The impact of an assisted conception unit on the workload of a general gynaecology unit

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1 BJOG: an International Journal of Obstetrics and Gynaecology February 2002, Vol. 109, pp The impact of an assisted conception unit on the workload of a general gynaecology unit Joanne McManus*, Anthony I. Traub The burden placed on a hospital by the presence of an assisted conception unit has been emphasised only in terms of its impact on neonatal services. This paper examines the previously neglected subject of the gynaecological workload generated by a tertiary fertility centre that provides treatments by assisted conception. As many IVF units operate independently this additional workload may not be appreciated. It has, however, significant practical and financial implications for neighbouring hospitals and trusts. This is of particular relevance in view of the move towards more uniform health service funding of assisted conception throughout the United Kingdom. Introduction It is well recognised that the introduction of assisted reproduction has been associated with a very significant increase in the workload of neonatal units 1,2. This is primarily due to the corresponding increase in multiple pregnancy that is a recognised complication or consequence of all forms of assisted conception and ovulation induction. With the daily cost of intensive care for a premature neonate approximately 1000, much has been written about the indirect additional cost of assisted conception as a result of the increased burden placed on neonatal and paediatric services. In contrast, the impact of a fertility unit on the workload of neighbouring gynaecology units has been neglected. Many in vitro fertilisation (IVF) units are either associated with a teaching hospital or district general hospital, and so have the support of the related maternity and gynaecological units. However, a large number operate independently, which means that associated gynaecological complications must be dealt with elsewhere. In addition, as a significant number of patients travel outside their local area or come from other countries for fertility treatment, it is difficult to quantify the gynaecological workload generated as a consequence of assisted conception. The burden placed on gynaecological services by assisted conception is twofold: 1. dealing with complications which occur during the treatment and 2. dealing with early pregnancy problems. Regional Fertility Centre, Royal Maternity Hospital, Belfast, UK * Correspondence: Dr J. McManus, Regional Fertility Centre, Royal Maternity Hospital, Grosvenor Road, Belfast BT12 6BB, UK. D RCOG 2002 BJOG: an International Journal of Obstetrics and Gynaecology PII: S (0 2) The aim of this study was to quantify the workload of a general gynaecology ward that was generated from an assisted conception unit situated on the same site. Background Several reviews have described the short term risks of IVF. Govaerts et al. 3 reported a 2.8% incidence of medical complications among 1500 IVF cycles, the most common being ovarian hyperstimulation syndrome. If severe, this condition is life-threatening, requiring intensive monitoring and expert management, while patients with even moderate ovarian hyperstimulation syndrome may also require hospital admission. In a series of 3500 treatment cycles, Serour et al. 4 reported complications in 291 women (8.3%). The major complication was with ovarian hyperstimulation syndrome, classified as moderate in 206 patients and severe in 60 patients among whom there were four cases of deep venous thrombosis and two cases of hemiparesis. Other early complications associated with IVF treatment are pelvic infection, bleeding, ovarian haemorrhage or torsion, and intraperitoneal trauma including bowel injury. Overall the expected rates of common complications are: moderate ovarian hyperstimulation syndrome 3% 4%, severe ovarian hyperstimulation syndrome 0.1% 0.2%, infection (e.g. tubo-ovarian abscess) 0.3% 0.4%, and direct trauma to pelvic organs during oocyte recovery 0.1% 0.2% 5. Women who conceive as a result of assisted conception are understandably anxious with regard to the viability and outcome of the pregnancy. Compared with women who conceive naturally, this concern begins at a much earlier stage, as pregnancy tests are often carried out less than two weeks after embryos are placed in the uterus. Following a positive pregnancy test a significant number of patients will present with complications such as pain or

2 208 bleeding. They all require a minimum of consultation, examination and ultrasound scan, and many will require careful follow up if an ectopic pregnancy is suspected, or viability is in doubt. Both situations may generate several visits and ultimately admission for a surgical procedure. This workload is considerable when miscarriage rates as high as 29% 2 and ectopic pregnancy rates of 5% 6% have been reported in IVF pregnancies. A postal survey was carried out on 250 women who had treatment with IVF or IVF with intracytoplasmic sperm injection in the Regional Fertility Centre between January and June The questionnaire enquired whether the woman had had to seek medical or nursing advice or required admission to hospital for any reason related to their treatment. Of 175 replies, 35 women (20%) sought telephone advice from medical or nursing staff; 17 (10%) attended either their general practitioner or local hospital with a problem; and 44 (24%) presented to a doctor in either the Regional Fertility Centre or the associated Royal Maternity Hospital. Of these 44 women, 21 (12% of total) were admitted to the Royal Maternity Hospital. Eleven were admitted with ovarian hyperstimulation syndrome, one had spontaneous rupture of membranes at 16 weeks of gestation and nine required evacuation of the uterus for a first trimester miscarriage. The rate of miscarriage among the women who replied to the survey was extremely low at only 12 out of 164 (7%). One woman with a complete miscarriage was not admitted and one was admitted to another hospital. Complications dealt with in the outpatient setting included: bleeding in early pregnancy, abdominal pain and mild ovarian hyperstimulation syndrome, a persistent large ovarian cyst requiring drainage, urinary retention and haematuria after egg collection, and drug reactions. In addition to complications of assisted conception treatments, there is a considerable workload generated by specialist fertility units with regard to investigative and therapeutic operative procedures. These include cervical dilatation, oocyte recovery, laparoscopy, hysteroscopy and operative treatment of pelvic pathology, discussed as follows. In women who have previously undergone a technically difficult embryo transfer, cervical dilatation under general anaesthetic has been shown to increase the chance of pregnancy if it is carried out two to three weeks before the subsequent embryo transfer 6. Some women cannot tolerate the procedure of oocyte recovery with systemic analgesia/sedation and so require admission for general anaesthetic as a day case. In some assisted conception units this is the standard practice for oocyte recovery but in our unit it is only on special request and so is not built into the cost of a treatment cycle. Laparoscopy is performed for investigation of infertility at the secondary care level and is not necessarily an additional expense associated with patients having assisted conception. However, the fact that a hospital has an assisted conception unit means that patients are often referred to it in preference to the local district general hospital where the initial fertility investigations could equally have been carried out. In addition, with the introduction of NHS funding for assisted conception, it is anticipated that more laparoscopies will be performed. These will be necessary to make a diagnosis of unexplained infertility as it is likely that stimulated intrauterine insemination in women with unexplained infertility will be a prerequisite for funded IVF. At present, for self-funded patients who are in their late thirties, laparoscopy, which is unlikely to detect correctable disease, is often omitted in an effort to expedite IVF. Hysteroscopy remains an investigation carried out mainly at a tertiary level, usually after unexplained failure of assisted conception. Surgical treatment of endometriosis is increasingly being performed, since ablation of minimal and mild endometriosis has been shown to result in an improved pregnancy rate compared with either expectant management or medical treatment. While this may be more appropriately carried out in a secondary care setting, many gynaecologists referring patients to tertiary infertility clinics prefer to minimise prior intervention. There is also an increasing trend towards carrying out elective salpingectomy before IVF for patients with hydrosalpinges, as it is thought that the presence of hydrosalpinx may have a negative effect on pregnancy rates. Methods Our study was carried out in the Royal Maternity Hospital, Belfast, a tertiary referral centre for obstetrics that also houses a general gynaecology unit, a regional neonatal unit and the Regional Fertility Centre. This is the only assisted conception unit in Northern Ireland and carries out approximately 1100 treatment cycles (IVF/intracytoplasmic sperm injection/frozen embryo transfer) per year. Over a two year period from August 1999 to July 2001 details of all women admitted to the gynaecology ward who had previously attended the Regional Fertility Centre were recorded. In order to audit this the ward clerk checked details of each woman admitted to the ward on the main hospital record system to establish if they had a prior attendance at the Regional Fertility Centre. In addition, the nursing care plan was modified so that all women were asked on admission if they had attended the Regional Fertility Centre. Results The resulting figures for admissions to the ward are shown in Table 1. There was a total of 498 women who

3 209 Table 1. Number of patients attending the Regional Fertility Centre who were admitted to the Gynaecology ward between August 1999 and July Patients admitted both as emergencies and for elective procedures are included. A duration of stay of 1 day represents a day case. Any overnight stay was counted as 2 days. Reason for admission Number of patients Average length of stay (days) Early pregnancy complications Ectopic pregnancy Threatened abortion 8 4 Evacuation uterus Hyperemesis Cervical cerclage 2 2 Admissions related to assisted conception treatments Oocyte recovery under GA 29 1 Complications of oocyte recovery Cervical dilatation 46 1 OHSS OHSS requiring paracentesis 15 Embryo transfer under GA 8 1 Infertility investigations/treatment Hysterosopy/laparoscopy Operative laparoscopy Miscellaneous Reversal sterilisation 7 4 Laparotomy Abdominal pain 9 4 Drainage of ovarian cyst 2 1 Drainage of pelvic abscess 1 2 Pelvic inflammatory disease 1 4 attended the Regional Fertility Centre and were admitted to the gynaecology ward over a two year period. This can be compared with 1640 women treated in the Regional Fertility Centre during the same period, with a total of 2215 treatment cycles including IVF, intracytoplasmic sperm injection and frozen embryo transfer and 1643 egg collections. If only the emergency admissions (i.e. the admissions for complications of treatment and early pregnancy (n ¼ 181)) are considered, this represents 8% of the total number of treatment cycles. This figure does not however take account of patients admitted elsewhere. If the service requirement procedures (i.e. cervical dilatations, oocyte recovery and embryo transfers under GA) are also included, this would represent 12% of the total number of treatment cycles. Women from the Fertility Centre represent 7% of the total number of 7242 treated in the gynaecology ward during that time. The investigative procedures of laparoscopy and hysteroscopy represent 33% of the total number diagnostic laparoscopies and hysteroscopies performed, while the number of fertility patients undergoing evacuation of the uterus performed represents almost 10% of the total (89 of 912). Out of 59 ectopic pregnancies treated in the study period 22 of these (37%) were in women who were attending the Regional Fertility Centre. Discussion It is clear that a tertiary fertility clinic will generate a significant gynaecological workload. As can be seen from Table 1, a large number of patients who attended the Regional Fertility Centre required admission to the gynaecological ward for a wide range of reasons. Although many were emergency admissions, a considerable part of the workload consisted of elective investigative procedures. These included hysteroscopies and laparoscopies, many of which were performed simultaneously. A significant proportion of the patients attending the Regional Fertility Centre come as tertiary referrals, and the basic investigations including laparoscopy may have already been performed. However almost none of the women will have had a prior hysteroscopy, a procedure which will then be performed if there is recurrent implantation failure, or endometrial pathology suspected on ultrasound. Since it has been suggested that surgical treatment of minimal and moderate endometriosis may increase pregnancy rates, more operative laparoscopies are being performed. All of the patients in this study who had an operative laparoscopy, had had a laparoscopy performed previously at which time the diagnosis of endometriosis was made. It remains to be seen however whether laparoscopic ablation of more severe endometriosis has a significant impact on success rates of assisted conception. It may actually be that the funding of an extra IVF cycle would be of more benefit to the couple with regard to pregnancy outcome, and hence more cost effective for the purchasers. It could be argued that these investigative and therapeutic procedures would be performed regardless of whether the patient is attending a tertiary fertility centre or not, and that they might actually reduce the number of patients that need to proceed to IVF. However in the context of this paper we are examining the gynaecological workload generated by our assisted conception unit, which in Northern Ireland attracts additional secondary care referrals from outside the catchment area of the hospital. During the period , 63 cervical dilatations were carried out under general anaesthetic in women about to undergo treatment with IVF, intracytoplasmic sperm injection or frozen embryo transfer, who had a history of a very difficult embryo transfer 6. This operation is rarely performed today except in relation to fertility treatment. In the two year period of this study 46 cervical dilatations were carried out. This represents 2.8% of patients treated in the Regional Fertility Centre, at a cost of 592 per patient.

4 210 Apart from the investigative and therapeutic procedures, a considerable number of admissions to the gynaecology ward were the result of complications of all fertility treatments. Predominantly these were complications of early pregnancy: hyperemesis and miscarriage as well as investigation and treatment of ectopic pregnancies. In addition to the surgical management of miscarriage, a large workload is generated by problems such as bleeding in early pregnancy leading to repeated outpatient attendances when there is either doubt or simply anxiety in relation to viability. They include attendances at the Fertility Centre itself, which the patient is encouraged to use as the first port of call, as well as attendances at the gynaecology admission unit and the Early Pregnancy Problem Clinic. Many of the women who were admitted with pregnancy complications, preferred to be admitted to this hospital only because they had attended the Regional Fertility Centre for treatment, although other hospitals may have been geographically more convenient for them. Ovarian hyperstimulation syndrome is the other major complication of treatment with which patients are strongly encouraged to present specifically to either the Fertility Centre itself or, out of hours, to the general gynaecology admission unit in Royal Maternity Hospital. This is a condition which necessitates management in a specialist unit, and which may have disastrous consequences for the patient if not managed by appropriately experienced medical personnel. A long stay in hospital is often required (average 5.7 days among our patients) with blood investigations on a daily basis. Many patients with this condition require paracentesis, and in the above series this procedure was carried in 15 of the 47 women who were admitted, with some having it performed more than once (Table 1). More severe cases may also require aspiration of pleural effusions or even admission to an intensive care unit if there are additional complications. At a daily bed cost of plus the costs of IV fluids, blood chemistry analysis, thrombophylaxis treatment and a minor operative procedure if paracentesis is required, this would increase considerably the cost of a patient s fertility treatment. In this study complications directly related to the procedure of egg collection fortunately were rare. However, the geographic situation of our unit in relation to referring district general hospitals may account for some patients with such complications other than immediate, being more likely to present to their local hospital. In the post-treatment survey performed, 10% of patients attended their general practitioner or local hospital with a problem related to their assisted conception treatment. In attempting to quantify this additional workload in terms of cost, we could consider only the procedures related directly to assisted conception treatment plus the emergency admissions occurring as a direct result of treatment. Including oocyte recoveries under GA, cervical dilatation and embryo transfer under GA, this amounts to 83 day cases at a cost of 592 per case, giving a total of 49,136. Women admitted with ovarian hyperstimulation syndrome incur a daily bed cost of 198 which over the two year period would amount to 53,44 considering 47 patients had an average length of stay of 5.7 days. This does not include the price of IV fluids, blood investigations, etc. An evacuation of the uterus is also costed at 592 for a day case procedure, with the 89 carried out resulting in a cost of 52,688. Twenty-two women with ectopic pregnancies all had the minimum of a laparoscopy performed, and with an average length of stay of 3.4 days, this added up 13,24 plus 10,454 for additional bed days (i.e. a total of 23,478). Eleven patients with hyperemesis staying an average of 8.8 days would incur a cost of 19,166. This makes a total of 197,512 over the two years and divided among the 1643 egg collections carried out would represent an additional cost of 120 per egg collection. If one also takes into account the investigative procedures and operative laparoscopies, an additional cost of 111,888 for 189 cases at 592 per case, would result, assuming all were day cases. However, the average length of stay was greater than one day for these procedures (Table 1) which would increase the cost further amounting to a total additional cost per treatment cycle of 188. Conclusion This paper clearly highlights the very significant gynaecological workload generated by a tertiary fertility centre. It is, however, an under-estimate, as it examines the workload related to the gynaecological ward but does not take account of all outpatient attendances (emergency scans etc). Where a fertility centre is part of a hospital incorporating general gynaecology and obstetrics, this workload can to some extent be realised. However, many IVF units within the UK are completely independent, lacking the backup of an associated gynaecology or maternity unit. The question then arises as to where the work generated by these units becomes absorbed, and what are the resultant implications both practically and financially for neighbouring gynaecology units and their incorporating trusts. The calculations in this paper suggest that the average IVF cycle is undercosted by approximately 10% ( ). The generally inadequate funding of assisted conception by health boards has not taken account of this additional workload and financial burden that is clearly significant for both the purchaser and the provider. References 1. Levenne MI, Wild J, Steer P. Higher multiple births and the modern management of infertility in Britain. For the British Association of Perinatal Medicine. Br J Obstet Gynaecol 1992;99: Mc Faul PB, Patel N, Mills J. An audit of the obstetric outcome of 148 consecutive pregnancies from assisted conception: implications for neonatal services. Br J Obstet Gynaecol 1993;100:

5 Govaerts I, Devreker F, Delbaere A, Revelard P, Englert Y. Short term medical complications of 1500 oocyte retrievals for in vitro fertilization and embryo transfer. Eur J Obstet Gynecol Reprod Biol 1998;77: Serour GI, Aboulghar MD, Mansour R, Sattar MA, Amin Y, Aboulghar H. Complications of medically assisted conception in 3,500 cycles. Fertil Steril 1998;70: Barlow DH. Short and long term risks for women having IVF: what is the evidence? Hum Fertil 1999;2: McManus J, McClure N, Traub AI. The effect of cervical dilatation in patients with previous difficult embryo transfer. Fertil Steril 2000; 74(Suppl):159. Accepted 31 October 2001

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