikken, Rigshospitalet
U-kursusiInfertilitet, Odense 2014
In “marriages which had lasted five years or more, and in which the husbands were under 75 years of age, ... one marriage in 6·5 was unproductive".
J Y Simpson
Survey of 495 British Peers, cited in Gibbons (1911)
de store efterkrigsårgangeop
Små fødselsårgange giver små fødselsårgange
”Reproductive health is a state of complete physical, mental and social well-being and not merely the abscence of disease or infirmity, in all matters relating to the reproductive system and to its function and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so”.
United Nations, 1995, p. 40
G. ”Infertility is one of the causes of demographicdecline and it shouldberecognised as a public-healthconcern and as a social problem affectingboth men and women”
26. ”Notes thatinfertility is a medicalconditionrecognised by WHO thatcan have severeeffectssuch as depression; points out thatinfertilitymaybeon the increase …; callson the Member States to ensure the right of couples to guarantee universal access to infertilitytreatment and medicallyassistedprocreation by taking steps with a view to reducing the financial and otherobstacles”
European Parliament. Reporton the demographic future of Europe. (2007/2156(INI)), 30th January 2008
OECD: The Role of Policies, 2005; Report 2007/2156(INI) 2008.
Bongaards JA. A method for estimation of fecundability. Demography 1975; 12, 645-60.
Kvinden har aldrig opnået graviditet trods mindst 12 måneders ubeskyttet sexuelt samliv
Kvinden har tidligere været gravid med har efterfølgende ikke opnået graviditet trods mindst 12 måneders ubeskyttet sexuelt samliv
Sterilitet anvendes ved definitivt ophævet graviditetsmulighed (hysterektomi, bilateralt salpingectomi, azoospermi)
Prævalenser blandt deltagere, der har forsøgt at få mindst et barn
Livstidsprævalensen af infertilitet > 1 år 17-26%
Livstidsprævalensen af infertilitet > 2 år 12-14%
Primær ufrivillig barnløshed (infekunditet) 3-8%
Sek. ufrivillig barnløshed (infekunditet) 4-6%
Andel infertile, der har søgt læge 50-80%
Live births per cycle
Amenorrhea: 10 months
Larsen U et al. Social Biology 2000; 47: 34-50
6,139 IUI-D cycles
1,001 treated women
All during 18 years
Botchan A et al. Hum Reprod 2001; 16: 2298-2304
Adapted from H. Leridon (2004) and
Broekmans et al,
Trends in Endocrinologi & Metabolism, 2007
Oligo-follikulære, lille, USA 2005
AFC = 34
AMH = 51 nmol/l
AFC = 2
AMH < 3 nmol/l
Total fertilitets rate er antallet af levende-fødte børn per kvinde, efter afslutning af hendes reproduktive periode (typisk udgangen af 49 år).
Total fertility rate er sammensat af biologiske, medicinske og samfundsmæssige forhold.
---------------------------- USA 2005
Total fertility rate
SUM: 4.5% unresolvedinfertility
Oakley et al. Lifetimeoprevalence of infertility and infertilitytreatment in the UK. Hum Reprod. 2008; 23, 447-50.
Federal Institute for Population Research; DIALOG (http://www.bosch-stiftung.de/content/language1/downloads/PPAS_en.pdf). The Demographic Future of Europe – Facts, Figures, Policies. Results of the Population Policy Acceptance Study (PPAS)
Danmarks Statistik Online: www.dst.dk
Age 1 child in Spain USA 2005
From Data Juan-C Velasque (Spanish Institute of statistics www.ine.es)
Diagnosis < 35 > 35
Ovulatory dysfunction 24% 11%
Endometriosis 5% 3%
Tubal factor 18% 25%
Unexplained 21% 27%
Male factor 35% 33%
Maheshwari, Hamilton and Bhattacharya. Hum Reprod, 208; 23,538-42
WHO task force on diagnosis and treatmnent of infertility. Lancet, 1985, sept. 14. 596-8
Analysis of prospective, standardised data from
Secondary infertility (16 – 40%) Africa 52%
Total tubal occlusion (11–20%) Africa 49%
4466 women, 2007. Scotland.
400 (9%) did not wantchildren
3283 (81%) conceivedwithin 12 month
783 (19%) experiencedinfertility (prim, sec, both)
550 (70%) soughtmedicaladvice
320 (58%) conceived
230 (29%) remainedinvolutarilychildless
Comparedwith a similarsurvey in the same geographical
area 20 yearsago, the prevalence of infertilitywaslower
Bhattacharya et al. Hum Reprod, 24, 12, 3096-3107.
Templeton et al. BMJ, 1990,301, 148-152
Data from ESHRE’s EIM consortium
Data from CDC
Expansion of ART Cycles in Japan USA 2005
FER: Frozen & Thawed Embryo Replacement
Danish National ART Registry
TreatmentsPregnancies, % Embryos
2010 15.830 23.0
2009 14.884 24.0
2008 13.316 23.7
2007 11.055 25.4
2006 9.936 26.1
2005 9.541 23.81
2004 9.598 26.7
2003 9.292 26.9
2002 9.650 25.2
2001 8.805 24.5
2000 8.282 24.5 2
1999 7.624 24.9
1998 7.281 24.0
1997 6.768 23.3
1996 4.763 24.5
1995 4.285 23.0 3
1994 3.480 20.6
France, UK, Germany
ESHRE EIM, Data from 2006, Amsterdam July 2009.
ICMART World Report, 2002. Hum Reprod, 2009, 24, 2310
ART cycles in Massachusetts
Wright et al. Surveillance Summaries, 2006, 55, SS-4
ART is increasingly used around the world – but the technology may not be equaly available for all those who need it – the infertile couples?
Denmark: 21 Fertility Clinics USA 2005
9 public, 12 private
Cycles per million inhabitants
The ideal equilibrium:
Patients have access to and use treatments to such an
extend that it will meet their demands.
The question: Would the demands be similar in different countries?
How many cycles per year would it take to meet the demands?
International estimates of infertility prevalence and treatment-seeking:
potential need and demand for infertility medical care
Jacky Boivin1,4, Laura Bunting1, John A. Collins2 and
Karl G. Nygren3 . Hum. Reprod, 2007, 22, 1506
Current prevalence of infertility, 12 month definition (25 surveys)
More developed nations 4 – 17%
Less developed nations 7 – 9 %
Overall mean of 9.0%
Seeking of Medical care (17 surveys)
More developed nations 56 (42 – 76%) Less developed nations 51 (27 – 74%)
Great similarity between countries and regions of the world
Jacky Boivin1,4, Laura Bunting1, John A. Collins2 and Karl G. Nygren3 . Hum. Reprod, June 6th, 2007
Reproductive age group
Number of women aged 20–44 years who are in a marital
or consensual union 122 039 123
Potential need (current prevalence of infertility)
Number of women 20–44 years in marital or consensual union
currently not conceiving in 1 year (while not using a
contraceptive method). Estimate (9%) 10 983 521
Demand for treatment.
Number of infertile couples seeking medical care.
Estimate (56%) 6 150 771
Boivin J et al. Hum Reprod, June 6th, 2007
Our ”target group” is 9% of females in the reproductive age groups (in our part of the world)
The 56% of those couples that seek medical care correspond to 6 million couples annually in the most developed part of the world – and 5-6 times more in the rest of the world.
Collins and Steirteghem. Overall prognosis with current
treatment of infertility. Hum Reprod Update, 2004, 10,309-16.
Average current National use of ART is much
below the optimal (5-8.000 cycles/mio)
needed if all eligible couples should be
given the full benefits of ART.
Consequence: law evasion – cross border reproductive care
Consequence: Socio-economic inequalities
Consequence: Lower use, higher drop-out and loss of pregnancies
Chambers GM et al: Fertil Steril 91:2281-94, 2009 number of cycles?
Their perceptions of the benefits (delivery rates) risks, inconvenience and ”cost” of ART.
bloodtests, oocyte retrieval
Ease of referral
Political criterias for referral
(Who ”qualify for ART”)
ART is considered a simple treatment
Single embryo transfer
NHS ART - a sign of acceptance from society – not just economy
Regulated and monitored by society – this cause trust and confidence in ART
As professionals we need to be active in political decision making as well as among professional colleaques to make ART accessible, affordable and acceptable for those who need it, by:
Thank you for your attention available for all who need it?