Evidence based Infertility Management
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Evidence based Infertility Management

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    Evidence based Infertility Management Evidence based Infertility Management Presentation Transcript

    • Evidence Based Fertility Practice
      Dr. Priya Bhave Chittawar
    • SCOPE OF THE PRESENTATION
      Need for information
      Sources
      EBM: the steps
      Examples
      Towards wisdom based medicine
    • What should I do?
      What should I not do?
      What is the correct way to treat/diagnose/operate/correct
      What is the incorrect way to treat/diagnose/operate/correct
    • Ask Mom….
    • Ask the Teacher…
    • Read a book….
    • Ask a friend…
    • Turn to God?
    • It is important to ask.
      It is important to ask the right questions
      It is important to ask the right person
      “Seek and you shall find……………”
    • Need for Information
      Our daily need for valid information regarding diagnosis, prognosis , therapy and prevention
      Three times per day for outpatients
      Upto five times per day for inpatients.
      ( Osheroff et all:Physicians information needs: Analysis of questions posed during clinical teaching. Ann Int Med 1991; 114:576-8)
    • INFORMATION OVERLOAD
    • Alternatives to EBM
      Eminence based medicine
      Vehemence based medicine
      Eloquence based medicine
      Providence based medicine
      Diffidence based medicine
      Nervousness based medicine
      Confidence based medicine
      Seven alternatives to evidence based medicine BMJ. 1999 December 18; 319(7225): 1618.
    • Why Evidence Based Fertility Practice?
      Infertility treatments have limited success
      Costly
      Most choices are based on statistical probabilities
      Female age is a critical factor
      Ethnic differences
    • EXAMPLE 1
      Metformin in Polycystic Ovarian Syndrome
      Insulin resistance
      Metformin is an insulin sensitizer
      Large number of small trials recommended use to improve insulin sensitivity, ovulation rates, pregnancy rates
      Cochrane review( Lord 2003): Metformin is an effective intervention in women with PCOS
    • Larger RCTs by Legro( 2007), Moll (2006) and Tang( 2007)
      Updated Cochrane review ( Tang 2009):
      “Adding Metformin to Clomiphene or Metformin alone does not improve Live birth rates”
    • How to practice EBM
      Ask: an answerable question
      Acquire: the best evidence to answer that question
      Appraise: critically the evidence for its validity, impact, size of effect and applicability
      Apply: integrate the clinical scenario, evidence with the patients expectations and background
      Asses : the outcome
    • Ask
      P: Who is the Patient or problem being addressed?
      I: What is the intervention or exposure?
      C: What is the comparison group?
      O: What is the outcome?
    • EXAMPLE 2
      In ovulation induction for anovulatory infertility, HCG is routinely given as ovulation trigger
      Better timing?
      Preventing Luteinized unruptured follicle syndrome?
      Better luteal phase?
      What is the evidence?
    • Ask
      Does triggering ovulation with HCG help get more pregnancies?
      In anovulatory women with PCOS, does triggering ovulation with HCG result in better pregnancy rate compared to spontaneous ovulation?
    • Ask
      Acquire
      Appraise
      Apply
      Analyze
    • Acquire
      Journals : Human Reproduction, Human Reproduction update, Fertility Sterility
      MEDLINE
      Pubmed
      Cochrane database
    • Acquire
      Two randomized controlled trials
      George et al: Compared spontaneous ovulation versus hCG triggered ovulation in anovulatory women treated with Clomiphene citrate. No statistically significant difference in ovulation and pregnancy rates.
      ( FertStert April 2007)
    • Yilmaz et al : No difference in pregnancy rate or ovulation rate in the two groups.
      ( FertStert 2006)
    • Ask
      Acquire
      Appraise
      Apply
      Analyze
    • Appraise
    • Appraise
    • Chance:
      Bias: Systematic error that deviates results from the truth
      Type 1: shows a difference when there is none
      Type 2: Shows no difference when there is one.
    • Reducing bias and random errors
      Adequate sample size
      Having a control group
      Randomization
      Allocation concealment
      Blinding
    • Internal Validity: If the conclusions are reliable
      External validity: If the conclusions are applicable to a different population
    • Synthesize the evidence:
      Reviews
      Meta analysis
    • How to interpret a meta analysis?
      Graphical display in the form of a Forrest plot
      All the contributing trials mentioned with the number of subjects
    • There is inadequate evidence to recommend or refute the use of urinary hCG as an ovulation trigger, in anovulatory women being treated with Clomiphene Citrate
    • Absence of evidence or evidence of absence?
    • There is absence of evidence to recommend giving HCG as ovulation trigger.
      Financial aspect
    • Ask
      Acquire
      Appraise
      Apply
      Analyze
    • Apply results to your clinical practice.
      Find more evidence
      Generate more evidence
      Financial aspect
    • Ask
      Acquire
      Appraise
      Apply
      Analyze
    • Should I use the latest treatment on the block?
      Wont I be depriving my patients of the ‘Benefits’ of this new magical drug/intervention if I dally?
    • Innocent until proved guilty?
      Guilty until proved innocent?
    • Primum Non Nocere…….
      First do no harm!
    • What is Evidence based healthcare?
      Integration of research evidence, clinical expertise and patient values.
    • When you know a thing, to hold that you know it;
      And when you don’t know a thing,
      To allow that you don’t know a thing,
      That is wisdom
      Confucious
    • "From inability to let well alone,From too much zeal for what is new, and contempt for what is old,From putting knowledge before wisdom, science before art,and cleverness before common sense,...From treating patients as cases, andFrom making the cure of a disease more grievous than its enduranceGood Lord deliver us."
    • Thank You….