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Science vs. Clinical Practice

Data collected through IVF-Worldwide.com

Zeev Shoham, MD Director of the Reproductive Medicine and IVF Unit Department Ob/Gyn, Kaplan Medical Center Rehovot , Israel

Evidence Based medicine

Best research evidence

Clinical expertise

Patients values.

Quality - estimate of effect is correct.

Dave Sackett Br Med J 1996;312:71-2.

Patient

concerns

Best

research

evidence Clinical

experience

The strength - recommendation will do more good than harm.

EBM

What is the evidence?

Should decision be based on clinical development?

Tradition That’s how we do it here

Article Few years ago we had a case just like this

Expert In my experience

Money rFSH is not really better than any hMG drug

EBM …….

3. Rapid Critical Appraisal

It’s peer-reviewed, therefore it must be OK?

Step 4: Applying to the individual

What do the results mean on average?

What do they mean for this individual?

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

When does it work?

Straightforward and of high quality.

Convince with the findings.

Like the findings.

Advantages are probably higher than the disadvantages.

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. 2000 Oct 21;356(9239):1375-83.

Getting EBM into practice

Easy – Much evidence exists

Good quality results

Poor quality – we like it – accepted

High quality – does not like it - disregard

Positive feedback

Guidelines

Education

Decision support system

Patients pressure

It is always better if it comes with:

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

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Latest news and

upcoming events

Interactive clinic

locator with over

3,400 clinics

Links to growing

business and

product directories

Links to latest

videos

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

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Wide use of online channels in patient diagnosis by physicians Web browsers, Medical websites and Online subscriptions

Database of

educational material

IVF-Worldwide Blogs

and Forums

"Physicians

consulting

physicians"

Medical professional can

review extensive

database of educational

material including

textbooks, videos and

articles

Medical professional can

interact with one another

to share knowledge and

raise awareness of

important issues

Physicians around the

world will be able to

consult the IVF-

Worldwide advisory

board on issues

regarding diagnosis and

treatment

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IVF-Worldwide

Clinic Locator

Education Center

News-letters

Surveys

Blogs / Forums

Social Media

Physicians consulting physicians

Online Journal

Online Informed Consent

Virtual university

Focus on professional education

Launched

2011 (LinkedIn, YouTube, Twitter,

Facebook)

Launched

2009

Launched

Q1 2013

Expected

launch 2014

Launched

2008

Launched

2008

Current products and services Future products and services

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Continuous Medical Education – Survey Results

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Is accredited CME mandatory in your country?

How important is accredited CME to you?

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What accredited CME activities do you find most useful and relevant to

your practice?

On line activities

21

What percent of your educational content do you receive

electronically (emails, online journals, websites, etc.)?

66%

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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.

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

Tsoumpou et al. Reprod Biomed Online. 2009 ;19:52-8. Optimal dose of HCG for final oocyte maturation in IVF cycles

The majority of studies concluded that the clinical outcomes were similar between women receiving 5000 or 10,000 IU of u-HCG.

Results Cont.

53%

Which P do you use?

For How long?

IVF survey

Looking at academic and none-academic practice on a global scale!

Results (97 IVF units from 35 countries responded to the survey)

IM-P 28%

A meta-analysis of the route of administration of luteal phase

support in assisted reproductive technology: vaginal versus

intramuscular progesterone.

RESULT(S):

Vaginal progesterone

Oil-in-capsule

Bioadhesive gel

IM P

Zarutskie PW, Phillips JA. Fertil Steril 2009 Jul;92(1):163-9.

Significantly lower rate of miscarriage was observed with vaginal P compared

with IM P (OR = 0.54, 95% [CI 0.29, 1.02]).

Cinical pregnancy (OR = 0.91, 95%

[CI 0.74, 1.13])

Survey - IM progesterone

IM progesterone, alone or in combination with vaginal progesterone, was used in

27% of the cycles

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):CD004830.

Results

Ludwig M, Diedrich K. Acta Obstet Gynecol Scand 2001;80:452-466.

Nyboe Andersen A, et al. Hum Reprod 2002;17:357-361.

Aboulghar et al Hum Reprod 2008;23:857-862.

Prolongation of progesterone supplementation for 3 more

weeks beyond the day of a positive pregnancy test had no

influence on the miscarriage rate

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.

Lets assume that there is a justification to continue P supplementation?

There is a science and there is a

practice and we are in practice…..

This survey was done again …..

Number of units Number of cycles Continent

52 26,200 USA & Canada

46 13,300

Central & South

America

14 17,900

Australia & New

Zealand

89 63,300 Asia

185 150,700 Europe

22 13,200 Africa

408 284,600

Previous study

(September 2009)

Current study

(June 2012)

64% 71.8% Use of vaginal

progesterone only

13% 5% Use of IM progesterone

only

2% 0.5% Use of Oral progesterone

only

16% 17.3% Use of combined drugs

5% 0% Use of hCG only

10-12 weeks – 67% 12 weeks – 28% Duration of use if the

patient conceived

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.

Education

Clinical guidelines

Follow-up

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