Upload
others
View
6
Download
0
Embed Size (px)
Citation preview
1
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
13
Latest news and
upcoming events
Interactive clinic
locator with over
3,400 clinics
Links to growing
business and
product directories
Links to latest
videos
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
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
16
17
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
18
Continuous Medical Education – Survey Results
19
Is accredited CME mandatory in your country?
How important is accredited CME to you?
20
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%
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.
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
Feedback