## Abstract

In this technical article, we are proposing ideas, that we have been developing on how machine learning and deep learning techniques can potentially assist obstetricians/gynecologists in better clinical decision-making, using infertile women in their treatment options in combination with mathematical modeling in pregnant women as examples.

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## Acknowledgments

We thank the following individuals in alphabetical order of their last name for very valuable comments: Medina Jackson-Browne (Brown University, Providence), N.V. Joshi (Indian Institute of Science, Bangalore), K. Praveen (Microsoft, Irvine), and P. Sashank (CEO, Exactco, Hyderabad).

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## Appendices

### Appendix 1

Machine Learning Algorithm for Fertility Treatment Outcome (MLAFTO)

Let *x*({*c*_{∗}, *d*_{∗}, *g*_{∗}, *o*_{∗}}) be the probability that an infertile woman with characteristics ∗ such that

∗ = 1, 2, …, *k* × *l* × *m* × *n* with *i*^{th}−ovulation induction (OI) treatment or *IVF* for *i* = 1, 2, …, *p* is conceived or delivered.

We compute *x* values for all ∗ combinations.

We compute \( \underset{i}{\max}\left(\underset{\ast }{\max }x\right) \), \( \underset{\ast }{\max}\left(\underset{i}{\max }x\right). \) Once the maximum probabilities are computed, ranking of these probabilities over various ∗ and *i* will provide relative chances of conceiving and delivering a live birth. AI quotient will match these combinations of ∗, and *i* is with the new couple who come to the clinic and suggest the probability of conceiving and delivering a live birth (see Appendix 2 for computing probabilities and descriptions related to *max* functions).

### Appendix 2

Computation of Probabilities Through Markov Chains

In this Appendix, we propose a Markov Chain-based approach in computing probabilities of conception and delivering a live birth under various treatment options.

Suppose we want to compute the probability of conception and then delivering a baby for an infertile woman with a combination of background variables, say {*c*_{5}, *d*_{4}, *g*_{1}, *o*_{1}} and with *OI*_{i} *or IVF* treatments explained in the paper. Let *B*_{1} be the set of all infertile women with background variables *B*_{1} = {{*c*_{5}, *d*_{4}, *g*_{1}, *o*_{1}} who will be on *OI*_{i} *or IVF* treatment options. Let \( x{\left({B}_1\right)}_{jc}^{(T)} \)be the probability that an infertile woman at the state *j* with characteristics {*c*_{5}, *d*_{4}, *g*_{1}, *o*_{1}} and with *i*^{th}−ovulation induction (OI) treatment or *IVF* for *i* = 1, 2, …, *p* is conceived in *T*− time steps. Let \( {x}_i{\left({B}_1\right)}_{jb}^{(T)} \)be such a probability to deliver a baby and *x*(*B*_{1})_{cb} be the probability of baby born to a woman within *B*_{1} given that the woman is conceived. These three probabilities can be computed using below formulas:

where \( {W}_{i,T}^{j\to c}(s) \) denotes *s*^{th} infertile woman in the state *j* who is on i^{th} treatment conceives in *T*− time steps and \( {W}_i^j(s) \) denotes *s*^{th} infertile woman in the state *j* who is on i^{th} treatment. \( \underset{s\epsilon {B}_1}{\int }{W}_{i,T}^{j\to c}(s) ds \) is the total number of infertile women in the set *B*_{1} who have moved from the state *j* to the state *c* who are on i^{th} treatment, and \( \underset{s\epsilon {B}_1}{\int }{W}_i^j(s) ds \) is the total number of women in the set *B*_{1} who are at the state *j* who are on i^{th} treatment. Suppose *B*_{2} be another set of all infertile women with different background variables, say *B*_{2} = {{*c*_{1}, *d*_{3}, *g*_{6}, *o*_{2}} with *OI*_{i} *or IVF* treatments}, and then we can compute corresponding transition probabilities by a similar type of formulas as in (*A*_{2.1}) − (*A*_{2.2}).

Probability of transition from the state *c* to the state *b* does not depend upon \( \underset{s\epsilon {B}_1}{\int }{W}_i^j(s) ds \) but only on the \( \underset{s\epsilon {B}_1}{\int }{W}_i^c(s) ds, \) so the random variable responsible for the transition between these two states, say *Y*, obeys Markov property. Moreover, the transition probability matrix *P*_{i}(*B*_{1}) for the set of infertile women *B*_{1} between states {*j*, *c*, *b*} who are on i^{th} treatment can be written as:

where *x*_{i}(*B*_{1})_{jj} + *x*_{i}(*B*_{1})_{jc} = 1, *x*_{i}(*B*_{1})_{cc} + *x*_{i}(*B*_{1})_{cb} = 1 and *x*_{i}(*B*_{1})_{bb} = 1. *x*_{i}(*B*_{1})_{jb} = 0 due to Markov property, whereas *x*_{i}(*B*_{1})_{cj} = *x*_{i}(*B*_{1})_{bj} = *x*_{i}(*B*_{1})_{bc} = 0 due to transition from *c* → *j*, *b* → *j*, and *b* → *c* are impossible. Similarly, we will compute:

for ∗ = 1, 2, …, *k* × *l* × *m* × *n*. Let \( {W}_i^j\left({B}_{\ast}\right) \) be the number of infertile women (state *j*) within background characteristics *B*_{∗} who are on i^{th} treatment, and let *W*^{j}(*B*_{∗}) be the total number of infertile women within background characteristics *B*_{∗} such that:

Once *P*_{i}(*B*_{∗}) is computed based on certain design of the sample population, the sizes of \( {W}_i^j\left({B}_{\ast}\right) \) are not changed for computing probabilities using (*A*_{2.1}) − (*A*_{2.2}). That is, the matrix *P*_{i}(*B*_{∗}) is not updated based on newer women who have started treatment after the designed time interval.

Two functions are \( \underset{i}{\max}\left\{{x}_i{\left({B}_{\ast}\right)}_{jc}\right\} \) and \( \underset{\ast }{\max}\left\{{x}_i{\left({B}_{\ast}\right)}_{jc.}\right\} \)

The function \( \underset{i}{\max}\left\{{x}_i{\left({B}_{\ast}\right)}_{jc}\right\} \) describes that the maximum of the probability values of women with background characteristics *B*_{∗} across all the treatments, which is obtained as:

Through the expression (*A*_{2.4}), we will obtain *k* × *l* × *m* × *n* maximum values, where each maximum value represents maximum probability of conceiving by an infertile woman from a particular set of background characteristics and corresponding treatment type for which this maximum value is obtained. Similarly, we can construct \( \underset{i}{\max}\left\{{x}_i{\left({B}_{\ast}\right)}_{cb}\right\}. \) The function \( \underset{i}{\max}\left\{{x}_i{\left({B}_{\ast}\right)}_{jc}\right\} \) describes that the maximum probability of conceiving within the women who are i^{th} treatment across different background characteristics, which is obtained as:

Let \( {W}_i^j\left({B}_{\ast}\right) \) be the number of infertile women (state *j*) within background characteristics *B*_{∗} who are on i^{th} treatment, and let *W*^{j}(*B*_{∗}) be the total number of infertile women within background characteristics *B*_{∗}, then:

See also Fig. 2 to see this disjoint property of infertile women within each background characteristics.

Result: Total infertile women with background characteristics {*B*_{∗}} can be written as the union of disjoint sets of women across all treatment options, i.e.,

### Appendix 3

Machine Learning Versus Deep Learning in Computing Probabilities of Conception and Delivery

Suppose a new infertile woman whose background characteristics {*B*_{N}} is interested to start one of the available treatments *OI*_{i} *or IVF*. Let us understand how machine learning techniques are applied to decide which of the treatment will give maximum chance of conception and delivering a baby. Prior to a decision-making process on treatment options for this woman, let us suppose that probabilities of conception and delivery were previously computed through MLAFTO explained in the Appendix 1 and *P*(*B*_{∗}) for all * in the Appendix 2. The data used for these two computations is usually a predetermined or pre-designed one, i.e., the time frame and other design aspects of the data were well defined and are without any data-related errors. MLAFTO matches the new infertile woman characteristic set *B*_{N} with the sets {*B*_{∗} : ∗ = 1, 2, …, *k* × *l* × *m* × *n*}. Let {*B*_{y}} be the set that matches with the new woman characteristics such that {*B*_{y}} − {*B*_{N}} = ∅ (null set). The corresponding values of

*x*(*B*_{y})_{jc} and *x*(*B*_{y})_{cb}

are considered as chances of conception and chances of delivery for the new woman who came to the clinic.

Note that the success or failure data of woman with {*B*_{N}} is not used in computation of *P*(*B*_{∗}) for all * which is the key for machine learning type of algorithm.

If each treatment trial of a woman whether or not that woman conceives is considered as onetime step of treatment (or one cycle of treatment) and the duration from conceiving of a woman to whether or not a baby is delivered is considered as onetime step of pregnancy (or one cycle of pregnancy), and let \( x{\left({B}_y\right)}_{jc}^{(n)} \) and \( x{\left({B}_y\right)}_{cb}^{(n)} \) be the corresponding *n*− step or *n*−cycle probabilities, then by Markov property, we have

When another infertile woman with background characteristics {*B*_{M}} comes to the clinic for the purpose of decision-making of which type of treatment will be needed for a successful delivery, the prior computed transition probability matrix *P*(*B*_{∗}) for all * that was used in matching for a woman with {*B*_{N}} was not updated with the success or failure information of the woman with {*B*_{N}}. In a way, the matrices *P*_{i}(*B*_{∗}) are static in case we are using machine learning algorithms, and these are not influenced by new data generated on newer infertile women who come to the clinic after constructing *P*_{i}(*B*_{∗}).

Once an infertile woman walks into the clinic with background characteristics {*B*_{M}}, if deep learning techniques are implemented to predict the probabilities of conceiving (say, *y*(*B*_{N})_{jc}) and the delivery (say, *y*(*B*_{N})_{jc}), then the computations of such probabilities are different than machine learning techniques. Each time a new infertile woman with {*B*_{M}} comes to the clinic for the treatment purposes, instead of matching procedure with the existing static model explained above, deep learning involves reconstructing of the transition probability matrices *P*_{i}(*B*_{∗}), for *i* = 1, 2, …, *p* for conceiving and delivery with whatever data that is available prior to arriving of the woman with {*B*_{M}}. Rest of the computational procedures explained in the Appendix 2 remains the same. Deep learning techniques usually delay the output due to reconstructing of the *P*_{i}(*B*_{∗}) each and every time a new infertile woman comes to clinic.

General introductions of machine learning techniques, motivations, and key ideologies that were explained in a variety of research areas can be found in [9,10,11,12,13]. Specific ideas related to deep learning techniques were also well developed [14], deep learning techniques and applications were summarized [15], and an overview of importance of machine learning algorithms in medicine can be found in [16]. As explained in our article, the machine learning and deep learning techniques broadly use the same data within the specific goals, but their approach of handling the data and models distinguish them from each other. Statistical thinking had contributed several aspects of machine learning, for example, in developing computationally intense data classification algorithms, methods in data search and matching probabilities, data mining techniques, model classification and model fitting algorithms, and a combination of all these (see, e.g. [17,18,19,20,21,22,23,24,25,26,27,28,29],, and for a collection of articles related to statistical methods in machine learning, see [30]. Model-based machine learning methods [31] and the construction of coefficients in a regression model can be benefited by machine learning methods [32].

Deep learning techniques, instead of focusing on model-based approaches, would assist in understanding intricate structures of the large data sets and various interlinkages between these data sets [33]. Importance of unsupervised pre-training to the structural architecture and the hypothesis of testing design effects of such experiments are well studied [34, 35]. Deep learning and machine learning techniques could also assist in questions related to health informatics, disease detection, item response theories, and bioinformatics research [36,37,38,39,40,41]. There were also successful methods in deep learning algorithms which score patients in intensive care unit (ICU) for their severity and predict mortality without using any model-based assumptions in scoring systems [42] and for other medical applications, for example, detection of worms through endoscopy [43], ophthalmology studies [44], cardiovascular studies [45], Parkinson’s disease data [46], and medical scoring systems [47]. Deep learning procedures involved in various levels of abstraction for ranking system models can be found in [48, 49]; applications for mathematical models, parameter computations, and stability of algorithms are found in [50,51,52,53,54,55,56].

Statistical and stochastic modeling principles were applied in deep learning algorithms to strengthen the object search capabilities or for improved model fitting in uncertainty [32, 57, 58]. Boltzmann machines assist in the deep understanding of the data by linking layer level structured data and then by estimating model parameters through maximum likelihood methods [59, 60]. Random backpropagation and backpropagation methods help in stochastics transition matrix formations and computing quicker search algorithms in higher dimensional stochastic matrices and literature related to backpropagation could be found in several places, for example, see in [61,62,63,64]. A survey of statistical learning algorithms and their performance evaluations can be found in [65].

### Appendix 4

Theorems

Theorem A.1: When *W*^{j} is the total number of infertile women (state *j*) whose data is used in the machine learning algorithm and *δ* ∈[1, *klmn*] and *α* ∈ [1, *p*] are considered as continuous for background characteristics and treatment options, then

*Proof:* We have,

and

Note that,

and

from the inequality (*A*_{4.3}), we can obtain,

from the inequality (*A*_{4.4}) we can obtain,

Required result is deduced from two inequalities (*A*_{4.5}) and (*A*_{4.6}).

Theorem A.2: For continuous *α* and *δ*, we have

*Proof:* We know,

These imply,

From (*A*_{5.7}) and (*A*_{5.8}), we can deduce required result.

Theorem A.3: Let *f* : *A* → *ℝ*^{+} and *g* : *B* → *ℝ*^{+} where *A* is the set of fractions of (*A*_{5.7}) and *B* is the set of all fractions of (*A*_{5.8}), and then *f* and *g* are defined only at the adherent points of *A* and *B*, respectively.

*Proof:* Note that,

and

Two sets *A* and *B* are constructed from (*A*_{5.7}) and (*A*_{5.8}) as

From the elements of the set *A* as in (*A*_{5.9}), *f* is not defined at open subintervals,

and from the elements of the set *B* as in (*A*_{5.10}), *g* is not defined at open subintervals

Hence, *f* and *g* are defined only at the adherent points of *A* and *B*.

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Srinivasa Rao, A.S., Diamond, M.P. Deep Learning of Markov Model-Based Machines for Determination of Better Treatment Option Decisions for Infertile Women.
*Reprod. Sci.* (2020). https://doi.org/10.1007/s43032-019-00082-9

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### Keywords

- Machine learning
- State spaces
- AI in medicine