Data collected through IVF- Worldwide.com

Transcription

1 Data collected through IVF- Worldwide.com Science vs. Clinical Practice Zeev Shoham, MD Director of the Reproductive Medicine and IVF Unit Department Ob/Gyn, Kaplan Medical Center Rehovot, Israel 1

2 Evidence Based medicine Best research evidence Clinical expertise Patients values. Quality - estimate of effect is correct. The strength - recommendation will do more good than harm. Patient concerns Dave Sackett Br Med J 1996;312:71-2. Best research evidence EBM Clinical experience

3 What is the evidence? Should decision be based on clinical development? Tradition Article Expert Money EBM That s how we do it here Few years ago we had a case just like this In my experience rfsh is not really better than any hmg drug.

4 3. Rapid Critical Appraisal It s peer-reviewed, therefore it must be OK?

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6 Step 4: Applying to the individual What do the results mean on average? What do they mean for this individual?

7 Ties with the industry: 87% of authors have ties to industry 58% receive financial support for research 38% serves as employs or consultants Roger Collier, CMAJ, 2011:183;3

8 When does it work? Straightforward and of high quality. Convince with the findings. Like the findings. Advantages are probably higher than the disadvantages.

9 Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomized multicentre trial. Term Breech Trial Collaborative Group. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Lancet Oct 21;356(9239):

10 Getting EBM into practice Easy Much evidence exists Good quality results Poor quality we like it accepted High quality does not like it - disregard

11 It is always better if it comes with: Positive feedback Guidelines Education Decision support system Patients pressure

12 Why evidence based fertility practice? Infertility treatment have limited success Costly Most choices are based on statistical probabilities Female age is a critical factor Ethnic differences

13 Latest news and upcoming events Links to growing business and product directories Links to latest videos 13 Interactive clinic locator with over 3,400 clinics

14 14 Locating an IVF clinic through the website is quick, easy and free; all clinics are verified before they are uploaded to the map

15 Wide use of online channels in patient diagnosis by physicians Web browsers, Medical websites and Online subscriptions "Physicians consulting physicians" IVF-Worldwide Blogs and Forums Physicians around the world will be able to consult the IVF- Worldwide advisory board on issues regarding diagnosis and treatment Medical professional can interact with one another to share knowledge and raise awareness of important issues Database of educational material Medical professional can review extensive database of educational material including textbooks, videos and articles 15

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17 Focus on professional education Launched 2009 Surveys Launched 2011 (LinkedIn, YouTube, Twitter, Facebook) Blogs / Forums Social Media Physicians consulting physicians Launched Q Launched 2008 Newsletters Online Journal Education Center IVF-Worldwide Online Informed Consent Expected launch 2014 Clinic Locator Virtual university Launched 2008 Current products and services Future products and services 17

18 18 Continuous Medical Education Survey Results

19 Is accredited CME mandatory in your country? How important is accredited CME to you? 19

20 What accredited CME activities do you find most useful and relevant to your practice? On line activities 20

21 What percent of your educational content do you receive electronically ( s, online journals, websites, etc.)? 66% 21

22 Minimising the risk of infection and bleeding at trans-vaginal ultrasound guided ovum pick-up Do you routinely give antibiotics? Severe pelvic infections is associated with significant morbidity. 22

23 EGG COLLECTION AND EMBRYO TRANSFER TECHNIQUES 261,300 IVF treatment cycles 359 centers from 71 countries

24 Results Cont. 53% The majority of studies concluded that the clinical outcomes were similar between women receiving 5000 or 10,000 IU of u-hcg. Tsoumpou et al. Reprod Biomed Online ;19:52-8. Optimal dose of HCG for final oocyte maturation in IVF cycles

25 Which P do you use? For How long? IVF survey Looking at academic and none-academic practice on a global scale!

26 Results (97 IVF units from 35 countries responded to the survey) IM-P 28%

27 Survey - IM progesterone IM progesterone, alone or in combination with vaginal progesterone, was used in 27% of the cycles A meta-analysis of the route of administration of luteal phase support in assisted reproductive technology: vaginal versus intramuscular progesterone. Zarutskie PW, Phillips JA. Fertil Steril 2009 Jul;92(1): RESULT(S): Vaginal progesterone Oil-in-capsule Bioadhesive gel IM P Cinical pregnancy (OR = 0.91, 95% [CI 0.74, 1.13]) Significantly lower rate of miscarriage was observed with vaginal P compared with IM P (OR = 0.54, 95% [CI 0.29, 1.02]).

28 Survey - hcg 6% Meta-analysis 95 studies OHSS was more than three-fold higher when hcg was administered compared with progesterone alone! Daya S, Gunby J. Luteal phase support in assisted reproduction cycles. Cochrane Database Syst Rev 2004(3):CD

29 Results

30 Prolongation of progesterone supplementation for 3 more weeks beyond the day of a positive pregnancy test had no influence on the miscarriage rate Ludwig M, Diedrich K. Acta Obstet Gynecol Scand 2001;80: Nyboe Andersen A, et al. Hum Reprod 2002;17: Aboulghar et al Hum Reprod 2008;23:

31 Lets assume that there is a justification to continue P supplementation? It is still not clear why in almost 30% of the cycles women should tolerate a prolonged treatment with daily IM injections, when the alternative vaginal route has comparable pregnancy rates.

32 There is a science and there is a practice and we are in practice..

33 This survey was done again..

34 Continent USA & Canada Number of cycles 26,200 Number of units 52 Central & South America 13, Australia & New Zealand Asia Europe Africa 17,900 63, ,700 13, ,

35 Current study (June 2012) Previous study (September 2009) Use of vaginal progesterone only Use of IM progesterone only Use of Oral progesterone only Use of combined drugs Use of hcg only Duration of use if the patient conceived 71.8% 5% 0.5% 17.3% 0% 12 weeks 28% 64% 13% 2% 16% 5% weeks 67%

36 Conclusion Daily practice Enable to raise and discuss the question why we do not follow the literature as it is? Data from academic and none academic clinics. EBM helps to find a framework for making optimal decision.

37 Education Clinical guidelines Follow-up Feedback

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