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Background The Surveillance and Treatment of Prisoners With Hepatitis C (SToP-C) study demonstrated that scaling up of direct-acting antiviral (DAA) treatment reduced hepatitis C virus (HCV) transmission. We evaluated the cost-effectiveness of scaling up HCV treatment in statewide prison services incorporating long-term outcomes across custodial and community settings. Methods A dynamic model of incarceration and HCV transmission among people who inject drugs (PWID) in New South Wales, Australia, was extended to include former PWID and those with long-term HCV progression. Using Australian costing data, we estimated the cost-effectiveness of scaling up HCV treatment in prisons by 44% (as achieved by the SToP-C study) for 10 years (2021–2030) before reducing to baseline levels, compared to a status quo scenario. The mean incremental cost-effectiveness ratio (ICER) was estimated by comparing the differences in costs and quality-adjusted life-years (QALYs) between the scale-up and status quo scenarios over 40 years (2021–2060) discounted at 5% per annum. Univariate and probabilistic sensitivity analyses were performed. Results Scaling up HCV treatment in the statewide prison service is projected to be cost-effective with a mean ICER of A$12 968/QALY gained. The base-case scenario gains 275 QALYs over 40 years at a net incremental cost of A$3.6 million. Excluding DAA pharmaceutical costs, the mean ICER is reduced to A$6 054/QALY. At the willingness-to-pay threshold of A$50 000/QALY, 100% of simulations are cost-effective at various discount rates, time horizons, and changes of treatment levels in prison and community. Conclusions Scaling up HCV testing and treatment in prisons is highly cost-effective and should be considered a priority in the national elimination strategy. Clinical Trials Registration NCT02064049. [ABSTRACT FROM AUTHOR]

STUDY QUESTION Does a public online IVF success prediction calculator based on real-world data help set patient expectations? SUMMARY ANSWER The YourIVFSuccess Estimator aided consumer expectations of IVF success: one quarter (24%) of participants were unsure of their estimated IVF success before using the tool; one half changed their prediction of success after using the tool and one quarter (26%) had their expectations of IVF success confirmed. WHAT IS KNOWN ALREADY Several web-based IVF prediction tools exist worldwide but have not been evaluated for their impact on patient expectations, nor for patient perceptions of usefulness and trustworthiness. STUDY DESIGN, SIZE, DURATION This is a pre–post evaluation of a convenience sample of 780 online users of the Australian YourIVFSuccess Estimator https://yourivfsuccess.com.au/ between 1 July and 31 November 2021. PARTICIPANTS/MATERIALS, SETTING, METHODS Participants were eligible if they were over 18 years of age, Australian residents, and considering IVF for themselves or their partner. Participants filled in online surveys before and after using the YourIVFSuccess Estimator. MAIN RESULTS AND THE ROLE OF CHANCE The response rate of participants who completed both surveys and the YourIVFSuccess Estimator was 56% (n = 439). The YourIVFSuccess Estimator aided consumer expectations of IVF success: one quarter (24%) of participants were unsure of their estimated IVF success before using the tool; one half changed their prediction of success after using the tool (20% increased, 30% decreased), bringing their predictions in line with the YourIVFSuccess Estimator , and one quarter (26%) had their IVF success expectations confirmed. One in five participants claimed they would change the timing of IVF treatment. The majority of participants found the tool to be at least moderately trustworthy (91%), applicable (82%), and helpful (80%), and would recommend it to others (60%). The main reasons given for the positive responses were that the tool is independent (government funded, academic) and based on real-world data. Those who did not find it applicable or helpful were more likely to have had a worse-than-expected prediction, or to have experienced non-medical infertility (e.g. single women, LGBTQIA+), noting that at the time of evaluation the Estimator did not accommodate these patient groups. LIMITATIONS, REASONS FOR CAUTION Those who dropped out between the pre- and post-surveys tended to have a lower education status or have been born outside of Australia or New Zealand, therefore there may be issues with generalizability. WIDER IMPLICATIONS OF THE FINDINGS With consumers demanding increasing levels of transparency and participation in decisions around their medical care, public-facing IVF predictor tools based on real-world data are useful for aligning expectations about IVF success rates. Given differences in patient characteristics and IVF practices internationally, national data sources should be used to inform country-specific IVF prediction tools. STUDY FUNDING/COMPETING INTEREST(s) The YourIVFSuccess website and evaluation of the YourIVFSuccess Estimator are supported by the Medical Research Future Fund (MRFF) Emerging Priorities and Consumer Driven Research initiative: EPCD000007. BKB, ND, and OF have no conflicts to declare. DM holds a clinical role at Virtus Health. His role did not influence the analysis plan or interpretation of results in this study. GMC is an employee of the UNSW Sydney, and Director of the UNSW NPESU. UNSW receives research funding on behalf of Prof Chambers from the MRFF to develop and manage the Your IVF Success website. Grant ID: MRFF Emerging Priorities and Consumer Driven Research initiative: EPCD000007. TRIAL REGISTRATION NUMBER N/A. [ABSTRACT FROM AUTHOR]

Study Question: Is geographic proximity to a fertility clinic associated with the likelihood of women of reproductive age undertaking different forms of medically assisted fertility treatment?Summary Answer: After adjusting for socioeconomic status (SES) and other confounders including a proxy for the need for infertility treatment, women who lived within 15 km of a fertility clinic were 21% more likely to undergo ART treatment and 68% more likely to undergo IUI treatment than those who lived further than 60 km away.What Is Known Already: In most countries, patients living outside of metropolitan areas are more likely to be more socio-economically disadvantaged and to have less equitable access to healthcare. However, how a woman's residential proximity to fertility clinics predicts utilization of high-cost/high-technology treatment (ART) and low-cost/low-technology treatment (IUI) is limited, and whether socio-economic disadvantage explains much of the hypothesized lower utilization is unknown. Australia's universal insurance scheme provides supportive reimbursement for almost all ART and IUI treatment regardless of age or number of cycles, providing a unique setting to investigate disparities in access to infertility treatment.Study Design, Size, Duration: National population-based observation study of ART and IUI treatment utilization by women across socio-economic gradients and Australian residential locations between August 2015 and December 2017.Participants/materials, Setting, Methods: Universal insurance claims information on female patients who underwent ART or IUI were provided by Services Australia, comprising 67 670 female patients who accessed 162 795 ART treatments, and 10 211 female patients who accessed 19 615 IUI treatments over a 29-month period. Incidence rates by SES and proximity to fertility clinics were calculated to describe the number of women undergoing at least one ART or IUI treatment cycle per 1000 women of reproductive age (25-44). Treatment frequencies were calculated to describe the average number of ART or IUI treatment cycles per woman of reproductive age who had undergone at least one ART or IUI treatment during the study period. Poisson regression analyses were used to estimate the independent effect on accessibility to infertility treatment by geographic proximity (based on small area locations) to the closest fertility clinic after adjusting for SES, childbearing delay, remoteness area, and marital status.Main Results and the Role Of Chance: On average, 19.1 women per 1000 women of reproductive age underwent at least one fresh or frozen ART cycle, with an average 2.3 ART cycles each, while 3.0 women per 1000 women of reproductive age received at least one IUI cycle, with an average of 1.6 IUI cycles each. After adjusting for SES and other confounders including a proxy for the need for infertility treatment, women who lived within 15 km of a fertility clinic were 21% more likely to undergo ART treatment and 68% more likely to undergo IUI than those who lived over 60 km away. Regardless of geographic location, there was a steady and independent gradient in access to ART treatment based on increasing SES, with women residing in the most advantaged residential quartile having a 37% higher rate of receiving ART treatment compared to those in the most disadvantaged quartile. The negative effect of social disadvantage on ART use became more pronounced as distance from a fertility clinic grew, indicating that the barriers to access to ART care caused by distance were further compounded by the level of socioeconomic advantage of the women's residential location. In contrast, socioeconomic status did not modify the likelihood of using IUI over and above the distance from a fertility clinic. In relation to IUI treatment, differences in utilization by SES disappeared after adjusting for geographic proximity to a fertility clinic, childbearing delay, remoteness area, and marital status.Limitations, Reasons For Caution: Information is aggregated by small geographic areas and it therefore may not reflect individual characteristics. Australia provides partial but comparably supportive reimbursement for both ART and IUI through its universal healthcare system and thus the results may not be fully generalizable to other settings.Wider Implications Of the Findings: Residential proximity to a fertility clinic is a persistent barrier to accessing ART and IUI treatment, regardless of SES, even in countries characterized by supportive public funding, such as Australia. SES is less of a barrier to accessing IUI than ART, presumably driven by the lower cost and fewer clinic visits required with IUI treatment. Safe and effective fertility treatment should be available to all women regardless of where they live.Study Funding/competing Interest(s): This work was supported by the Australian National University Research scholarship and by the Higher Degree Research Fee Merit Scholarship. The authors have no conflict of interest.Trial Registration Number: N/A. [ABSTRACT FROM AUTHOR]

Study Question: In a country with supportive funding for medically assisted reproduction (MAR) technologies, what is the proportion of MAR births over-time?Summary Answer: In 2017, 6.7% of births were conceived by MAR (4.8% ART and 1.9% ovulation induction (OI)/IUI) with a 55% increase in ART births and a stable contribution from OI/IUI births over the past decade.What Is Known Already: There is considerable global variation in utilization rates of ART despite a similar infertility prevalence worldwide. While the overall contribution of ART to national births is known in many countries because of ART registries, very little is known about the contribution of OI/IUI treatment or the socio-demographic characteristics of the parents. Australia provides supportive public funding for all forms of MAR with no restrictions based on male or female age, and thus provides a unique setting to investigate the contribution of MAR to national births as well as the socio-demographic characteristics of parents across the different types of MAR births.Study Design, Size, Duration: This is a novel population-based birth cohort study of 898 084 births using linked ART registry data and administrative data including birth registrations, medical services, pharmaceuticals, hospital admissions and deaths. Birth (a live or still birth of at least one baby of ≥400 g birthweight or ≥20 weeks' gestation) was the unit of analysis in this study. Multiple births were considered as one birth in our analysis.Participants/materials, Setting, Methods: This study included a total of 898 084 births (606 488 mothers) in New South Wales and the Australian Capital Territory, Australia 2009-2017. We calculated the prevalence of all categories of MAR-conceived births over the study period. Generalized estimating equations were used to examine the association between parental characteristics (parent's age, parity, socio-economic status, maternal country of birth, remoteness of mother's dwelling, pre-existing medical conditions, smoking, etc.) and ART and OI/IUI births relative to naturally conceived births.Main Results and the Role Of Chance: The proportion of MAR births increased from 5.1% of all births in 2009 to 6.7% in 2017, representing a 30% increase over the decade. The proportion of OI/IUI births remained stable at around 2% of all births, representing 32% of all MAR births. Over the study period, ART births conceived by frozen embryo-transfer increased nearly 3-fold. OI/IUI births conceived using clomiphene citrate decreased by 39%, while OI/IUI births conceived using letrozole increased 56-fold. Overall, there was a 55% increase over the study period in the number of ART-conceived births, rising to 56% of births to mothers aged 40 years and older. In 2017, almost one in six births (17.6%) to mothers aged 40 years and over were conceived using ART treatment. Conversely, the proportion of OI/IUI births was similar across different mother's age groups and remained stable over the study period. ART children, but not OI/IUI children, were more likely to have parents who were socio-economically advantaged compared to naturally conceived children. For example, compared to naturally conceived births, ART births were 16% less likely to be born to mothers who live in the disadvantaged neighbourhoods after accounting for other covariates (adjusted relative risk (aRR): 0.84 [95% CI: 0.81-0.88]). ART- or OI/IUI-conceived children were 25% less likely to be born to immigrant mothers than births after natural conception (aRR: 0.75 [0.74-0.77]).Limitations, Reasons For Caution: The social inequalities that we observed between the parents of children born using ART and naturally conceived children may not directly reflect disparities in accessing fertility care for individuals seeking treatment.Wider Implications Of the Findings: With the ubiquitous decline in fertility rates around the world and the increasing trend to delay childbearing, this population-based study enhances our understanding of the contribution of different types of MARs to population profiles among births in high-income countries. The parental socio-demographic characteristics of MAR-conceived children differ significantly from naturally conceived children and this highlights the importance of accounting for such differences in studies investigating the health and development of MAR-conceived children.Study Funding/competing Interest(s): This study was funded through Australian National Health and Medical Research Council (NHMRC) grant: APP1127437. G.M.C. is an employee of The University of New South Wales (UNSW) and Director of the National Perinatal Epidemiology and Statistics Unit (NPESU), UNSW. The NPESU manages the Australian and New Zealand Assisted Reproduction Database with funding support from the Fertility Society of Australia and New Zealand. C.V. is an employee of The University of New South Wales (UNSW), Director of Clinical Research of IVFAustralia, Member of the Board of the Fertility Society of Australia and New Zealand, and Member of Research Committee of School of Women's and Children's Health, UNSW. C.V. reports grants from Australian National Health and Medical Research Council (NHMRC), and Merck KGaA. C.V. reports consulting fees, and payment or honoraria for lectures, presentations, speakers, bureaus, manuscript, writing or educational events or attending meeting or travel from Merck, Merck Sparpe & Dohme, Ferring, Gedon-Richter and Besins outside this submitted work. C.V. reported stock or stock options from Virtus Health Limited outside this submitted work. R.J.N. is an employee of The University of Adelaide, and Chair DSMC for natural therapies trial of The University of Hong Kong. R.J.N. reports grants from NHMRC. R.J.N. reports lecture fees and support for attending or travelling for lecture from Merck Serono which is outside this submitted work. L.R.J. is an employee of The UNSW and Foundation Director of the Centre for Big Data Research in Health at UNSW Sydney. L.R.J. reports grants from NHMRC. The other co-authors have no conflict of interest.Trial Registration Number: N/A. [ABSTRACT FROM AUTHOR]

BACKGROUND Despite the widespread use of assisted reproductive technology (ART), few studies analyse its impact on the total fertility rate (TFR). Furthermore, very little is known about how ART affects fertility at older reproductive ages and contributes to family size. OBJECTIVE We aim to quantify the contribution of ART to total and age-specific fertility rates and in relation to the transition to first and subsequent births in Australia. METHODS Using data from a comprehensive clinical registry of ART treatments, age-specific ART and non-ART fertility rates were calculated and used to decompose the change in the TFR between 2010 and 2017 into ART and non-ART components. RESULTS ART represented an increasing and relevant contribution to the TFR, corresponding to an impact of the order of 4% to 5% per annum, or approximately to 1 in 20 births. Increasing fertility rates at age 33 and above exerted a positive effect on the overall TFR, and they were almost entirely attributable to the increasing use of ART. Women resorted to ART especially to have a first child. [ABSTRACT FROM AUTHOR]

Objectives: To prepare more accurate population-based Australian birthweight centile charts by using the most recent population data available and by excluding pre-term deliveries by obstetric intervention of small for gestational age babies.Design: Population-based retrospective observational study.Setting: Australian Institute of Health and Welfare National Perinatal Data Collection.Participants: All singleton births in Australia of 23-42 completed weeks' gestation and with spontaneous onset of labour, 2004-2013. Births initiated by obstetric intervention were excluded to minimise the influence of decisions to deliver small for gestational age babies before term.Main Outcome Measures: Birthweight centile curves, by gestational age and sex.Results: Gestational age, birthweight, sex, and labour onset data were available for 2 807 051 singleton live births; onset of labour was spontaneous for 1 582 137 births (56.4%). At pre-term gestational ages, the 10th centile was higher than the corresponding centile in previous Australian birthweight charts based upon all births.Conclusion: Current birthweight centile charts probably underestimate the incidence of intra-uterine growth restriction because obstetric interventions for delivering pre-term small for gestational age babies depress the curves at earlier gestational ages. Our curves circumvent this problem by excluding intervention-initiated births; they also incorporate more recent population data. These updated centile curves could facilitate more accurate diagnosis of small for gestational age babies in Australia. [ABSTRACT FROM AUTHOR]

Study Question: What are the success rates for women returning to ART treatment in the hope of having a second ART-conceived child.Summary Answer: The cumulative live birth rate (LBR) for women returning to ART treatment was between 50.5% and 88.1% after six cycles depending on whether women commenced with a previously frozen embryo or a new ovarian stimulation cycle and the assumptions made regarding the success rates for women who dropped-out of treatment.What Is Known Already: Previous studies have reported the cumulative LBR for the first ART-conceived child to inform patients about their chances of success. However, most couples plan to have more than one child to complete their family and, for that reason, patients commonly return to ART treatment after the birth of their first ART-conceived child. To our knowledge, there are no published data to facilitate patient counseling and clinical decision-making regarding the success rates for these patients.Study Design, Size, Duration: A population-based cohort study with 35 290 women who commenced autologous (using their own oocytes) ART treatment between January 2009 and December 2013 and achieved their first treatment-dependent live birth from treatment performed during this period. These women were then followed up for a further 2 years of treatment to December 2015, providing a minimum of 2 years and a maximum of 7 years of treatment follow-up.Participants/materials, Setting, Methods: Cycle-specific LBR and cumulative LBR were calculated for up to six complete ART cycles (one ovarian stimulation and all associated transfers). Three cumulative LBR were calculated based on the likelihood of success in women who dropped-out of treatment (conservative, optimal and inverse probability-weighted (IPW)). A multivariable logistic regression model was used to predict the chance of returning to ART treatment for a second ART-conceived child, and a discrete time logistic regression model was used to predict the chance of achieving a second ART-conceived child up to a maximum of six complete cycles. The models were adjusted for patient characteristics and previous and current treatment characteristics.Main Results and the Role Of Chance: Among the women who had their first ART-conceived live birth, 15 325 (43%) returned to treatment by December 2015. LBRs were consistently better in women who recommenced treatment with a previously frozen embryo, compared to women who underwent a new ovarian stimulation cycle. After six complete cycles, plus any surplus frozen embryos, the cumulative LBR was between 60.9% (95% CI: 60.0-61.8%) (conservative) and 88.1% (95% CI: 86.7-89.5%) (optimal) [IPW 87.2% (95% CI: 86.2-88.2%)] for women who recommenced treatment with a frozen embryo, compared to between 50.5% (95% CI: 49.0-52.0%) and 69.8% (95% CI: 67.5-72.2%) [IPW 68.1% (95% CI: 67.3-68.9%)] for those who underwent a new ovarian stimulation cycle. The adjusted odds of a second ART-conceived live birth decreased for women ≥35 years, who waited at least 3 years before returning to treatment, or who required a higher number of ovarian stimulation cycles or double embryo transfer to achieve their first child.Limitations, Reasons For Caution: Our estimates do not fully account for a number of individual prognostic factors, including duration of infertility, BMI and ovarian reserve.Wider Implications Of the Findings: This is the first study to report success rates for women returning to ART treatment to have second ART-conceived child. These age-specific success rates can facilitate individualized counseling for the large number of patients hoping to have a second child using ART treatment.Study Funding/competing Interest(s): No funding was received to undertake this study. R. Paul and O. Fitzgerald have nothing to declare. D. Lieberman reports being a fertility specialist and receiving non-financial support from MSD and Merck outside the submitted work. C. Venetis reports being a fertility specialist and receiving personal fees and non-financial support from MSD, personal fees and non-financial support from Merck Serono and Beisins and non-financial support from Ferring outside the submitted work. G.M. Chambers reports being a paid employee of the University of New South Wales, Sydney (UNSW) and Director of the National Perinatal Epidemiology and Statistics Unit (NPESU), UNSW. The Fertility Society of Australia (FSA) contracts UNSW to prepare the Australian and New Zealand Assisted Reproductive Technology Database (ANZARD) annual report series and benchmarking reports.Trial Registration Number: NA. [ABSTRACT FROM AUTHOR]

Study Question: What is the number of oocytes where the maximum cumulative live birth rate per aspiration (CLBR) is observed during ART in women of different ages?Summary Answer: The maximum CLBR was observed when around 25 oocytes were retrieved in women between 18-35 years of age, around 9 oocytes in women more than 45 years of age and continued to increase beyond 30 oocytes in women between 36-44 years of age.What Is Known Already: The live birth rate per fresh or frozen/thaw embryo transfer (FET) procedure has traditionally been the main measure of ART success. However, with the introduction of highly efficient embryo cryopreservation methods, CLBR encompassing live delivery outcomes from the fresh and all subsequent FET following a single ovarian stimulation and oocyte collection is increasingly viewed as a more meaningful measure of treatment success. There is evidence suggesting that larger oocyte yields are associated with increased likelihood of cumulative live birth per aspiration. Whether this association is the same across female ages has not yet been properly investigated.Study Design, Size, Duration: This is a large retrospective population-based cohort study using data from the Australian and New Zealand Assisted Reproduction Database (ANZARD). ANZARD contains information from all ART treatment cycles carried out in all fertility centres in Australia and New Zealand. Overall, 221 221 autologous oocyte aspiration cycles carried out between January 2009 to December 2015 were included in the analysis.Participants/materials, Setting, Methods: Cumulative live birth per aspiration was defined as at least one liveborn baby at ≥20 weeks gestation resulting from an ART aspiration cycle, including all fresh and FET resulting from the associated ovarian stimulation, until one live birth occurred or all embryos were used. Cycles where no oocytes were retrieved were excluded from analysis as there is no possibility of live birth. Analyses of data were performed using generalized estimating equations to account for the clustered nature of data (multiple cycles undertaken by a woman). Univariate and multivariable regression analysis was performed to identify and adjust for factors known to independently affect cumulative live birth per aspiration. An interaction term between female age and the number of oocytes retrieved was included to assess whether the age of the women was associated with a different optimal number of oocytes to achieve at least one live birth from an aspiration cycle (i.e. the effect-modifying role of female age). The likelihood of cumulative live birth per aspiration was calculated as odds ratios (ORs) with 95% CI.Main Results and the Role Of Chance: The median number of oocytes retrieved was 7 (interquartile range, 4-12) and median age of patients was 36 (interquartile range, 33-40). The overall CLBR was 32.2%. The results from the multivariable regression analysis showedthat the number of oocytes retrieved remained a significant predictor (P < 0.001) of cumulative live birth per aspiration after adjusting for female age, parity and cycle count. Compared to the reference group of 10-14 oocytes retrieved, the adjusted odds for cumulative live birth per aspiration increased with the number of oocytes retrieved: 1-3 oocytes, 0.21 (95% CI, 0.20-0.22); 4-9 oocytes, 0.56 (95% CI, 0.55-0.58); 15-19 oocytes, 1.38 (95% CI, 1.34-1.43); 20-24 oocytes, 1.75 (95% CI, 1.67-1.84); and 2.10 (95% CI, 1.96-2.25) with more than 25 oocytes. After stratifying by female age group, the rate of increase in CLBR per additional oocyte retrieved was lower in the older age groups, indicating that higher oocyte yields were more beneficial in younger women. CLBR of patients in the <30 years and 30-34 years age groups appeared to reach a plateau (with only minimal increase in CLBR per additional oocyte retrieved) after retrieval of 25 oocytes at 73% and 72%, respectively, while CLBR of patients in the 35-39 years and 40-44 years age groups continued to increase with higher oocyte yields, reaching 68% and 40%, respectively, when 30 or more oocytes were retrieved. CLBR of patients aged 45 years and above remained consistently below 5%. Findings suggest that the number of oocytes retrieved where CLBR appears to be maximized is around 25 in women between 18-35 years, more than 30 in women between 36-44 years and around 9 in women 45 years and older. However, results for women aged 45 years and older may not be as robust due to the relatively small sample size available in this age group.Limitations, Reasons For Caution: As with all large retrospective database studies, there are potential confounders that cannot be accounted for. Despite the current study being based on complete ascertainment of ART cycles across two countries, ovarian stimulation protocols, oocyte quality parameters and a number of important patient characteristics are not collected by ANZARD. Additionally, a small number of cycles were available for women over 45 years yielding more than 15 oocytes, making these estimates unreliable.Wider Implications Of the Findings: The results from this study demonstrate that the number of oocytes retrieved where the maximum CLBR is observed during ART is dependent on female age. This provides information for clinicians and patients to understand the modifying effect of age on the number of oocytes retrieved and the likelihood of success with ART.Study Funding/competing Interest(s): No external funding was used for this study. The Fertility Society of Australia funds the National Perinatal Epidemiology and Statistics Unit to manage ANZARD and conduct national reporting of ART in Australia and New Zealand. Associate Professor Georgina Chambers (G.C.) is employed by the University of New South Wales (UNSW) and is director of the National Perinatal Epidemiology and Statistics Unit at UNSW. G.C. was also a paid member of the Australian governments Medicare Benefits Scheme taskforce on assisted reproductive technologies in 2017. [ABSTRACT FROM AUTHOR]

Background: Current evidence suggests that preimplantation genetic testing for aneuploidy (PGT‐A) used during assisted reproductive technology improves per‐cycle live‐birth rates but cumulative live‐birth rate (CLBR) was similar to a strategy of morphological assessment (MA) of embryos. No study has assessed the cost‐effectiveness of repeated cycles with PGT‐A using longitudinal patient‐level data. Aim: To assess the cost‐effectiveness of repeated cycles with PGT‐A compared to MA of embryos in older women. Materials and Methods: Micro‐costing methods were used to value direct resource consumption of 2093 assisted reproductive technology‐naïve women aged ≥37 years undergoing up to three 'complete assisted reproductive technology cycles' (fresh plus cryopreserved embryos) with either PGT‐A or MA in an Australian clinic between 2011 and 2014. Incremental cost‐effective ratios were calculated from healthcare and patient perspectives with uncertainty assessed using non‐parametric bootstrap methods. Cost‐effectiveness acceptability curves were constructed to evaluate the probability of PGT‐A being cost‐effective over a range of willingness‐to‐pay thresholds. Results: The CLBR and mean healthcare costs per patient were 30.90% and $22 962 for the PGT‐A group, and 26.77% and $21 801 for the MA group, yielding an incremental cost‐effective ratio of $28 103 for an additional live birth with PGT‐A. At a willingness‐to‐pay threshold of $50 000 and above, there is more than an 80% probability of PGT‐A being cost‐effective from the healthcare perspective and a 50% likelihood from a patient perspective. Conclusion: This is the first study to use real‐world patient‐level data to assess the cost‐effectiveness of PGT‐A in older women from the healthcare and patient perspectives. The findings contribute to the ongoing debate on the role of PGT‐A in clinical practice. [ABSTRACT FROM AUTHOR]

Background: Data on burden of severe influenza in children with a range of chronic lung diseases (CLDs) remain limited. Method: We performed a cohort study to estimate burden of influenza‐associated hospitalization in children with CLDs using population‐based linked data. The cohort comprised all children in New South Wales, Australia, born between 2001 and 2010 and was divided into five groups, children with: (a) severe asthma; (b) bronchopulmonary dysplasia (BPD); (c) cystic fibrosis (CF); (d) other congenital/chronic lung conditions; and (e) children without CLDs. Incidence rates and rate ratios for influenza‐associated hospitalization were calculated for 2001‐2011. Average cost/episode of hospitalization was estimated using public hospital cost weights. Results: Our cohort comprised 888 157 children; 11 058 (1.2%) had one of the CLDs. The adjusted incidence/1000 child‐years of influenza‐associated hospitalization in children with CLDs was 3.9 (95% CI: 2.6‐5.2) and 0.7 (95% CI: 0.5‐0.9) for children without. The rate ratio was 5.4 in children with CLDs compared to children without. The adjusted incidence/1000 child‐years (95% CI) in children with severe asthma was 1.1 (0.6‐1.6), with BPD was 6.0 (3.7‐8.3), with CF was 7.4 (2.6‐12.1), and with other congenital/chronic lung conditions was 6.9 (4.9‐8.9). The cost/episode (95% CI) of influenza‐associated hospitalization was AUD 19 704 (95% CI: 11 715‐27 693) for children with CLDs compared to 4557 (95% CI: 4129‐4984) for children without. Discussion: This large population‐based study suggests a significant healthcare burden associated with influenza in children with a range of CLDs. [ABSTRACT FROM AUTHOR]

Background: Stillbirth remains a public health concern in high-income countries. Over the past 20 years, stillbirth rates globally have shown little improvement and large disparities. The overall stillbirth rate, which measures risk among births at all gestations, masks diverging trends at different gestations. This study investigates trends over time in gestation-specific risk of stillbirth in Australia.Methods: Analytical epidemiological study using nationally reported gestational age data for births in Australia, 1994-2015. Average annual change in gestation-specific prospective risk of stillbirth (per 1000 fetuses at risk [FAR]) was calculated among births in 1994-2009 and 2010-2015 at term (37-41 weeks) and for preterm gestational age subgroups: 28-36, 24-27, and 20-23 weeks.Results: The decline in risk of stillbirth at term from 2010 to 2015 from 1.43 to 1.16 per 1000 FAR was more rapid than from 1994 to 2009; for preterm gestations from 24 to 27 weeks, there were no discernible trends; from 28 to 36 weeks, the decline between 1994 and 2009 was not sustained; among births from 20 to 23 weeks, the risk of stillbirth plateaued in 2010-2015, fluctuating around 3.3 per 1000 FAR.Conclusions: Improvement in the stillbirth rate from 28 weeks' gestation aligns with changes in other high-income countries, but more work is needed in Australia to achieve the levels of reduction seen elsewhere. Gestation-specific risk of stillbirth is more informative than the overall stillbirth rate. The message that the overall risk of stillbirth is not changing disregards gains at different stages of pregnancy. [ABSTRACT FROM AUTHOR]

Objective: To quantify total provider fees, benefits paid by the Australian Government and out-of-pocket patients' costs of mental health Medicare Benefits Schedule (MBS) consultations provided to women in the perinatal period (pregnancy to end of the first postnatal year). Method: A retrospective study of MBS utilisation and costs (in 2011–12 A$) for women giving birth between 2006 and 2010 by state, provider-type, and geographic remoteness was undertaken. Results: The cost of mental health consultations during the perinatal period was A$17.5 million for women giving birth in 2007, rising to A$29 million in 2010. Almost 9% of women giving birth in 2007 had a mental health consultation compared with more than 14% in 2010. An increase in women accessing consultations, along with an increase in the average number of consultations received, were the main drivers of the increased cost, with costs per service remaining stable. There was a shift to non-specialist care and bulk billing rates increased from 44% to 52% over the study period. In 2010, the average total cost (provider fees) per woman accessing mental health consultations during the perinatal period was A$689, and the average cost per service was A$133. Compared with women residing in regional and remote areas, women residing in major cities where more likely to access consultations, and these were more likely to be with a psychiatrist rather than an allied health professional or general practitioner. Conclusion: Increased access to mental health consultations has coincided with the introduction of recent mental health initiatives, however disparities exist based on geographic location. This detailed cost analysis identifies inequities of access to perinatal mental health services in regional and remote areas and provides important data for economic and policy analysis of future mental health initiatives. What is known about the topic?: The mental healthcare landscape in Australia has changed significantly over the last decade, with the introduction of numerous policies aimed at prevention, screening and improving access to treatment. Several of these policies have been aimed at perinatal depression, which affects 15% of women giving birth. What does this paper add?: This is the first population-based, cost analysis of mental health consultations during the perinatal period (pregnancy to end of the first postnatal year) in Australia. Almost 9% of women giving birth in 2007 had a mental health consultation funded though the MBS, compared with more than 14% in 2010. Over the same period there was a shift from psychiatric consultations to allied health and primary care consultations. In 2010, the total cost (provider fee) of these consultations was A$29 million, equating to an average cost per woman of A$689 and A$133 per service. Despite the changing policy environment, significant disparities exist in access to care according to geographic remoteness. What are the implications for practitioners?: Recent policy initiatives have resulted in increasing access to mental health consultations for women around the time of childbirth. However, policies are needed that target women outside of major cities. Furthermore, evidence is needed on whether the increase in access has resulted in improved mental health outcomes for women at this vulnerable time. The cost data provided by this study are unique and will inform future mental health policy development and health economic evaluations. [ABSTRACT FROM AUTHOR]

Study Question: Have ART live birth rates improved in Australia over the last 12 years?Summary Answer: There were striking improvements in per-cycle live birth rates observed for frozen/thaw embryo transfers, blastocyst transfer and single embryo transfer (SET), while live birth rates following ICSI were lower than IVF for non-male factor infertility in most years.What Is Already Known: ART and associated techniques have become the predominant treatment of infertility over the past 30 years in most developed countries. However, there are differences in ART laboratory and clinical practices, and success rates worldwide. Australia has one of the highest ART utilization rates and lowest multiple birth rates in the world, thus providing a unique setting to investigate the contribution of common ART strategies in an unrestricted population of patients to ART success rates.Study Design, Size, Duration: A retrospective cohort study of 585 065 ART treatment cycles performed in Australia between 2002 and 2013 using the Australian and New Zealand Assisted Reproduction Database (ANZARD).Participants Materials, Setting, Method: An unrestricted population of all women who underwent autologous ART treatment between 2002 and 2013. Visual descriptive analysis was used to assess the trends in ART procedures by the calendar years. Adjusted odds ratios (aORs) of a live birth for four common ART techniques were calculated after controlling for important confounders including female age, infertility diagnosis, stage of the embryo (blastocyst versus cleavage stage), type of embryo (fresh versus thawed), fertilization method (IVF versus ICSI) and number of embryos transferred (SET versus multiple embryos).Main Results and the Role Of Chance: The overall live birth rate per embryo transfer increased from 19.2% in 2002 to 23.3% in 2013 (21.9-24.3% for fresh embryo transfers and 14.6-23.3% for frozen/thaw embryo transfers). This occurred concurrently with an increase in SET from 29.7% to 78.9%, and an increase in the average age of women undergoing treatment from 35.0 to 35.9 years. Individuals who had a frozen/thaw embryo transfer cycle in 2002 had 43% (aOR: 0.57, 95% CI: 0.53-0.61) reduced odds of a live birth compared with a fresh embryo transfer cycle. This contrasted with 16% (aOR: 0.84, 95% CI: 0.80-0.98) reduced odds of a live birth from frozen/thaw embryo transfer cycles in 2013. In 2013, the odds of blastocyst transfer resulting in a live birth were more than twice as great as for cleavage stage transfer (aOR 2.01, 95% CI: 1.92-2.11). The adjusted odds of live birth per SET compared with multiple embryo transfer increased significantly over the last 12 years, from a 38% reduced odds of a live birth follow SET in 2002 (aOR: 062, 95% CI: 0.57-0.67) compared to an 8% reduced odds in 2013 (aOR: 0.92, 95% CI: 0.87-0.98). The aOR of a live birth using ICSI compared to IVF in non-male factor patients was lower in most years bringing into question its widespread use.Limitation, Reasons For Caution: This is a retrospective cohort analysis and cannot confirm causality. High-level evidence on the effectiveness of particular ART techniques, particularly ICSI and blastocyst culture, requires prospective randomized controlled trials or detailed statistical analysis using large-scale data that counts for fertilization failure, embryo loss, prognostic factors and cycle characteristics.Wider Implication Of the Findings: The most striking improvements in ART success rates in Australia have been observed for frozen/thaw embryo transfers, blastocyst transfer and SET. Further studies of the role of ICSI in non-male factor infertility and blastocyst transfer success rates that take into account embryo loss are needed.Study Funding/competing Interests: No funding was received to undertake this study. The authors declare that they do not have competing interests with this study.Trial Registration Number: NA. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the impact of the National Perinatal Depression Initiative on access to Medicare services for women at risk of perinatal mental illness. Method: Retrospective cohort study using difference-in-difference analytical methods to quantify the impact of the National Perinatal Depression Initiative policies on Medicare Benefits Schedule mental health usage by Australian women giving birth between 2006 and 2010. A random sample of women of reproductive age enrolled in Medicare who had not given birth where used as controls. The main outcome measures were the proportions of women giving birth each month who accessed a Medicare Benefits Schedule mental health items during the perinatal period (pregnancy through to the end of the first postnatal year) before and after the introduction of the National Perinatal Depression Initiative. Results: The proportion of women giving birth who accessed at least one mental health item during the perinatal period increased from 88 to 141 per 1000 between 2007 and 2010. The difference-in-difference analysis showed that while there was an overall increase in Medicare Benefits Schedule mental health item access as a result of the National Perinatal Depression Initiative, this did not reach statistical significance. However, the National Perinatal Depression Initiative was found to significantly increase access in subpopulations of women, particularly those aged under 25 and over 34 years living in major cities. Conclusion: In the 2 years following its introduction, the National Perinatal Depression Initiative was found to have increased access to Medicare funded mental health services in particular groups of women. However, an overall increase across all groups did not reach statistical significance. Further studies are needed to assess the impact of the National Perinatal Depression Initiative on women during childbearing years, including access to tertiary care, the cost-effectiveness of the initiative, and mental health outcomes. It is recommended that new mental health policy initiatives incorporate a planned strategic approach to evaluation, which includes sufficient follow-up to assess the impact of public health strategies. [ABSTRACT FROM AUTHOR]

Background Abnormal fetal growth is a risk factor for perinatal mortality and morbidity. There is considerable debate about the choice and performance of growth charts to classify newborns as small or large for gestational age (SGA and LGA) as a proxy for the at-risk infants. Several international charts have been proposed to be adopted worldwide. We aim to evaluate the performance of commonly-used growth charts (including international INTERGROWTH-21st-standards) for predicting adverse outcomes among SGA and LGA babies. Methods A population cohort of 2.4 million singleton births (24+0–40+6 weeks) delivered in Australia, 2004–2013. Performance was evaluated by prevalence, relative risk and diagnostic accuracy for adverse outcome based on AUC. Results There was wide variation in SGA and LGA classification across charts. For example, compared to other charts, the INTERGROWTH-21st-standards classified half of the number of term-SGA babies (prevalence: 3-4% vs. 7-10%) (<10th-centile) and double the number of LGA babies (prevalence: 24-25% vs. 8-18%) (>90th-centile), resulting in a smaller cohort of term-SGA at higher-risk of adverse outcome, and a larger LGA cohort with lower-risk of adverse outcome. All charts performed poorly for detecting adverse outcomes (AUC range for a composite outcome: 0.49-0.68) and across birthweight centiles. Conclusions Significant differences in the classification of newborns and the chart performance raises concerns about whether the INTERGROWTH-21st-standards are applicable to a multi-ethnic population such as Australia. Key messages Significant differences in the classification of newborns and the relatively poor predictive ability of growth charts means that over reliance on infant size alone may misclassify, and thus miss at-risk infants. [ABSTRACT FROM AUTHOR]

Objective Evaluating cost-effectiveness of induction of labour ( IOL) using outpatient mechanical cervical ripening using a Foley catheter ( OFC) compared to inpatient chemical ripening using prostin gel ( IPG). Study Design Cost-effectiveness analysis from a hospital perspective alongside a RCT. Women in a metropolitan Australian maternity hospital with an unfavourable cervix requiring IOL at term were randomised to IPG ( n = 51) or OFC ( n = 50). Primary economic measures were mean patient costs, incremental cost per predelivery inpatient hour prevented, and incremental cost per vaginal delivery within 12 h of admission to the birthing unit. Bootstrapping estimates were used to construct 95% confidence intervals. Estimates of net monetary benefit were calculated to aid interpretation of the results. Results Mean hospital costs per woman were nonsignificantly higher ($6524 OFC vs $5876 IPG) and mean difference $643; 95% CI −$366 to $1652. OFC group experienced fewer predelivery inpatient hours, resulting in an incremental cost per inpatient hour prevented of $57 (95% CI −$79.44 to $190.65). However, OFC patients were less likely to deliver vaginally within 12 h of admission to birthing unit. Other cost influencing clinical outcomes, including caesarean section rates and total inpatient hours, were not statistically different. Results were not sensitive to changes in costs or the cost-effectiveness thresholds. Conclusion OFC had fewer inpatient hours and costs prior to birth. However, OFC did not reduce overall inpatient hours and failed to achieve comparable rates of vaginal delivery within 12 h of birthing unit admission. Therefore, OFC is unlikely to be considered cost-effective compared to IPG in current hospital settings. [ABSTRACT FROM AUTHOR]

Objective: To investigate whether there is an increased risk of preterm birth with blastocyst transfer compared with cleavage-stage embryo transfer (ET) after assisted reproductive technology (ART).Design: A retrospective, population-based study.Setting: Not applicable.Patient(s): A total of 50,788 infants conceived after ART treatment performed from 2009 to 2012.Intervention(s): None.Main Outcome Measure(s): The rates of preterm birth, low birth weight (LBW), and small for gestational age (SGA) for 43,952 singleton and 3,418 twin deliveries after transfers of blastocyst or cleavage-stage embryos.Result(s): Among singletons, there was no significant difference in the odds of preterm birth between blastocyst and cleavage-stage ET (9.1% compared with 9.3%, respectively, adjusted odds ratio 1.00, 95% confidence interval 0.94-1.08). Among twins, the crude rates of preterm birth were similar after blastocyst and cleavage-stage ETs (61.5% and 64.4%, respectively). However, after adjusting for potential confounders, blastocyst transfer was associated with a lower odds of preterm birth among twins (adjusted odds ratio 0.80, 95% confidence interval 0.70-0.93). There was no difference in risks of LBW and SGA between blastocyst and cleavage-stage ETs for both singletons and twins after adjusting for potential confounders.Conclusion(s): In contrast with the findings from a number of other studies, blastocyst culture in Australian and New Zealand is not associated with an increased risk of preterm, LBW, and SGA for singletons. Further studies are needed to assess longer-term outcomes of children born after ART treatment and possible biological or treatment factors related to adverse outcomes. [ABSTRACT FROM AUTHOR]

Background: There is a need to have uniformed reporting of perinatal mortality for births following assisted reproductive technology (ART) treatment to enable international comparison and benchmarking of ART practice.Methods: The Australian and New Zealand Assisted Reproduction Database was used in this study. Births of ≥ 20 weeks gestation and/or ≥ 400 grams of birth weight following embryos transfer cycles in Australia and New Zealand during the period 2004 to 2008 were included. Differences in the mortality rates by different perinatal periods from a gestational age cutoff of ≥ 20, ≥ 22, ≥ 24, or ≥ 28 weeks (wks) to a neonatal period cutoff of either < 7 or < 28 days after birth were assessed. Crude and specific (number of embryos transferred and plurality) rates of perinatal mortality were calculated for selected gestational and neonatal periods.Results: When the perinatal period is defined as ≥ 20 wks gestation to < 28 days after birth, the perinatal mortality rate (PMR) was 16.1 per 1000 births (n = 630). A progressive contraction of the gestational age groups resulted in marked reductions in the PMR for deaths at < 28 days (22 wks 11.0; 24 wks 7.7; 28 wks 5.6); and similarly for deaths at < 7 days (20 wks 15.6, 22 wks 10.5; 24 wks 7.3; 28 wks 5.3). In contrast, a contraction of the perinatal period from < 28 to < 7 days after birth only marginally reduced the PMR from 16.2 to 15.6 per 1000 births which was consistent across all gestational ages.The PMR for single embryo transfer (SET) births (≥ 20 weeks gestation to < 7 days post-birth) was significantly lower (12.8 per 1000 SET births) compared to double embryo transfer (DET) births (PMR 18.3 per 1000 DET births; p < 0.001, Fisher's Exact Test). Similarly, the PMR for SET births (≥ 22 weeks gestation to < 7 days post-birth) was significantly lower (8.8 per 1000 SET births, p < 0.001, Fisher's Exact Test) when compared to DET births (12.2 per 1000 DET births). The highest PMR (50.5 per 1000 SET births, 95% CI 36.5-64.5) was for twins following SET births (≥ 20 weeks gestation to < 7 days post-birth) compared to twins following DET (23.9 per 1000 DET births, 95% CI 20.8-27.1).Conclusion: Reporting of perinatal mortality of ART births is an essential component of quality ART practice. This should include measures that monitor the impact on perinatal mortality of multiple embryo transfer. We recommend that reporting of perinatal deaths following ART treatment, should be stratified for three gestation-specific perinatal periods of ≥ 20, ≥ 22 and ≥ 28 completed weeks to < 7 days post-birth; and include plurality specific rates by SET and DET. This would provide a valuable international evidence-base of PMR for use in evaluating ART policy, practice and new research. [ABSTRACT FROM AUTHOR]

Background: Almost all assisted reproductive technology (ART) and intrauterine insemination (IUI) treatments performed in Australia are subsidized through the Australian Government's universal insurance scheme, Medicare. In 2010 restrictions on the amount Medicare paid in benefits for these treatments were introduced, increasing patient out-of-pocket payments for fresh and frozen embryo ART cycles and IUI. The aim of this study was to evaluate the impact of the policy on access to treatment, savings in Medicare benefits and the number of ART conceived children not born. Methods: Pooled quarterly cross-sectional Medicare data from 2007 and 2011 where used to construct a series of Ordinary Least Squares (OLS) regression models to evaluate the impact of the policy on access to treatment by women of different ages. Government savings in the 12 months after the policy was calculated as the difference between the predicted and observed Medicare benefits paid. Results: After controlling for underlying time trends and unobserved factors the policy change reduced the number of fresh embryo cycles by almost 8600 cycles over 12 months (a 16% reduction in cycles, <0.001). The policy effect was greatest on women aged 40 years and older (38% reduction in cycles, p<0.001). Younger women engaged in relatively more anticipatory behaviour by bringing forward their fresh cycles to 2009. Frozen embryo cycles, which are approximately one quarter of the cost of a fresh cycle, were only marginally impacted by the policy. Utilisation of IUI cycles were not impacted by the policy. After adjusting for anticipatory behaviour, $76 million in Medicare benefits was saved in the 12 months after the policy change (0.47% of annual Medicare benefits). Between 1200 and 1500 ART conceived children were not born in 2010 as a consequence of the policy. Conclusions: The introduction of the policy resulted in a significant reduction in fresh ART cycles in the first 15 months after its introduction. Further evaluation on the long term impact of the policy with regard access to treatment and on clinical practice, particularly the number of embryos transferred, is crucial to ensuring equitable access to fertility treatment and the health and welfare of ART children. [ABSTRACT FROM AUTHOR]

The article discusses a study to mitigate the number of fetuses produced through assisted reproductive technology (ART) in Australia, and the cost savings this would provide the government. It states that data was gleaned between 2002 to 2008 from several national medical databases on ART treatment cycles. It found that in that period, the number of multiple births fell from 18.8% to 8.6%, because of improved methods and technology, saving the government 47.6 million dollars.

What is the optimal number of oocytes retrieved at which maximum live birth rate is observed after fresh autologous assisted reproductive technology (ART) cycles for women of different ages? Retrospective cohort study of all fresh autologous ART aspiration cycles (n = 256,643) undertaken in Australia and New Zealand between 2009 and 2015. Primary outcome measure was live birth rate (LBR) (delivery of at least one liveborn baby at 20 weeks' gestation or over per fresh aspiration cycle). Cycles were grouped according to female age (<30, 30–34, 35–49, 40–44 and ≥45 years) and ovarian response (one to three, four to nine, 10–14, 15–19, 20–25 and ≥25 oocytes). Secondary outcome was incidence of ovarian hyperstimulation syndrome (OHSS) requiring hospitalization. At different oocyte yields, LBR per fresh aspiration cycle peaked and then declined at, depending on female age: <30 years: six to 11 oocytes (LBR 31–34%); 30–34 years: 11–16 oocytes (LBR 29–30%); 35–39 years: nine to 17 oocytes (LBR 21–24%); and 40–44 years: 15–17 oocytes (LBR 11–12%). The incidence of OHSS increased significantly with the number of oocytes retrieved, from 1.2% with 15 oocytes retrieved to 9.3% with 30 or more oocytes retrieved (P < 0.001). The optimal number of oocytes at which maximum LBR was observed in a fresh aspiration cycle was highly dependent on age. Because of the observational nature of the results, a cause–effect relationship between the number of oocytes retrieved and LBR should not be assumed; evidence from well-designed randomized control trials is required before clinical advice can be suggested. [ABSTRACT FROM AUTHOR]

From November 2019 to January 2020, eastern Australia experienced the worst bushfires in recorded history. Two months later, Sydney and surrounds were placed into lockdown for six weeks due to the COVID-19 pandemic, followed by ongoing restrictions. Many pregnant women at this time were exposed to both the bushfires and COVID-19 restrictions. To assess the impact of exposure to bushfires and pandemic restrictions on perinatal outcomes. The study included 60 054 pregnant women who gave birth between November 2017 and December 2020 in South Sydney. Exposure cohorts were based on conception and birthing dates: 1) bushfire late pregnancy, born before lockdown; 2) bushfires in early-mid pregnancy, born during lockdown or soon after; 3) conceived during bushfires, lockdown in second trimester; 4) conceived after bushfires, pregnancy during restrictions. Exposure cohorts were compared with pregnancies in the matching periods in the two years prior. Associations between exposure cohorts and gestational diabetes, preeclampsia, hypertension, stillbirth, mode of birth, birthweight, preterm birth and small for gestational age were assessed using generalised estimating equations, adjusting for covariates. A decrease in low birth weight was observed for cohort 1 (aOR 0.81, 95%CI 0.69, 0.95). Conversely, cohort 2 showed an increase in low birth weight, and increases in prelabour rupture of membranes, and caesarean sections (aOR 1.18, 95%CI 1.03, 1.37; aOR 1.21, 95%CI 1.07, 1.37; aOR 1.10 (1.02, 1.18) respectively). Cohort 3 showed an increase in unplanned caesarean sections and high birth weight babies (aOR 1.15, 95%CI 1.04, 1.27 and aOR 1.16, 95%CI 1.02, 1.31 respectively), and a decrease in gestational diabetes mellitus was observed for both cohorts 3 and 4. Pregnancies exposed to both severe climate events and pandemic disruptions appear to have increased risk of adverse perinatal outcomes beyond only experiencing one event, but further research is needed. [ABSTRACT FROM AUTHOR]

Study Question: Can we develop a prediction model for the chance of a live birth following the transfer of an embryo created using donated oocytes?, Summary Answer: Three primary models that included patient, past treatment, and cycle characteristics were developed using Australian data to predict the chance of a live birth following the transfer of an embryo created using donated oocytes; these models were well-calibrated to the population studied, achieved reasonable predictive power and generalizability when tested on New Zealand data., What Is Known Already: Nearly 9% of ART embryo transfer cycles performed globally use embryos created using donated oocytes. This percentage rises to one-quarter and one-half in same-sex couples and women aged over 45 years, respectively., Study Design, Size, Duration: This study uses population-based Australian clinical registry data comprising 9384 embryo transfer cycles that occurred between 2015 and 2021 for model development, with an external validation cohort of 1493 New Zealand embryo transfer cycles., Participants/materials, Setting, Methods: Three prediction models were compared that incorporated patient characteristics, but differed in whether they considered use of prior autologous treatment factors and current treatment parameters. We internally validated the models on Australian data using grouped cross-validation and reported several measures of model discrimination and calibration. Variable importance was measured through calculating the change in predictive performance that resulted from variable permutation. The best-performing model was externally validated on data from New Zealand., Main Results and the Role of Chance: The best-performing model had an internal validation AUC-ROC of 0.60 and Brier score of 0.20, and external validation AUC-ROC of 0.61 and Brier score of 0.23. While these results indicate ∼15% less discriminatory ability compared to models assessed on an autologous cohort from the same population the performance of the models was clearly statistically significantly better than random, demonstrated generalizability, and was well-calibrated to the population studied. The most important variables for predicting the chance of a live birth were the oocyte donor age, the number of prior oocyte recipient embryo transfer cycles, whether the transferred embryo was cleavage or blastocyst stage and oocyte recipient age. Of lesser importance were the oocyte-recipient parity, whether donor or partner sperm was used, the number of prior autologous embryo transfer cycles and the number of embryos transferred., Limitations, Reasons for Caution: The models had relatively weak discrimination suggesting further features need to be added to improve their predictive power. Variation in donor oocyte cohorts across countries due to differences such as whether anonymous and compensated donation are allowed may necessitate the models be recalibrated prior to application in non-Australian cohorts., Wider Implications of the Findings: These results confirm the well-established importance of oocyte age and ART treatment history as the key prognostic factors in predicting treatment outcomes. One of the developed models has been incorporated into a consumer-facing website (YourIVFSuccess.com.au/Estimator) to allow patients to obtain personalized estimates of their chance of success using donor oocytes., Study Funding/competing Interest(s): This research was funded by the Australian government as part of the Medical Research Future Fund (MRFF) Emerging Priorities and Consumer Driven Research initiative: EPCD000007. L.R. declares personal consulting fees from Abbott and Merck, lecture fees from Abbott, receipt of an educational grant from Merck, past presidency of the Fertility Society of Australia & New Zealand and World Endometriosis Society and being a minor shareholder in Monash IVF Group (ASX:MVF). G.M.C. declares receipt of Australian government grant funding for the research study and the development and maintenance of the YourIVFSuccess website. O.F., J.N., and A.P. report no conflicts of interest., Trial Registration Number: N/A., (© The Author(s) 2024. Published by Oxford University Press on behalf of European Society of Human Reproduction and Embryology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: More than 2 million children are conceived annually using assisted reproductive technologies (ARTs), with a similar number conceived using ovulation induction and intrauterine insemination (OI/IUI). Previous studies suggest that ART-conceived children are at increased risk for congenital anomalies (CAs). However, the role of underlying infertility in this risk remains unclear, and ART clinical and laboratory practices have changed drastically over time, particularly there has been an increase in intracytoplasmic sperm injection (ICSI) and cryopreservation., Objective: To investigate the role of underlying infertility and fertility treatment on CA risks in the first 2 years of life., Design: Propensity score-weighted population-based cohort study., Setting: New South Wales, Australia., Participants: 851 984 infants (828 099 singletons and 23 885 plural children) delivered between 2009 and 2017., Measurements: Adjusted risk difference (aRD) in CAs of infants conceived through fertility treatment compared with 2 naturally conceived (NC) control groups-those with and without a parental history of infertility (NC-infertile and NC-fertile)., Results: The overall incidence of CAs was 459 per 10 000 singleton births and 757 per 10 000 plural births. Compared with NC-fertile singleton control infants ( n  = 747 018), ART-conceived singleton infants ( n  = 31 256) had an elevated risk for major genitourinary abnormalities (aRD, 19.0 cases per 10 000 births [95% CI, 2.3 to 35.6]); the risk remained unchanged (aRD, 22 cases per 10 000 births [CI, 4.6 to 39.4]) when compared with NC-infertile singleton control infants ( n  = 36 251) (that is, after accounting for parental infertility), indicating that ART remained an independent risk. After accounting for parental infertility, ICSI in couples without male infertility was associated with an increased risk for major genitourinary abnormalities (aRD, 47.8 cases per 10 000 singleton births [CI, 12.6 to 83.1]). There was some suggestion of increased risk for CAs after fresh embryo transfer, although estimates were imprecise and inconsistent. There were no increased risks for CAs among OI/IUI-conceived infants ( n  = 13 574)., Limitations: This study measured the risk for CAs only in those children who were born at or after 20 weeks' gestation. Observational study design precludes causal inference. Many estimates were imprecise., Conclusion: Patients should be counseled on the small increased risk for genitourinary abnormalities after ART, particularly after ICSI, which should be avoided in couples without problems of male infertility., Primary Funding Source: Australian National Health and Medical Research Council., Competing Interests: Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M23-0872.

Objective: To assess the association between maternal asthma and adverse perinatal outcomes in an Australian Indigenous population., Methods: This prospective cohort study included all Indigenous mother and baby dyads for births from 2001 to 2013 in Western Australia (n = 25 484). Data were linked from Western Australia Births, Deaths, Midwives, Hospital, and Emergency Department collections. Maternal asthma was defined as a self-reported diagnosis at an antenatal visit or hospitalization or emergency visit for asthma during pregnancy or less than 3 years before pregnancy. Associations with birth, labor, and pregnancy outcomes were assessed using generalized estimating equations. Asthma exacerbation during pregnancy and stratification by remoteness was also assessed., Results: Maternal asthma was associated with placental abruption (adjusted odds ratio [aOR], 1.59 [95% confidence interval (CI), 1.07-2.35]), threatened preterm labor (aOR, 1.58 [95% CI, 1.39-1.79]), and emergency cesarean sections (aOR, 1.27 [95% CI, 1.13-1.44]). These risks increased further with an asthma exacerbation during pregnancy or if the mother was from a remote area. No associations were found for low birth weight, preterm birth, small for gestational age, or perinatal mortality., Conclusion: Maternal asthma in Indigenous women is associated with an increased risk of emergency cesarean sections, placental abruption, and threatened preterm labor. These risks may be mitigated by improved management of asthma exacerbations during pregnancy., (© 2022 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Background: Infertility is a medical condition affecting an estimated 186 million people worldwide. Medically assisted fertility treatments allow many of these individuals to have a baby. Insights about preferences of patients who have experienced fertility treatment should be used to inform funding policies and treatment configurations that best reflect the patients' voice and the value of fertility treatment to patients., Objective: To explore the preferences for fertility treatment attributes of infertile women who had previously undergone or were undergoing fertility treatments-ex post perspective., Methods: We used data from a stated-preference discrete choice experiment (DCE) among 376 Australian women who had undergone or were undergoing fertility treatment. Respondents chose their preferred treatment choices in 12 hypothetical treatment choice scenarios described by seven attributes (success rates, side effects, counselling/peer support, treatment journey, continuity of care, availability of experimental treatment and out-of-pocket cost). We estimated random parameter logit (RPL) and latent class (LC) models that accounted for preference heterogeneity. The results were used to derive price elasticities of demand and marginal willingness-to-pay (WTP) values for the treatment attributes explored within the DCE survey., Results: Income level did not have a significant effect on marginal WTP for fertility treatment attributes. The demand for fertility treatment from an ex post perspective was found to be highly inelastic (treatment cost changes had almost no impact on demand). Success rates and out-of-pocket costs were significant and important predictors of individuals' treatment choices conditional on the attributes and levels included in the study. These were followed by counselling/peer support, side effects, treatment journey, continuity of care, and availability of experimental treatment, in that order. Respondents were willing to pay $383-$524 per one percentage point increase in the treatment success rate and over $2000 and over $3500 to avoid moderate and significant side effects, respectively (values are reported in AU$). Latent class models revealed that the majority of respondents (51%) were risk-averse success-rate seekers., Conclusion: Infertile women who had previously undergone or were undergoing fertility treatment valued fertility treatment highly as reflected by highly price-inelastic demand. Success rate of treatment and out-of-pocket costs were the most important attributes and largely determined patients' WTP for fertility treatment relative to the attributes and levels used in the study. While further research should investigate the price sensitivity of women who have not experienced fertility treatment, these results might explain why women continue fertility treatment once they have commenced despite their financial capacity to pay. Future research should also determine patients' price elasticities for a fertility treatment program with multiple treatment cycles., (© 2022. The Author(s).)

Purpose: The early postnatal period is a time of increased risk for psychiatric admission. However, there is scope to further examine if this increase in risk extends to the entire perinatal period (pregnancy and first postnatal year), and how it compares to admission outside of the perinatal period., Methods: Data were linked across birth and hospital admission registers from July 2000 to December 2009. The study cohort, consisting of all pregnant and childbearing women with a psychiatric history, was divided into two groups: case women (at least one perinatal principal psychiatric admission in the study period) (38%) and comparison women (no perinatal principal psychiatric admissions) (62%). Outcomes were admission rate and length of stay adjusted for diagnosis, socio-demographic factors and timing of admission., Results: Antenatal and postnatal admissions rates were both higher than non-perinatal admission rates for case women for all diagnoses. There was little evidence that women with perinatal admissions were at an increased risk of admissions at other times. Socially disadvantaged women had significantly fewer and shorter admissions than their respective counterparts., Conclusions: The entire perinatal period is a time of increased risk for admission across the range of psychiatric disorders, compared to other times in a woman's childbearing years. Reduced admission rate and length of stay for socially disadvantaged women suggest lack of equity of access highlighting the importance of national perinatal mental health policy initiatives inclusive of disadvantaged groups., (© 2021. Crown.)

Background and Aims: Between 2014 and 2019, the SToP-C trial observed a halving in HCV incidence in four Australian prisons following scale-up of direct-acting antiviral (DAA) therapy. However, the contribution of HCV treatment to this decline is unclear because the study did not have a control group. We used modeling to consider this question., Approach and Results: We parameterized and calibrated a dynamic model of HCV transmission in prisons to data from each SToP-C prison on incarceration dynamics, injecting drug use, HCV prevalence trends among prison entrants, baseline HCV incidence before treatment scale-up, and subsequent HCV treatment scale-up. The model projected the decrease in HCV incidence resulting from increases in HCV treatment and other effects. We assessed whether the model agreed better with observed reductions in HCV incidence overall and by prison if we included HCV treatment scale-up, and its prevention benefits, or did not. The model estimated how much of the observed decrease in HCV incidence was attributable to HCV treatment in prison. The model projected a decrease in HCV incidence of 48.5% (95% uncertainty interval [UI], 41.9-54.1) following treatment scale-up across the four prisons, agreeing with the observed HCV incidence decrease (47.6%; 95% CI, 23.4-64.2) from the SToP-C trial. Without any in-prison HCV treatment, the model indicated that incidence would have decreased by 7.2% (95% UI, -0.3 to 13.6). This suggests that 85.1% (95% UI, 72.6-100.6) of the observed halving in incidence was from HCV treatment scale-up, with the remainder from observed decreases in HCV prevalence among prison entrants (14.9%; 95% UI, -0.6 to 27.4)., Conclusions: Our results demonstrate the prevention benefits of scaling up HCV treatment in prison settings. Prison-based DAA scale-up should be an important component of HCV elimination strategies., (© 2021 The Authors. Hepatology published by Wiley Periodicals LLC on behalf of American Association for the Study of Liver Diseases.)

Introduction: Assisted reproductive technologies (ART), such as in-vitro fertilisation (IVF), have revolutionised the treatment of infertility, with an estimated 8 million babies born worldwide. However, the long-term health outcomes for women and their offspring remain an area of concern. Linking IVF treatment data to long-term health data is the most efficient method for assessing such outcomes., Objectives: To describe the creation and performance of a bespoke population-based data linkage of an ART clinical quality registry to state-based and national administrative datasets., Methods: The linked dataset was created by deterministically and probabilistically linking the Australia and New Zealand Assisted Reproduction Database (ANZARD) to New South Wales (NSW) and Australian Capital Territory (ACT) administrative datasets (performed by NSW Centre for Health Record Linkage (CHeReL)) and to national claims datasets (performed by Australian Institute of Health and Welfare (AIHW)). The CHeReL's Master Linkage Key (MLK) was used as a bridge between ANZARD's partially identifiable patient data (statistical linkage key) and NSW and ACT administrative datasets. CHeReL then provided personal identifiers to the AIHW to obtain national content data. The results of the linkage were reported, and concordance between births recorded in ANZARD and perinatal data collections (PDCs) was evaluated., Results: Of the 62,833 women who had ART treatment in NSW or ACT, 60,419 could be linked to the CHeReL MLK (linkage rate: 96.2%). A reconciliation of ANZARD-recorded births among NSW residents found that 94.2% (95% CI: 93.9-94.4%) of births were also recorded in state/territory-based PDCs. A high concordance was found in plurality status and birth outcome ≥99% agreement rate, Cohen's kappa ranged: 0.78-0.98) between ANZARD and PDCs., Conclusion: The data linkage resource demonstrates that high linkage rates can be achieved with partially identifiable data and that a population spine, such as the CHeReL's MLK, can be successfully used as a bridge between clinical registries and administrative datasets., Competing Interests: Statement on conflicts of interest: G.C. is an employee of The University of New South Wales (UNSW) and Director of the National Perinatal Epidemiology and Statistics Unit (NPESU), UNSW. The NPESU manages the Australian and New Zealand Assisted Reproduction Database with funding support from the Fertility Society of Australia and New Zealand.

Background: Limited empirical evidence exists for the effectiveness of hepatitis C virus (HCV) treatment-as-prevention. The Surveillance and Treatment of Prisoners with hepatitis C (SToP-C) study aimed to assess the effect of HCV treatment-as-prevention in the prison setting., Methods: SToP-C was a prospective study, including a before-and-after analysis, within a cohort of people incarcerated in two maximum-security prisons (male) and two medium-security prisons (one male, one female) in New South Wales, Australia. All prison inmates aged at least 18 years were eligible for enrolment. After HCV testing, participants were monitored for risk behaviours and HCV infection, among three sub-populations: uninfected (HCV antibody-negative); previously infected (HCV antibody-positive, HCV RNA-negative); and infected (HCV antibody and HCV RNA-positive). Uninfected participants were followed up every 3-6 months to detect HCV primary infection and previously infected participants were followed up every 3-6 months to detect re-infection. Participants with HCV infection were assessed for treatment, initially standard-of-care treatment (administered by prison health services) from 2014 to mid-2017, then direct-acting antiviral (DAA) treatment scale-up from mid-2017 onwards (12 weeks of sofosbuvir plus velpatasvir, administered through SToP-C). Participants were followed up until study closure in November, 2019. The primary study outcome was HCV incidence before and after DAA treatment scale-up among participants at risk of HCV primary infection or re-infection. This study is registered with ClinicalTrials.gov, NCT02064049., Findings: Between Oct 30, 2014, and Sept 30, 2019, 3691 participants were enrolled in the SToP-C study. 719 (19%) participants had detectable HCV RNA, 2240 (61%) were at risk of primary HCV infection, and 725 (20%) were at risk of re-infection at baseline. DAA treatment was initiated in 349 (70%) of 499 eligible participants during the treatment scale-up period. The HCV incidence analysis comprised 1643 participants at risk of HCV infection or re-infection during longitudinal follow-up (median age 33 years [IQR 27-42]; 1350 [82%] male). 487 (30%) of 1643 participants reported injecting drugs in prison. HCV incidence decreased from 8·31 per 100 person-years in the pre-treatment scale-up period to 4·35 per 100 person-years in the post-treatment scale-up period (incidence rate ratio [IRR] 0·52 [95% CI 0·36-0·78]; p=0·0007). The incidence of primary infection decreased from 6·64 per 100 person-years in the pre-treatment scale-up period to 2·85 per 100 person-years in the post-treatment scale-up period (IRR 0·43 [95% CI 0·25-0·74]; p=0·0019), whereas the incidence of re-infection decreased from 12·36 per 100 person-years to 7·27 per 100 person-years (0·59 [0·35-1·00]; p=0·050). Among participants reporting injecting drugs during their current imprisonment, the incidence of primary infection decreased from 39·08 per 100 person-years in the pre-treatment scale-up period to 14·03 per 100 person-years in the post-treatment scale-up period (IRR 0·36 [95% CI 0·16-0·80]; p=0·0091), and the incidence of re-infection decreased from 15·26 per 100 person-years to 9·34 per 100 person-years (0·61 [0·34-1·09]; p=0·093). The adjusted analysis (adjusted for age, Indigenous Australian ethnicity, duration of stay in prison, previous imprisonment, injecting drug use status, and prison site) indicated a significant reduction in the risk of HCV infection between the pre-DAA treatment scale-up and post-DAA treatment scale-up periods (adjusted hazard ratio 0·50 [95% CI 0·33-0·76]; p=0·0014)., Interpretation: DAA treatment scale-up was associated with reduced HCV incidence in prison, indicative of a beneficial effect of HCV treatment-as-prevention in this setting. These findings support broad DAA treatment scale-up within incarcerated populations., Funding: Australian National Health and Medical Research Council Partnership Project Grant and Gilead Sciences., Competing Interests: Declaration of interests GJD is a consultant and adviser for, and has received research grants from, Gilead, AbbVie, Merck, Bristol-Myers Squibb, and Cepheid. ARL is a consultant and adviser for, and has received investigator-initiated research grants from, Gilead, Merck, and Bristol-Myers Squibb. JG is a consultant and adviser for, and has received research grants from, Gilead, AbbVie, Merck, and Cepheid. PV has received investigator-initiated untied grants from Gilead and honorarium from Gilead and Merck. NKM has received unrestricted research grants from Gilead and Merck. JGMc is a stockholder and ex-employee of Gilead Sciences. DMB is a stockholder and employee of Gilead Sciences. All other authors declare no competing interests., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Study Question: What was the utilization, effectiveness and safety of practices in ART globally in 2012 and what global trends could be observed?, Summary Answer: The total number of ART cycles increased by almost 20% since 2011 and the main trends were an increase in frozen embryo transfers (FET), oocyte donation, preimplantation genetic testing and single embryo transfers (SET), whereas pregnancy and delivery rates (PR, DR) remained stable, and multiple deliveries decreased., What Is Known Already: ART is widely practiced throughout the world, but continues to be characterized by significant disparities in utilization, availability, practice, effectiveness and safety. The International Committee for Monitoring Assisted Reproductive Technologies (ICMART) annual world report provides a major tool for tracking trends in ART treatment for over 25 years and gives important data to ART professionals, public health authorities, patients and the general public., Study Design, Size, Duration: A retrospective, cross-sectional survey on the utilization, effectiveness and safety of ART procedures performed globally during 2012 was carried out., Participants/materials, Setting, Methods: Sixty-nine countries and 2600 ART clinics submitted data on ART cycles performed during the year 2012, and their pregnancy outcome, through national and regional ART registries. ART cycles and outcomes are described at country, regional and global levels. Aggregate country data were processed and analyzed based on methods developed by ICMART., Main Results and Role of Chance: A total of 1 149 817 ART cycles were reported for the treatment year 2012. After imputing data for missing values and non-reporting clinics in reporting countries, 1 948 898 cycles (an increase of 18.6% from 2011) resulted in >465 286 babies (+17.9%) in reporting countries. China did not report and is not included in this estimate. The best estimate of global utilization including China is ∼2.8 million cycles and 0.9 million babies. From 2011 to 2012, the number of reported aspirations and FET cycles increased by 6.9% and 16.0%, respectively. The proportion of women aged 40 years or older undergoing non-donor ART increased from 24.0% in 2011 to 25.2% in 2012. ICSI, as a percentage of non-donor aspiration cycles, increased from 66.5% in 2011 to 68.9% in 2012. The IVF/ICSI combined delivery rates per fresh aspiration and FET cycles were 19.8% and 22.1%, respectively. In fresh non-donor cycles, SET increased from 31.4% in 2011 to 33.7% in 2012, while the average number of transferred embryos decreased from 1.91 to 1.88, respectively-but with wide country variation. The rates of twin deliveries following fresh non-donor transfers decreased from 19.6% in 2011 to 18.0% in 2012, and the triplet rate decreased from 0.9% to 0.8%. In FET non-donor cycles, SET was 54.8%, with an average of 1.54 embryos transferred and twin and triplet rates of 11.1% and 0.4%, respectively. The cumulative DR per aspiration increased from 28.0% in 2011 to 28.9% in 2012. The overall perinatal mortality rate per 1000 births was 21.4 following fresh IVF/ICSI and 15.9 per 1000 following FET., Limitations, Reasons for Caution: The data presented depend on the quality and completeness of data submitted by individual countries to ICMART directly or through regional registries. This report covers approximately two-thirds of` world ART activity, with a major missing country, China. Continued efforts to improve the quality and consistency of reporting ART data by registries are still needed, including the use of internationally agreed standard definitions (International Glossary of Infertility and Fertility Care)., Wider Implications of the Findings: The ICMART world reports provide the most comprehensive global statistical census and review of ART utilization, effectiveness, safety and quality. While ART treatment continues to increase globally, the wide disparities in access to treatment, procedures performed and embryo transfer practices warrant attention by clinicians and policy makers. With the increasing practice of SET and of freeze all and resulting increased proportion of FET cycles, it is clear that PR and DR per aspiration in fresh cycles do not give an overall accurate estimation of ART efficiency. It is time to use cumulative live birth rate per aspiration, combining the outcomes of FET cycles with the associated fresh cycle from which the embryos were obtained, and to obtain global consensus on this approach., Study Funding/competing Interest(s): The authors declare no conflict of interest and no specific support from any organizations in relation to this manuscript. ICMART gratefully acknowledges financial support from the following organizations: American Society for Reproductive Medicine; European Society for Human Reproduction and Embryology; Fertility Society of Australia; Japan Society for Reproductive Medicine; Japan Society of Fertilization and Implantation; Red Latinoamericana de Reproduccion Asistida; Society for Assisted Reproductive Technology; Ferring Pharmaceuticals and Abbott (both providing ICMART unrestricted grants unrelated to world reports)., Trial Registration Number: NA., (© The Author(s) 2020. Published by Oxford University Press on behalf of European Society of Human Reproduction and Embryology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objective: To quantify the economic and health-related quality of life (HRQoL) burden incurred by households with a child affected by spinal muscular atrophy (SMA)., Methods: Hospital records, insurance claims, and detailed resource use questionnaires completed by caregivers were used to capture the direct and indirect costs to households of 40 children affected by SMA I, II, and III in Australia between 2016 and 2017. Prevalence costing methods were used and reported in 2017 US dollar (USD) purchasing power parity (PPP). The HRQoL for patients and primary caregivers was quantified with the youth version of the EQ-5D and CareQoL multiattribute utility instruments and Australian utility weights., Results: The average total annual cost of SMA per household was $143,705 USD PPP for all SMA types (SMA I $229,346, SMA II $150,909, SMA III $94,948). Direct costs accounted for 56% of total costs. The average total indirect health care costs for all SMA types were $63,145 per annum and were highest in families affected by SMA II. Loss of income and unpaid informal care made up 24.2% and 19.8% respectively, of annual SMA costs. Three of 4 (78%) caregivers stated that they experienced financial problems because of care tasks. The loss in HRQoL of children affected by SMA and caregivers was substantial, with average caregiver and patient scores of 0.708 and 0.115, respectively (reference range 0 = death and 1 = full health)., Conclusion: Our results demonstrate the substantial and far-ranging economic and quality of life burden on households and society of SMA and are essential to fully understanding the health benefits and cost-effectiveness associated with emerging disease-modifying therapies for SMA., (© 2020 American Academy of Neurology.)

This study estimates the future utilization of medically assisted fertility treatments in Australia, focusing on assisted reproductive technologies (ARTs), intrauterine insemination (IUI), and ovulation induction. A multistate cohort component population projection model is used to determine future fertility rates from 2016 to 2026 by age and education level. These are combined with information on recent trends in use and success rates to indirectly estimate future age-specific probabilities of fertility treatment utilization. The number of ART cycles is expected to increase by 61 per cent between 2016 and 2026 if treatment success rates remain at 2015 levels, or by 34 per cent if recent improvements in ART success rates continue. The model also predicts that numbers of IUI cycles and ovulation induction cycles will decrease by 17 and 3 per cent, respectively. This research confirms the importance of including both technological improvements and socio-demographic changes when predicting future fertility treatment utilization.

Background: Indigenous Australian children are twice as likely to score poorly on developmental outcomes at age 5 years than their non-Indigenous peers. Indigenous children are also more likely to be born to younger mothers. We aimed to quantify the relationship between maternal age at childbirth and early childhood development outcomes in Indigenous and non-Indigenous children., Methods: In this population-based, retrospective cohort study, we used data from the Australian Early Development Census (AEDC) that were probabilistically linked by the New South Wales (NSW) Centre for Health Record Linkage to several NSW administrative datasets, including the Perinatal Data Collection, the Register of Births, Deaths and Marriages (for birth registrations), the Admitted Patient Data Collection, and public school enrolment records, as part of the Seeding Success study. The resulting data resource comprises a cohort of 166 278 children born in NSW whose first year of school was reported in a 2009 or 2012 AEDC record (which were the years of AEDC data available at the time of data linkage). The primary outcome was the aggregate outcome of developmental vulnerability (scores in the bottom decile, according to the 2009 benchmark, on one or more of the five AEDC domains, which include physical, social, emotional, language and cognitive, and communication development). This outcome was measured in singleton children without special needs recorded on the AEDC, in those with available developmental data. As a secondary outcome analysis, we also repeated the main analyses on the outcome of developmental vulnerability on the individual domains. We estimated the absolute risk of developmental vulnerability by maternal age in Indigenous and non-Indigenous populations, and we also estimated the risk difference and relative risk between Indigenous and non-Indigenous children by use of modified Poisson regression., Findings: Of 166 278 children in the cohort, 107 666 (64·8%) children were enrolled in a public school in NSW in 2009 or 2012, of whom 7994 (7·4%) children were Indigenous (ie, they, or either parent, were recorded as Aboriginal or Torres Strait Islander on one or more birth records) and 99 672 (92·6%) children were not Indigenous. After exclusions, the final study population included 99 530 children (7206 [7·2%] Indigenous and 92 324 [92·8%] non-Indigenous). Of those for whom developmental outcome data were available, 2581 (35·9%) of 7180 Indigenous children and 18 071 (19·7%) of 91 835 non-Indigenous children were developmentally vulnerable on one domain or more. The risk of developmental vulnerability decreased with maternal ages between 15 and 39 years, but the decrease in risk with maternal age was significantly steeper in non-Indigenous than Indigenous children., Interpretation: Developmental vulnerability is most common in Indigenous and non-Indigenous children born to young mothers; however, Indigenous children have an increased risk of this outcome across most of the maternal age range. Policies that improve the socioeconomic circumstances of Indigenous children and families could promote better developmental outcomes among Indigenous children. Culturally appropriate support for Indigenous children, including those born to young mothers and disadvantaged families, could also reduce early childhood developmental inequalities., Funding: The Australian National Health and Medical Research Council, Manitoba Centre for Health Policy., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Study Question: How did general practitioners (GPs) (family physicians) manage infertility in females and males in primary care between 2000 and 2016?, Summary Answer: The number of GP infertility consultations for females increased 1.6 folds during the study period, with 42.9% of consultations resulting in a referral to a fertility clinic or specialist, compared to a 3-fold increase in the number of consultations for men, with 21.5% of consultations resulting in a referral., What Is Known Already: Infertility affects one in six couples and is expected to increase with the trend to later childbearing and reports of declining sperm counts. Despite GPs often being the first contact for infertile people, very limited information is available on the management of infertility in primary care., Study Design, Size, Duration: Data from the Bettering the Evaluation and Care of Health programme were used, which is a national study of Australian primary care (general practice) clinical activity based on 1000 ever-changing, randomly selected GPs involved in 100 000 GP-patient consultations per year between 2000 and 2016., Participants/materials, Setting, Methods: Females and males aged 18-49 years attending GPs for the management of infertility were included in the study. Details recorded by GPs included patient characteristics, problems managed and management actions (including counselling/education, imaging, pathology, medications and referrals to specialists and fertility clinics). Analyses included trends in the rates of infertility consultations by sex of patient, descriptive and univariate analyses of patient characteristics and management actions and multivariate logistic regression to determine which patient and GP characteristics were independently associated with increased rates of infertility management and referrals., Main Results and the Role of Chance: The rate of infertility consultations per capita increased 1.6 folds for women (17.7-28.3 per 1000 women aged 18-49 years) and 3 folds for men over the time period (3.4-10.2 per 1000 men aged 18-49 years). Referral to a fertility clinic or relevant specialist occurred in 42.9% of female infertility consultations and 21.5% of male infertility consultations. After controlling for age and other patient characteristics, being aged in their 30s, not having income assistance, attending primary care in later years of the study and coming from a non-English-speaking background, were associated with an increased likelihood of infertility being managed in primary care. In female patients, holding a Commonwealth concession card (indicating low income), living in a remote area and having a female GP all indicated a lower adjusted odds of referral to a fertility clinic or specialist., Limitations, Reasons for Caution: Data are lacking for the period of infertility and infertility diagnosis, which would provide a more complete picture of the epidemiology of treatment-seeking behaviour for infertility. Australia's universal insurance scheme provides residents with access to a GP, and therefore these findings may not be generalizable to other settings., Wider Implications of the Findings: This study informs public policy on how infertility is managed in primary care in different patient groups. Whether the management actions taken and rates of secondary referral to a fertility clinic or specialist are appropriate warrants further investigation. The development of clinical practice guidelines for the management of infertility would provide a standardized approach to advice, investigations, treatment and referral pathways in primary care., Study Funding/competing Interest(s): This paper is part of a study being funded by an Australian National Health and Medical Research Council project grant APP1104543. G.C. reports that she is an employee of The University of New South Wales (UNSW) and Director of the National Perinatal Epidemiology and Statistics Unit (NPESU), UNSW. The NPESU manages the Australian and New Zealand Assisted Reproductive Technology Database on behalf of the Fertility Society of Australia. W.L. reports being a part-time paid employee and minor shareholder of Virtus Health, a fertility company. R.N. reports being a small unitholder in a fertility company, receiving grants for research from Merck and Ferring and speaker travel grants from Merck., Trial Registration Number: NA., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For permissions, please e-mail: journals.permission@oup.com.)

Background: Maternity populations are becoming increasingly multiethnic. Conflicting findings exist regarding the risk of adverse perinatal outcomes among immigrant mothers from different world regions and which growth charts are most appropriate for identifying the risk of adverse outcomes., Objective: To evaluate whether infant mortality and morbidity, and the categorisation of infants as small for gestational age or large for gestational age (SGA or LGA) vary by maternal country of birth, and to assess whether the choice of growth chart alters the risk of adverse outcomes in infants categorised as SGA and LGA., Methods: A population cohort of 601 299 singleton infants born in Australia to immigrant mothers was compared with 1.7 million infants born to Australian-born mothers, 2004-2013. Infants were categorised as SGA and LGA according to a descriptive Australian population-based birthweight chart (Australia-2012 reference) and the prescriptive INTERGROWTH-21st growth standard. Propensity score reweighting was used for the analysis., Results: Compared to Australian-born infants, infants of mothers from Africa, Philippines, India, other Asia countries, and the Middle East had between 15.4% and 48.1% elevated risk for stillbirth, preterm delivery, or low Apgar score. The association between SGA and LGA and perinatal mortality varied markedly by growth chart and country of birth. Notably, SGA infants from African-born mothers had a relative risk of perinatal mortality of 6.1 (95% CI 4.3, 6.7) and 17.3 (95% CI 12.0, 25.0) by the descriptive and prescriptive charts, respectively. LGA infants born to Australian-born mothers were associated with a 10% elevated risk of perinatal mortality by the descriptive chart compared to a 15% risk reduction by the prescriptive chart., Conclusions: Country-of-birth-specific variations are becoming increasingly important for providing ethnically appropriate and safe maternity care. Our findings highlight significant variations in risk of adverse perinatal outcomes in immigrant subgroups, and demonstrate how the choice of growth chart alters the quantification of risk associated with being born SGA or LGA., (© 2019 John Wiley & Sons Ltd.)

Background: The Maternity Care Classification System is a novel system developed in Australia to classify models of maternity care based on their characteristics. It will enable large-scale evaluations of maternal and perinatal outcomes under different models of care independently of the model's name., Aim: To assess the accuracy, repeatability and reproducibility of the Maternity Care Classification System., Method: All 70 public maternity services in New South Wales, Australia, were invited to classify three randomly allocated model case-studies using a web-based survey tool and repeat their classifications 4-6 weeks later. Accuracy of classifications was assessed against the correct values for the case-studies; repeatability (intra-rater reliability) was analysed by percent agreement and McNemar's test between the same participants in both surveys; and reproducibility (inter-rater reliability) was assessed by percent agreement amongst raters of the same case-study combined with Krippendorff's alpha coefficient for a subset of characteristics., Results: The accuracy of the Maternity Care Classification System was high with 90.8% of responses correctly classified; was repeatable, with no statistically significant change in the responses between the two survey instances (mean agreement 91.5%, p>0.05 for all but one variable); and was reproducible with a mean percent agreement across 9 characteristics of 83.6% and moderate to substantial agreement as assessed by a Krippendorff's alpha coefficient of 0.4-0.8., Conclusion: The results indicate the Maternity Care Classification System is a valid system for classifying models of care in Australia, and will enable the legitimate evaluation of outcomes by different models of care., (Copyright © 2018 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

This paper helps to quantify the impact of the Australian National Perinatal Depression Initiative (NPDI) on postnatal inpatient psychiatric hospitalisation. Based on individual hospital admissions data from New South Wales and Western Australia, we found that the NPDI reduced inpatient psychiatric hospital admission by up to 50% [0.9% point reduction (95% CI 0.70-1.22)] in the first postnatal year. The greatest reduction was observed for adjustment disorders. The NPDI appears to be associated with fewer post-birth psychiatric disorders hospital admissions; this suggests earlier detection of psychiatric disorders resulting in early care of women at risk during their perinatal period.

Objective: To investigate preferences for fertility treatment from the Australian general population with the aims of calculating the willingness to pay in tax contribution for attributes (characteristics) that make up treatment and for an "ideal" fertility treatment program. We also assessed whether willingness-to-pay varies by the relationship status or sexual orientation of the patient. Methods: A stated preference discrete choice experiment was administered to a panel of 801 individuals representative of the Australian general population. Seven attributes of fertility treatment under three broad categories were included: outcome, process, and cost. Attributes were identified through published literature, focus group discussions, expert knowledge, and a pilot study. A Bayesian fractional experimental design was used, and data analysis was performed using a generalized multinomial logit model. Further analyses included interaction terms and latent class modeling. Results: Six of the seven attributes influenced the choice of a treatment program. Under process attributes, individuals preferred: continuity of care of clinic staff, where patients are seen by the same doctor but different nurses at each visit; "alternative" treatments being offered to all patients; and onsite clinic counseling and peer-support groups. Personalization and tailoring of the treatment journey were not important. Among outcome attributes, the improved success rate of having a baby per cycle and significant side-effects were considered important. Cost of treatment also influenced the choice of treatment program. Individual preferences for fertility treatment were not associated with patients' relationship status or sexual orientation. Latent class modeling revealed sub-groups with distinct fertility treatment preferences. Conclusion: This study provides important insights into the attributes that influence the preferences of fertility treatment in Australia. It also estimates socially-inclusive willingness-to-pay values in tax contributions for an "ideal" package of treatment. The results can inform economic evaluations of fertility treatment programs.

Background: Without a standard terminology to classify models of maternity care, it is problematic to compare and evaluate clinical outcomes across different models. The Maternity Care Classification System is a novel system developed in Australia to classify models of maternity care based on their characteristics and an overarching broad model descriptor (Major Model Category)., Aim: This study aimed to assess the extent of variability in the defining characteristics of models of care grouped to the same Major Model Category, using the Maternity Care Classification System., Method: All public hospital maternity services in New South Wales, Australia, were invited to complete a web-based survey classifying two local models of care using the Maternity Care Classification System. A descriptive analysis of the variation in 15 attributes of models of care was conducted to evaluate the level of heterogeneity within and across Major Model Categories., Results: Sixty-nine out of seventy hospitals responded, classifying 129 models of care. There was wide variation in a number of important attributes of models classified to the same Major Model Category. The category of 'Public hospital maternity care' contained the most variation across all characteristics., Conclusion: This study demonstrated that although models of care can be grouped into a distinct set of Major Model Categories, there are significant variations in models of the same type. This could result in seemingly 'like' models of care being incorrectly compared if grouped only by the Major Model Category., (Copyright © 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Study Question: Do births following single embryo transfers (SET) have a reduced risk of perinatal mortality compared with those following double embryo transfers (DET)?, Summary Answer: SET is associated with reduced risk of perinatal mortality compared with DET., What Is Known Already: Fetal, neonatal and perinatal mortality are important indicators for monitoring pregnancy and childbirth, particularly for births following assisted reproductive technology (ART) treatments. Following the introduction of SET, there has been a decline in the perinatal mortality rate (PMR) among babies born after ART in Australia and New Zealand., Study Design, Size, Duration: This population study (census) included 50,258 births of ≥ 20 weeks gestation and/or ≥ 400 g of birthweight following embryos transfer cycles in Australia and New Zealand during the period 2004-2008., Participants/materials, Setting, Methods: The PMR was calculated according to the number of embryos transferred and other demographic and treatment-related factors. Perinatal deaths were defined as the number of fetal deaths (stillbirths) plus the number of neonatal deaths (deaths that occur before 28 days after birth)., Main Results and the Role of Chance: The PMR was 16.2 per 1000 births (n= 813). Of the 813 perinatal deaths, 630 were fetal deaths and 183 neonatal deaths. Twins had a significantly higher PMR (27.8 per 1000 births) than singletons (12.4 per 1000 births). The risk of perinatal mortality for all births following DET was 53% higher than for all births following SET (adjusted risk ratio 1.53, 95% confidence interval (95% CI): 1.29-1.80). Births following fresh DET had a 58% increased risk of perinatal mortality compared with births following fresh SET (risk ratio 1.58, 95% CI: 1.32-1.90)., Limitations, Reasons for Caution: Information on outcomes was missing from <1% of clinical pregnancies recorded in Australian and New Zealand Assisted Reproduction Database for the study period. There are no data on the timing of fetal death, the cause of perinatal death or on late termination of pregnancy at ≥ 20 weeks' gestation., Wider Implications of the Findings: Double and higher order embryo transfer is associated with a higher risk of perinatal mortality when compared with SET. The number of embryos transferred is determined by the clinician with consent of the patient and is a modifiable treatment factor. SET should be advocated as the first-line management in ART as it is the single most effective public health intervention for preventing excess perinatal mortality among ART pregnancies., Study Funding/competing Interest(s): Nil.

Background: Currently, about one-third of infants born after assisted reproductive technology (ART) worldwide are twins or triplets. This study compared the inpatient birth-admission costs of singleton and multiple gestation ART deliveries to non-ART deliveries., Methods: A cohort of 5005 mothers and 5886 infants conceived following ART treatment were compared to 245 249 mothers and 248 539 infants in the general population. Birth-admission costs were calculated using Australian Refined Diagnosis Related Groups and weighted national average costs (2003-2004 euro)., Results: ART infants were 4.4 times more likely to be low birthweight (LBW) compared with non-ART infants, translating into 89% higher birth-admission costs (euro2,832 and euro1,502, respectively). ART singletons were also more likely to be LBW compared with non-ART singletons, translating into 31% higher birth-admission costs (euro1,849 and euro1,415, respectively). After combining infant and maternal admission costs, the average cost of an ART singleton delivery was euro4,818 compared with euro13 890 for ART twins and euro54 294 for ART higher order multiples. Findings were not sensitive to changes in casemix., Conclusions: The poorer neonatal outcomes of ART singletons compared with non-ART singletons are significant enough to impact healthcare resource consumption. The high costs associated with ART multiple births add to the overwhelming clinical and economic evidence in support of single embryo transfer.

Objectives: To calculate the cost of assisted reproductive technology (ART) treatment cycles and resultant live-birth events., Design: Cost-outcome study based on a decision analysis model of significant clinical and economic outcomes of ART., Setting and Participants: All non-donor ART treatments initiated in Australia in 2002. Treatment cycles, maternal age and birth outcome data were obtained from the Australian and New Zealand Assisted Reproduction Database. Direct health care costs were obtained from fertility centres, and included government, private insurer and patient costs., Main Outcome Measures: Average health care cost of non-donor, fresh and frozen embryo ART treatment cycles. Average and age-specific costs per live-birth event following ART treatment., Results: Average health care cost per non-donor ART live-birth event was 32,903 US dollars (range, 24,809 US dollars for women < 30 years to 97,884 US dollars for women > or = 40 years). The cost per live birth for women aged > or = 42 years was 182,794 US dollars. The average treatment cost of a fresh cycle was 6,940 US dollars, compared with 1,937 US dollars for a frozen embryo transfer cycle., Conclusions: Debate regarding funding for ART services has been hindered by a lack of economic studies of ART treatments and outcomes in Australia. This is the most comprehensive costing study of ART services to date in terms of resources consumed during ART treatment. It confirms that ART treatment is less cost-effective in older women. Alongside economic considerations of ART, community values, ethical judgements and clinical factors should influence policy decision-making.