ABSTRACT
Since the birth of the first in vitro fertilization (IVF) baby almost 40 years ago, dramatic developments have occurred in IVF. IVF was initially designed to overcome the problem of tubal infertility, but is now widely held to represent the treatment of choice for unexplained infertility, male factor infertility, endometriosis, and ovarian dysfunction resistant to ovulation induction (1,2). The introduction of intracytoplasmic sperm injection (ICSI) has rendered severe forms of male infertility amenable to treatment and further widened the scope of IVF. High-profile publicity given to the latest achievements with IVF has led to its perception as a panacea for all those having difficulty in conceiving a pregnancy. This has been reflected in the rapid expansion of both the indications for IVF and the current annual number of IVF cycles worldwide (3). The degree to which IVF merits this growth in application remains unclear, however, since prospective randomized trials comparing the effectiveness of IVF with simpler fertility treatments remain scarce.In recent years, increasing attention has been given to the balance between benefits, burdens, and risks of IVF treatment, and the concept of achieving pregnancy at all costs has been increasingly rejected (4). The level of provision of IVF treatment varies greatly from country to country, and few provide access to IVF treatment to all those who may benefit (5). The challenge is therefore twofold: firstly to identify those couples for whom the potential benefits of IVF treatment merit the associated risks and costs; and secondly to improve the risk/benefit balance in favor of the latter. In recent years, progress has been made on both counts. New studies focusing on IVF outcomes have further clarified those factors that determine outcome and offer the prospect of individualizing ovarian stimulation protocols and embryo transfer policies. The concept of considering indications for IVF has become more sophisticated than simply identifying a cause for infertility that might be amenable to IVF.
