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Man JKY, Parker AE, Broughton S, Ikhlaq H, Das M. Should IUI replace IVF as first-line treatment for unexplained infertility? A literature review. BMC Womens Health 2023; 23:557. [PMID: 37891606 PMCID: PMC10612289 DOI: 10.1186/s12905-023-02717-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 10/17/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Unexplained infertility accounts for 25% of infertility causes in the UK. Active intervention methods, such as intrauterine insemination (IUI) or in vitro fertilisation (IVF), are often sought. Despite the National Institute for Health and Care Excellence (NICE) recommending IVF for unexplained infertility, this recommendation has generated an ongoing debate, with few fertility clinics discontinuing the use of IUI as the first-line management of choice. In contrast to NICE, recent guidance released from the European Society for Human Reproduction and Embryology (ESHRE) in August 2023 supports the use of IUI as first-line. High-quality evidence behind such interventions is lacking, with current literature providing conflicting results. AIMS This review aims to provide a literature overview exploring whether IUI or IVF should be used as first-line treatment for couples with unexplained infertility, in the context of current guidelines. METHODS The primary outcome used to assess efficacy of both treatment methods is live birth (LB) rates. Secondary outcomes used are clinical pregnancy (CP) and ongoing pregnancy (OP) rates. A comprehensive literature search of 4 databases: Ovid MEDLINE, EMBASE, Maternity & Infant Care and the Cochrane Library were searched in January 2022. Upon removal of duplications, abstract screening, and full-text screening, a total of 34 papers were selected. DISCUSSION/CONCLUSION This review highlights a large discrepancy in the literature when examining pregnancy outcomes of IUI and IVF treatments. Evidence shows IUI increases LB and CP rates 3-fold compared to expectant management. Literature comparing IUI to IVF is less certain. The review finds the literature implies IVF should be used for first-line management but the paucity of high-quality randomised controlled trials (RCTs), coupled with heterogeneity of the identified studies and a lack of research amongst women > 40 years warrants the need for further large RCTs. The decision to offer IUI with ovarian stimulation (IUI-OS) or IVF should be based upon patient prognostic factors. We suggest that IUI-OS could be offered as first-line treatment for unexplained infertility for women < 38 years, with good prognosis, and IVF could be offered first to those > 38 years. Patients should be appropriately counselled to enable informed decision making.
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Affiliation(s)
- Jessica Ka-Yan Man
- Faculty of Medicine, Imperial College London (Hammersmith Campus), Du Cane Road, London, W12 0NN, UK.
| | - Anne Elizabeth Parker
- Faculty of Medicine, Imperial College London (Hammersmith Campus), Du Cane Road, London, W12 0NN, UK
| | - Sophie Broughton
- Faculty of Medicine, Imperial College London (Hammersmith Campus), Du Cane Road, London, W12 0NN, UK
- Medical School, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Hamza Ikhlaq
- Faculty of Medicine, Imperial College London (Hammersmith Campus), Du Cane Road, London, W12 0NN, UK
| | - Mausumi Das
- Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London, W12 0HS, UK
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Sarwari M, Beilby K, Hammarberg K, Hickey M, Lensen S. Endometrial scratching in Australia, New Zealand and the United Kingdom (UK): a follow-up survey. HUM FERTIL 2023; 26:599-604. [PMID: 34905720 DOI: 10.1080/14647273.2021.1995902] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 08/30/2021] [Indexed: 10/19/2022]
Abstract
Endometrial scratching is a common IVF add-on. In 2015, a survey in Australia, New Zealand and the United Kingdom (UK) reported that 83% of fertility specialists recommended endometrial scratching for IVF. Several large trials have since been published reporting no clear evidence for improved live birth rates following endometrial scratching before IVF. An online survey was undertaken to ascertain the current practices and views across Australia, New Zealand, and the UK. A total of 121 eligible responses were received between October and December 2020 (fertility specialists (n = 61), embryologists (n = 26) and fertility nurses (n = 24)). Among fertility specialists, 34% currently offer endometrial scratching, mostly in the case of recurrent implantation failure. Most respondents were neutral or did not believe endometrial scratching improved pregnancy and live birth rates (>90%), except for in women with recurrent implantation failure (29% believed it can increase pregnancy and live birth rates in this group). More than half of respondents viewed reducing psychological distress as a benefit of endometrial scratching (55%). Among fertility specialists not offering endometrial scratching, 51% previously offered it but no longer do. The decline in use over the last five years likely reflects a response to recent evidence reporting no benefit from the procedure.
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Affiliation(s)
- Madina Sarwari
- Department of Obstetrics & Gynaecology, Monash University, Melbourne, Australia
| | - Kiri Beilby
- Department of Obstetrics & Gynaecology, Monash University, Melbourne, Australia
| | - Karin Hammarberg
- Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Martha Hickey
- Department of Obstetrics and Gynaecology, Royal Women's Hospital, University of Melbourne, Melbourne, Australia
| | - Sarah Lensen
- Department of Obstetrics and Gynaecology, Royal Women's Hospital, University of Melbourne, Melbourne, Australia
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3
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Moore V, Rumbold A, Fernandez R, McElroy H, Moore L, Giles L, Grzeskowiak L, Roughead E, Stark M, Davies M. Dispensing of clomiphene citrate to treat infertility: medication supplied and population prevalence of assisted pregnancies and multiple births. Fertil Steril 2021; 117:202-212. [PMID: 34656304 DOI: 10.1016/j.fertnstert.2021.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/30/2021] [Accepted: 08/16/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the proportion of pregnancies resulting in birth that were conceived with the use of clomiphene citrate (CC) and the frequency of multiple pregnancy. DESIGN Whole-of-population cohort study, constructed through data linkage. Comprehensive Australian Government records of dispensed medications were linked to state Perinatal Registry records for all births of at least 20 weeks' gestation. SETTING The state of South Australia. PATIENT(S) Women who maintained pregnancy for at least 20 weeks and gave birth between July 2003 and December 2015, a total of 150,713 women with 241,561 pregnancies. INTERVENTION(S) Not applicable. MAIN OUTCOME MEASURE(S) Ongoing pregnancy occurring in proximity to CC, defined as dispensing from 90 days before to the end of a conception window derived from newborn date of birth and gestational age. RESULT(S) Linkage to dispensed prescription records was achieved for 97.9% of women. Women who conceived with CC tended to be older and socioeconomically advantaged and more likely than other women to have a history of miscarriage. Ongoing pregnancies associated with CC comprised 1.6% of the total; 5.7% were multiple births (mostly twins, 94.6%) compared with 1.5% in the remainder (98.5% twins). CONCLUSION(S) In South Australia, 1.6% of pregnancies (1 in 60) of at least 20 weeks' gestation were conceived proximal to CC dispensing. Of these, 5.7% were multiple pregnancies. This takes the proportion of women who achieved an ongoing pregnancy with medical assistance from 4.4%, based on reports from assisted reproductive technology clinics, to 6% in total.
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Affiliation(s)
- Vivienne Moore
- School of Public Health, The University of Adelaide, South Australia; Robinson Research Institute, The University of Adelaide, South Australia.
| | - Alice Rumbold
- Robinson Research Institute, The University of Adelaide, South Australia; South Australian Health and Medical Research Institute, South Australia
| | - Renae Fernandez
- Robinson Research Institute, The University of Adelaide, South Australia; Discipline of Obstetrics and Gynaecology, The University of Adelaide, South Australia
| | - Heather McElroy
- Discipline of Obstetrics and Gynaecology, The University of Adelaide, South Australia
| | - Lynette Moore
- SA Pathology, Women's and Children's Hospital, Adelaide, South Australia; Discipline of Medical Sciences, The University of Adelaide, South Australia
| | - Lynne Giles
- School of Public Health, The University of Adelaide, South Australia; Robinson Research Institute, The University of Adelaide, South Australia
| | - Luke Grzeskowiak
- Robinson Research Institute, The University of Adelaide, South Australia; South Australian Health and Medical Research Institute, South Australia; Discipline of Obstetrics and Gynaecology, The University of Adelaide, South Australia; College of Medicine and Public Health, Flinders University, South Australia
| | - Elizabeth Roughead
- Quality Use of Medicines and Pharmacy Research Centre, University of South Australia, South Australia
| | - Michael Stark
- Robinson Research Institute, The University of Adelaide, South Australia; Discipline of Obstetrics and Gynaecology, The University of Adelaide, South Australia
| | - Michael Davies
- Robinson Research Institute, The University of Adelaide, South Australia; Discipline of Obstetrics and Gynaecology, The University of Adelaide, South Australia
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4
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Siristatidis C, Pouliakis A, Sergentanis TN. Special characteristics, reproductive, and clinical profile of women with unexplained infertility versus other causes of infertility: a comparative study. J Assist Reprod Genet 2020; 37:1923-1930. [PMID: 32504303 DOI: 10.1007/s10815-020-01845-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 05/28/2020] [Indexed: 01/19/2023] Open
Abstract
PURPOSE To investigate whether women with unexplained infertility (UI) demonstrate different demographic and IVF characteristics compared to those with other causes of infertility. METHODS Data on 245 couples that underwent a total of 413 IVF/ICSI cycles were analyzed (UI 114 cycles, 73 women; anovulation (PCO/PCOS) 83 cycles, 51 women; tubal factor 85 cycles, 47 women; male factor 131 cycles, 74 women). Features of UI were compared versus other infertility groups, after adjustment for multiple comparisons. Generalized least squares (GLS) and random-effects logistic regression analysis were also performed. RESULTS Live birth rates, consisting of the primary outcome, were similar in all compared infertility groups. Compared to male infertility, UI was associated with woman's older age at cycle, lower body mass index (BMI), and higher follicle-stimulating hormone (FSH). Compared to tubal infertility, UI was linked to lower endometrial thickness at oocyte retrieval and lower BMI; compared to anovulatory infertility related to PCO/PCOS, UI was linked to woman's older age, more frequent smoking, and poorer ovarian reserve tests (FSH and antral follicle count). After adjustment for other types of infertility, woman's age, age at menarche, and FSH levels, anovulatory infertility presented with higher odds of clinical pregnancy compared to UI (adjusted OR = 2.13, 95% C: 1.01-4.52). CONCLUSIONS Infertile women with UI undergoing assisted reproduction demonstrate different demographic and clinical characteristics compared to those of other causes of infertility, albeit live birth rates are similar.
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Affiliation(s)
- Charalampos Siristatidis
- Assisted Reproduction Unit, Third Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, "Attikon" University Hospital, 1 Rimini Street, Chaidari, 12642, Athens, Greece.
- Assisted Reproducton Unit, Second Department of Obstetrics and Gynecology, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - Abraham Pouliakis
- Second Department of Pathology, Medical School, National and Kapodistrian University of Athens, "Attikon" University Hospital, 1 Rimini Street, Chaidari, 12642, Athens, Greece
| | - Theodoros N Sergentanis
- Department of Clinical Therapeutics, Medical School, National and Kapodistrian University of Athens, "Alexandra" Hospital, 80 Vas. Sofias Ave, 11528, Athens, Greece
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Garthwaite H, Stewart J, King K, McGarry K, Wilkes S. Ultrasound monitoring during first-cycle treatment with clomifene citrate: a national survey of compliance with NICE. HUM FERTIL 2018; 23:193-199. [PMID: 30388382 DOI: 10.1080/14647273.2018.1535201] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The National Institute for Health and Care Excellence Clinical Guideline 156 advises that transvaginal ultrasonography (TVUS) should be used in the first cycle of treatment with clomifene citrate, to assess for multifollicular development and hence the risk of multiple pregnancy. This guidance is based on expert opinion rather than research evidence. We conducted a cross-sectional online and postal survey among UK-based consultant gynaecologists and fertility specialists, to explore compliance with this guideline. A total of 110 responses met the inclusion criteria. During first-cycle treatment with clomifene, 50.9% of respondents were not always using TVUS, and 21.8% never were. Clinicians who did not have immediate access to TVUS were significantly less likely to scan (p < 0.01). Other key factors influencing practice were, personal experience of the clinician, lack of an evidence base to support the guideline and a willingness to accept the risk of multiple pregnancy. Several respondents questioned the value of scanning the first cycle only and highlighted that over-response may be seen in subsequent cycles. This study confirms that there is variation in adherence to the guideline and uncertainty about the clinical need for scan monitoring. Further evidence to support or refute the guideline is required.
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Affiliation(s)
- Heather Garthwaite
- Faculty of Health Sciences & Wellbeing, University of Sunderland, Sunderland, UK
| | - Jane Stewart
- Newcastle Fertility Centre, International Centre for Life, Newcastle-upon-Tyne, UK
| | - Kathryn King
- Faculty of Health Sciences & Wellbeing, University of Sunderland, Sunderland, UK
| | - Ken McGarry
- Faculty of Health Sciences & Wellbeing, University of Sunderland, Sunderland, UK
| | - Scott Wilkes
- Faculty of Health Sciences & Wellbeing, University of Sunderland, Sunderland, UK
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Does intra-uterine insemination have a place in modern ART practice? Best Pract Res Clin Obstet Gynaecol 2018; 53:3-10. [DOI: 10.1016/j.bpobgyn.2018.08.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 08/08/2018] [Accepted: 08/20/2018] [Indexed: 11/23/2022]
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7
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Quaas AM. Local privileges not universal rights: geographic variations in the science and clinical practice of reproductive medicine. J Assist Reprod Genet 2018; 35:1559-1563. [PMID: 29974368 DOI: 10.1007/s10815-018-1249-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 06/21/2018] [Indexed: 11/28/2022] Open
Abstract
Based on personal experience in the science and clinical practice of reproductive medicine in different settings, enormous variations are highlighted, demonstrating that freedom of research and clinical practice in reproductive medicine is a local privilege, not a universal right.
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Affiliation(s)
- Alexander M Quaas
- University Hospital, Clinic for Reproductive Medicine and Gynecologic Endocrinology, University of Basel, Basel, Switzerland. .,Gyn. Endokrinologie (RME), Vogesenstrasse 134, 4031, Basel, Switzerland. .,Reproductive Partners San Diego, San Diego, CA, USA. .,Division of Reproductive Endocrinology and Infertility, University of California, San Diego, CA, USA.
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8
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García-Cruz E, Romero-Otero J, Fode M, Alcaraz A. The digital environment in men's sexual disorders: A systematic review. Actas Urol Esp 2018; 42:365-374. [PMID: 29102483 DOI: 10.1016/j.acuro.2017.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 05/15/2017] [Accepted: 05/16/2017] [Indexed: 01/23/2023]
Abstract
CONTEXT The revolution of digital technologies constitutes a new setting for the patient-physician relationship and provides patients with a scenario of privacy and universal access to a vast amount of information. However, there is little information on how digital resources are used and what their advantages and disadvantages are. OBJECTIVES To explore the scope of the scientific research on the use of digital technology related to men's sexual disorders and to analyze the primary sources of digital information related to this field. ACQUISITION OF EVIDENCE Systematic searches of the scientific literature, websites (10 first results in each google search) and mobile applications (apps). The searches combined the keywords "web" and "app" with "erectile dysfunction", "premature ejaculation", "Peyronie", "male hypogonadism", and "infertility". Websites and apps were assessed for quality according to predefined indicators. SYNTHESIS OF EVIDENCE The qualitative analysis of the scientific literature included 116 manuscripts; 47% were clinical studies based on online survey, 9% dealt with digital treatments, 11% with quality/safety of digital healthcare environment, 3% with digital activity, 21% with patient empowerment, and 9% with online drug selling. Of 50 websites assessed for quality, 29 (58%) scored 4 or 5 on a 5-point Likert scale. The app search yielded 40 apps; only 3 of them (8%) reported the identity of a health center or healthcare professional involved. CONCLUSIONS Patients and healthcare professionals may benefit from digital resources related to men's sexual disorders; however, a strong commitment by the scientific and healthcare community is essential to increase the quality of these resources.
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Affiliation(s)
- E García-Cruz
- Departmento de Urología, Hospital Plató, Barcelona, España; Departmento de Urología, Hospital Clínic de Barcelona, Barcelona, España; European Association of Urology's Young Academic Urologist's, Men's Health Group member.
| | - J Romero-Otero
- Departmento de Urología, Hospital Universitario 12 de octubre, Madrid, España
| | - M Fode
- Department of Urology, Roskilde Hospital, Roskilde, Dinamarca; Department of Urology, Herlev University Hospital, Herlev, Dinamarca
| | - A Alcaraz
- Departmento de Urología, Hospital Clínic de Barcelona, Barcelona, España
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9
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Nandi A, Bhide P, Hooper R, Gudi A, Shah A, Khan K, Homburg R. Intrauterine insemination with gonadotropin stimulation or in vitro fertilization for the treatment of unexplained subfertility: a randomized controlled trial. Fertil Steril 2017; 107:1329-1335.e2. [DOI: 10.1016/j.fertnstert.2017.03.028] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 03/23/2017] [Accepted: 03/27/2017] [Indexed: 11/28/2022]
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Tjon-Kon-Fat RI, Bensdorp AJ, Scholten I, Repping S, van Wely M, Mol BWJ, van der Veen F. IUI and IVF for unexplained subfertility: where did we go wrong? Hum Reprod 2016; 31:2665-2667. [PMID: 27664205 DOI: 10.1093/humrep/dew241] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 08/21/2016] [Accepted: 08/26/2016] [Indexed: 11/14/2022] Open
Abstract
IUI is a first-line treatment for couples with unexplained or mild male subfertility and has become one of the most widely used fertility-enhancing treatments. The results of a recent trial comparing IVF to IUI, demonstrating similar live birth rates, have been used to build a case supporting the effectiveness of IUI. Yet, this conclusion might be somewhat premature, as the superiority of neither IUI nor IVF over no treatment has ever been proven. The evidence on the effectiveness and safety of IUI and IVF has been evaluated in two Cochrane reviews which both suggested that there is insufficient evidence to conclude that IUI or IVF is effective compared to sexual intercourse in couples with unexplained subfertility. Recommendations for clinical practice have been given in the most recent National Institute for Health and Care Excellence fertility guideline that advises not to offer IUI any longer and suggests 2 years of sexual intercourse followed by IVF. This recommendation has generated an ongoing debate, with only 4% of all gynecologists in the UK discontinuing the use of IUI. We feel that it is high time to provide proper scientific evidence for the effectiveness of IUI, or lack thereof, and invite the medical community to start RCTs comparing IUI to sexual intercourse.
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Affiliation(s)
- R I Tjon-Kon-Fat
- Centre for Reproductive Medicine, Academic Medical Centre, University of Amsterdam, 1100 DD Amsterdam, the Netherlands
| | - A J Bensdorp
- Centre for Reproductive Medicine, Academic Medical Centre, University of Amsterdam, 1100 DD Amsterdam, the Netherlands
| | - I Scholten
- Centre for Reproductive Medicine, Academic Medical Centre, University of Amsterdam, 1100 DD Amsterdam, the Netherlands
| | - S Repping
- Centre for Reproductive Medicine, Academic Medical Centre, University of Amsterdam, 1100 DD Amsterdam, the Netherlands
| | - M van Wely
- Centre for Reproductive Medicine, Academic Medical Centre, University of Amsterdam, 1100 DD Amsterdam, the Netherlands
| | - B W J Mol
- The Robinson Research Institute, School of Medicine, University of Adelaide, SA 5000, Adelaide, Australia
- The South Australian Health and Medical Research Unit, SA 5000, Adelaide, Australia
| | - F van der Veen
- Centre for Reproductive Medicine, Academic Medical Centre, University of Amsterdam, 1100 DD Amsterdam, the Netherlands
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Should obtaining a preoperative audiogram before tympanostomy tube placement be used as a quality metric? A survey of pediatric otolaryngologists. Int J Pediatr Otorhinolaryngol 2016; 88:82-8. [PMID: 27497391 DOI: 10.1016/j.ijporl.2016.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Obtaining a preoperative audiogram prior to tympanostomy tube placement is recommended by the American Academy of Otolaryngology-Head and Neck Surgery clinical practice guideline (CPG): Tympanostomy tubes in Children, and this process measure is also used as a quality metric by payers. However, whether audiograms should be mandated in cases of tube placement for both chronic otitis media with effusion (COME) and recurrent acute otitis media (RAOM) is controversial. The objective of this study is to determine reports of practice patterns of pediatric otolaryngologists regarding obtaining audiograms before and after tympanostomy tube placement and opinions regarding utility of CPGs and use of this process measure as a quality metric. METHODS A 16-question cross-sectional survey of American Society of Pediatric Otolaryngology (ASPO) members was conducted. Per ASPO policy, no repeated requests or other enhanced response techniques were permitted. Independent t-tests for proportions were used to compare responses. RESULTS 127 pediatric otolaryngologists completed the survey (response rate 26.9%). Nearly 70% of respondents reported being in practice for >10 years. 74% of respondents reported obtaining preoperative audiograms "always" or "most of the time" for COME, vs. 56.7% for RAOM (p < 0.0001). 76% agreed that obtaining a preoperative audiogram was representative of high quality for COME, vs. 52% for RAOM (p < 0.0001). 12% of respondents "completely agreed" that compliance with all aspects of CPGs represented high quality, while 68.8% responded that they somewhat agreed. CONCLUSION There is no consensus among pediatric otolaryngologists regarding the necessity of a preoperative audiogram in tympanostomy tube placement, especially for RAOM. Further evidence demonstrating the benefit of preoperative audiogram obtainment should be developed prior to inclusion as a guideline recommendation and as a quality metric.
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Bahadur G, Homburg R, Muneer A, Racich P, Alangaden T, Al-Habib A, Okolo S. First line fertility treatment strategies regarding IUI and IVF require clinical evidence. Hum Reprod 2016; 31:1141-6. [PMID: 27076499 DOI: 10.1093/humrep/dew075] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 03/14/2016] [Indexed: 12/30/2022] Open
Abstract
The advent of intracytoplasmic sperm injection (ICSI) has contributed to a significant growth in the delivery of assisted conception technique, such that IVF/ICSI procedures are now recommended over other interventions. Even the UK National Institute for Health Care Excellence (NICE) guidelines controversially recommends against intrauterine insemination (IUI) procedures in favour of IVF. We reflect on some of the clinical, economic, financial and ethical realities that have been used to selectively promote IVF over IUI, which is less intrusive and more patient friendly, obviates the need for embryo storage and has a global application. The evidence strongly favours IUI over IVF in selected couples and national funding strategies should include IUI treatment options. IUI, practised optimally as a first line treatment in up to six cycles, would also ease the pressures on public funds to allow the provision of up to three IVF cycles for couple who need it. Fertility clinics should also strive towards ISO15189 accreditation standards for basic semen diagnosis for male infertility used to triage ICSI treatment, to reduce the over-diagnosis of severe male factor infertility. Importantly, there is a need to develop global guidelines on inclusion policies for IVF/ICSI procedures. These suggestions are an ethically sound basis for constructing the provision of publicly funded fertility treatments.
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Affiliation(s)
- G Bahadur
- Reproductive Medicine Unit, North Middlesex University Hospital, Old Admin Block, Sterling Way, London N18 1QX, UK Homerton Fertility Unit, Homerton University Hospital, Homerton Row, London E9 6SR, UK
| | - R Homburg
- Homerton Fertility Unit, Homerton University Hospital, Homerton Row, London E9 6SR, UK
| | - A Muneer
- University College London Hospital, 250 Euston Road, London NW1 2BU, UK
| | - P Racich
- Linacre College, Oxford University, St. Cross Road, Oxford OX1 3JA, UK
| | - T Alangaden
- Subfertility Unit, Chelsea and Westminster Hospital & West Middlesex University Hospital, Twickenham Road, Isleworth, Middlesex TW7 6AF, UK
| | - A Al-Habib
- Reproductive Medicine Unit, North Middlesex University Hospital, Old Admin Block, Sterling Way, London N18 1QX, UK
| | - S Okolo
- Reproductive Medicine Unit, North Middlesex University Hospital, Old Admin Block, Sterling Way, London N18 1QX, UK
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13
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Lensen S, Sadler L, Farquhar C. Endometrial scratching for subfertility: everyone's doing it. Hum Reprod 2016; 31:1241-4. [PMID: 27008891 DOI: 10.1093/humrep/dew053] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 02/26/2016] [Indexed: 11/13/2022] Open
Abstract
STUDY QUESTION What proportion of clinicians across Australia, New Zealand and the UK are currently offering or recommending endometrial scratching for subfertility? SUMMARY ANSWER Eighty-three percent of clinicians responding to this survey are recommending endometrial scratching to women undergoing IVF. WHAT IS KNOWN ALREADY Endometrial scratching is currently being proposed as a technique to increase the probability of implantation in women undergoing IVF. While trial results provide evidence in favour of this procedure, there remains some uncertainty about both the extent of any beneficial effect and the subgroups of women most likely to benefit. STUDY DESIGN, SIZE, DURATION Cross-sectional survey with responses from a total of 143 public and private fertility care providers surveyed between August and October 2015. PARTICIPANTS/MATERIALS, SETTING, METHODS An online survey was distributed to all 189 fertility clinics across Australia, New Zealand and the UK. All clinicians, nurses and embryologists were eligible to take part. One hundred and forty-three of the 152 responses received were eligible for inclusion, with multiple responses per clinic in 33 cases. At least one response was received from 68 clinics (36% response rate per clinic). MAIN RESULTS AND THE ROLE OF CHANCE This survey found that 83% of clinicians commend endometrial scratching prior to IVF. Of these, 92% recommend endometrial scratching to women with recurrent implantation failure (RIF) and 6% recommend it to all women having IVF. Most respondents (73%) agreed that the procedure is beneficial in women with RIF undergoing IVF and disagreed (53%) that the procedure is beneficial for women undergoing their first IVF cycle. The most common timeframe for performing endometrial scratching is the luteal phase of the cycle prior to the IVF cycle. Additionally, only 4% of clinicians recommend endometrial scratching to women undergoing intrauterine insemination or trying to conceive naturally. LIMITATIONS, REASONS FOR CAUTION Fertility care providers who recommend endometrial scratching may be more likely to respond to the survey and this could exaggerate the use of the procedure reported here. WIDER IMPLICATIONS OF THE FINDINGS This study was conducted across three countries and may be generalizable to similar settings. While this procedure already appears to be offered by the majority of respondents, the results of further studies in this area may further refine or expand the context in which this procedure is beneficial. STUDY FUNDING/COMPETING INTERESTS No funding or competing interests. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- S Lensen
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - L Sadler
- Women's Health, Auckland District Health Board, Auckland, New Zealand
| | - C Farquhar
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
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Kim D, Child T, Farquhar C. Intrauterine insemination: a UK survey on the adherence to NICE clinical guidelines by fertility clinics. BMJ Open 2015; 5:e007588. [PMID: 25979869 PMCID: PMC4442173 DOI: 10.1136/bmjopen-2015-007588] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate the awareness and response of fertility clinics in the UK to the National Institute for Health and Care Excellence (NICE) guideline recommendation that intrauterine insemination (IUI) should not be offered routinely, in order to report on current practice in the UK. DESIGN Online questionnaire survey of fertility clinics in the UK regarding their current clinical practice of IUI, formal discussion of the guideline recommendations, and any alterations made since the recommendations. SETTING 66 UK fertility clinics licensed to provide IUI. PARTICIPANTS 46 fertility clinics, including 6 clinic groups which represent 70% of all clinics and clinic groups licensed to provide IUI in April 2014 when the survey email was sent. RESULTS Of the 46 clinics that responded, 96% (44/46) of clinics continue to offer IUI. 98% (43/44) of those offering IUI also use ovarian stimulation. The most commonly used medications for ovarian stimulation are gonadotrophins (95%), followed by clomiphene citrate (49%) and letrozole (19%). 78% (36/46) of clinics had formally discussed NICE guideline recommendations. 17 clinics (37%) had made some changes to their practices; as a result, four clinics reported a reduction in the number of IUI cycles, six clinics had restricted the indications for IUI, and five clinics had begun informing patients of the guideline recommendations, while two did not specify. CONCLUSIONS The majority of clinics were aware of the guideline recommendations. However, only a small proportion of clinics had made significant changes to their practice by reducing the number of IUI cycles or restricting the clinical indications for IUI. The availability of further evidence will assist NICE and clinicians in making recommendations on the use of IUI. There is a need to further explore the reasons for the lack of adherence to the recommendations.
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Affiliation(s)
- Dongah Kim
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - Tim Child
- Oxford Fertility Unit, University of Oxford, Oxford, UK
| | - Cynthia Farquhar
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
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