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OT4@ASRM -SF Postgraduate April 1999[E]JWHEN TO PROCEED TO ART: WHAT PROCEDURE FOR WHICH COUPLE AT WHOSE PROGRAM? BK$1$ K DAVID ADAMSON, MD, FRCSC, FACOG, FACS Director, Fertility Physicians of Northern California Clinical Professor, Stanford University Associate Clinical Professor, UCSF f' 6`M   ^LEARNING OBJECTIVES  v1. To list factors which determine when patients should proceed to ART. 2. To describe the effectiveness of different procedures and to differentiate optimal outcomes from maximum pregnancy rates in an ART program. 3. To identify and enumerate attributes of a good ART program. 4. To describe decision-making approaches which result in appropriate patient selection for ART.&w-I w _ INTRODUCTION  I1978 Louise Brown 2001 An international industry >150,000 U.S. births(22 J THE DOLLAR COST OF ART  \Numerous estimates US average 1995 $6,233 HMO $6,265 Ohio 1996 $7,500 US average 2001 $11,000 ($7,000-$15,000) Problems with estimates Different geographical areas Different years Different health care systems Poor differentiation of charges, costs and paid L|| ] WHO S PAYING?  Different payers Patient Employer Insurance company Government Real economic costs Actual costs Tax status of organization Lost income to patient Lost work time to employer Lost personal, family and social productivityL..  `+WHEN TO PROCEED TO ART Absolute Indications , Fallopian tube damage Obstruction or non-reparable damage Two or more ectopic pregnancies Length < 4 cm post reversal Endometriosis (severe) Male Factor TMS < 1 M Strict morphology < 4% Limited quantity post cryopreservation Ovulatory dysfunction Unacceptable risk of OHHS Oocyte donation Duration of infertility > 3 or 4 years Multiple factor infertility ` # H  * C `"+*) d a+WHEN TO PROCEED TO ART Relative Indications , Fallopian tube damage Limited prognosis following surgery High antichlamydia antibody titer One prior ectopic Failure to conceive one year post reanastomosis Endometriosis Failure to conceive 18 months postopL%%  b5WHEN TO PROCEED TO ART Relative Indications (contin.)&6,  6  Male factor Moderate sperm dysfunction and failure to conceive post COH/IUI Failure to respond to male factor treatment Moderately limited sperm quantity post cryopreservation Failure to conceive following COH/IUI Unacceptable risk of multiple pregnancy with COH/IUI 6 \ \  c2INFERTILITY FACTORS WHICH CANNOT BE TREATED BY ART 3 Poor response to gonadotropins Myomas Adenomyosis Intrauterine adhesions Congenital uterine anomalies, including DES Absolute azoospermia Repeated pregnancy loss Incompetent cervix  dHYDROSALPINX AND ART$    V Increase LBR from 15% to 25% Patient selection--ultrasound Laparoscopy Repair Removal<GG W eMYOMAS AND ART$   Historically Uterine cavity distortion Single myoma 8 cm 3+ myomas 5 cm or larger Menorrhagia New Data (Wood 1998) No myomas LBR 39% Myomas Intramural LBR 16% Subserosal LBR 10%` Q' Q'    f  WHAT ART PROCEDURE?($$  gIVF vs. GIFT vs. ZIFT  GIFT LBR > IVF LBR ? Superior technique ? Patient selection 1997 SART LBR per Retrieval IVF 27.9% (94% of cycles) GIFT 30.0% (4% of cycles) ZIFT 28.0% (2% of cycles) GIFT equivalent to ZIFTv)T         hICSI vs. SPERM DONOR  ICSI Indications TMS < 100,000 Strict morphology < 5% ICSI Results 1997 SART data ICSI LBR < 27.1% vs. non-ICSI 28.4% Used in 35.6% of IVF cycles Donor Sperm Option LBR 6 - 10% / month Cost $500 / month CounselingPZ&Z ZQZZ3Z                        i*ASSISTED HATCHING vs. NO ASSISTED HATCHING + Literature results mixed Indications Woman > 38 Thickened zona pellucida Failed prior IVF SART / ASRM Possibly helpful in selected patientsr%5 &%.&  j"IMMUNOTHERAPY vs. NO IMMUNOTHERAPY # Controversial but recent studies have clarified Anticardiolipin Antibody Syndrome APTT and anticardiolipin antibodies test Aspirin and heparin treatment Very small number of patients Paternal leukocyte immunization: experimental Immune globulin: experimentalZReLRe  k1BLASTOCYST CULTURE / TRANSFER vs. EMBRYO TRANSFER$2 2 DOpportunity to reduce high-order multiple birth Pregnancy rate probably not increased Limited number of patients with sufficient day 3 embryos to culture Culture success rate 30% - 60% Should all embryos be grown to blastocysts--NO Variability in blastocyst culture success Lower pregnancy rates with frozen/thaw blastocystsnVZcZZV[ 9    lNUMBER OF EMBRYOS TO TRANSFER  SART Guidelines <35 good prognosis 2 < 35 3 35 - 39 4 40+ 5 Factors Ability to identify good-quality embryos Blastocyst culture capabilities Cryopreservation success rates Insurance coverage3{  b  m;1996 SART PREGNANCY RATES PER NUMBER OF EMBRYOS TRANSFERRED < $IMPACT OF HIGH-ORDER MULTIPLE BIRTHS % Neonatal morbidity and mortality Maternal morbidity and mortality Long-term health problems of children Family dysfunction Loss of economic productivity Loss of societal support for infertility coverage Loss of societal support for reproductive medicine   AVOIDANCE OF MULTIPLE BIRTHS  Non-ART treatments when appropriate Lower dose of stimulation drugs Cancel non-IVF cycles with >5 follicles Replace fewer embryos Blastocyst culture and transfer Therapeutic fetal reduction Excellent obstetrical care  n=PROPORTION OF MULTIPLE BIRTHS CORRELATED WITH LIVE BIRTH RATE > o9NUMBER OF MULTIPLE BIRTHS CORRELATED WITH LIVE BIRTH RATE : p2COSTS OF PERINATAL CARE PER BABY AND PER PREGNANCY 3 qCOSTS OF PERINATAL CARE  r(CRYOPRESERVATION vs. NO CRYOPRESERVATION ) s20% of cycles cryopreserved LBR / transfer 18.8% (CF 27.9% fresh) SART guidelines for number of embryos to transfer~t 3 t s3INDUCED REDUCTION vs. HIGH-ORDER MULTIPLE PREGNANCY 4 "Moral and psychological issues Loss of pregnancy < 5% Improved fetal outcome Limitation of embryo transfer number if IR not acceptable Counseling$1`  t!DONOR OOCYTES vs. PATIENT OOCYTES " Alternative, not treatment Choice based on: Age FSH, E2 Response to gonadotropins Failed IVF cycles SART LBR 40% Issues Oocyte sharing Payment to donors Health risks to donor Counseling 8 7  - 7   uHOST UTERUS vs. PATIENT UTERUS  Effective alternative for medical conditions Absent or removed uterus Adenomyosis Intrauterine adhesions Myomas Incompetent cervix Counseling SART LBR 35%j-@V `(-V         vASRM / SART GUIDELINES$  AClinical Practice Laboratory Practice Advertising Research Ethics B w  WHAT ART PROGRAM?($$  xHIGH QUALITY LABORATORY  Maximum fertilization, maturation and implantation rates Personnel Physical plant Systems and protocols SART guidelines Accreditation  yHIGH QUALITY CLINICAL CARE  Trained physicians Experience in all aspects of reproductive medicine and surgery, and andrology Supportive staff and ambience   zCOMPREHENSIVE SERVICES  IVF, GIFT and ZIFT Donor gametes, host uterus ICSI, embryo hatching Blastocyst culture Cryopreservation Access to endocrinology, andrology and genetics laboratories  {PATIENT CHOICE  Consultation regarding all choices Costs and benefits of all options Risks and complications Patient-specific prognosis Appropriate consent forms Second opinions$d=  |EXCELLENT DOCUMENTATION  Clinical history and physical Laboratory testing Diagnosis, prognosis and plan Informed consent Clinical care Embryology laboratory Standardized protocols and forms  }RESEARCH  RClinical research Laboratory research Increased knowledge More critical assessment S ~PROFESSIONAL MANAGEMENT  2Business management Financial management Insurance 3 COST-EFFECTIVE CARE  FClinically-appropriate services Reasonable charges Outcomes assessment$G < G PSYCHOLOGICAL SUPPORT  vLife crisis for many patients All staff involved Physicians must set tone Referral RESOLVE Mental health professionals0S$S w  ETHICAL CARE  Ethical issues IVF Multifetal reduction Religious proscriptions Third party reproduction Marital and sexual orientation status Managed care limitations Sex selection Embryo and stem cell research&     WHICH COUPLE SHOULD UNDERGO ART?(!$$ !  WHICH COUPLE SHOULD UNDERGO ART?$! ! _Complex question History and physical Patient objectives Identify options Cost-benefit analysis$`N ` COST-BENEFIT ANALYSIS$  Benefit = Cost =8 @   QValue to patient X Probability of occurrence Financial + Time + Physical + Mental-@% %  R FACTORS FAVORING ART  Age > 35 Diagnosis Prior treatment Duration of infertility Prior pregnancy history Number prior ART attempts Reasonable prognosis$}  SUMMARY  WPowerful new technology Rapid advances Issues Ethical Health Cost Physician involvement6.. X /  ` ff3Ý` fff3f` ___>?" dd@$?l2d@nf3  d3@lA|Ĝ`nP n?" dd@   @@``PR    @ ` `ϝp>> ph(  ZF   P`~  N2?~  N2?  ZTngg ?P )  V CLICK TO EDIT MASTER TITLE STYLE! ! <  Tngg ? )  RClick to edit Master text styles Second Level Third Level Fourth Level Fifth Level!     S    `ngg ?`, )  [*     `tngg ?`  )  ]*  Z  B3dfއh? ? 3f)))3f Double Lines  yq@ (     Z4~gg ?P )  V Click to edit Master title style! !   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No place to keep them. No basement. Sometimes having little space is a good thing. If I had to look at the boxes every day they'd be outta here a long time ago. Now it's just going to be a pain getting rid of them. > > > That sounds great. It's fun to create and organize. > Well it's easier once everything is organized. Now I can visualize doing other things. > Are you going to make the kayak over the winter and have ready for spring? That's the plan. Kathy's is going to be first since it'll be the easiest. > > When do classes start? Classes start on August 27. The last day is Dec 7. Then Finals are over the 17th. But I lucked out! My finals are the first day of Finals so I'm out super early!!!! Yippeeeee. > I installed AOE yesterday. So now I just have to find a good time. Just let me know. I'll even play in the morning hours. My pal in Germany is now in North Carolina. He'll be online in a couple of weeks with DSL also and is willing to play a little AOE. Hey, I'm setting up a Fantasy football league. If you wanna join up just let me know. Take it easy. John > Jim ===== __________________________________________________ Do You Yahoo!? Make international calls for as low as $.04/minute with Yahoo! Messenger http://phonecard.yahoo.com/ From ???@??? Sat Aug 18 23:49:54 2001 Return-Path: Received: from [206.19.13.72] (san-28-b-72.san.dsl.cerfnet.com [206.19.13.72]) by dwm2.dwmi.com (8.9.3/8.9.3) with ESMTP id QAA09225 for ; Sat, 18 Aug 2001 16:07:29 -0700 User-Agent: Microsoft-Outlook-Express-Maci#_H Jim Bremner001 16:07:30 -0700 Subject: store From: "jim@dwmi.com" To: Jim Bremner Message-ID: Mime-version: 1.0 Content-type: text/plain; charset="US-ASCII" Content-transfer-encoding: 7bit X-UIDL: 0#E!!,/)"!7MM"!F[(!! Hi I have updated all the store pages so you need to run a new search of the store products. Jim Bremner Digital West Media Inc. dba DesertUSA.com 16855 West Bernardo Drive Suite 240 San D