Evidence based Infertility Management
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Evidence based Infertility Management Presentation Transcript

  • 1. Evidence Based Fertility Practice
    Dr. Priya Bhave Chittawar
  • 2. SCOPE OF THE PRESENTATION
    Need for information
    Sources
    EBM: the steps
    Examples
    Towards wisdom based medicine
  • 3. 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
  • 4. Ask Mom….
  • 5. Ask the Teacher…
  • 6. Read a book….
  • 7. Ask a friend…
  • 8. Turn to God?
  • 9.
  • 10. 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……………”
  • 11. 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)
  • 12. INFORMATION OVERLOAD
  • 13. 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.
  • 14.
  • 15. 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
  • 16. 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
  • 17. 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”
  • 18. 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
  • 19. 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?
  • 20. 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?
  • 21. 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?
  • 22. Ask
    Acquire
    Appraise
    Apply
    Analyze
  • 23. Acquire
    Journals : Human Reproduction, Human Reproduction update, Fertility Sterility
    MEDLINE
    Pubmed
    Cochrane database
  • 24. 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)
  • 25. Yilmaz et al : No difference in pregnancy rate or ovulation rate in the two groups.
    ( FertStert 2006)
  • 26. Ask
    Acquire
    Appraise
    Apply
    Analyze
  • 27. Appraise
  • 28. Appraise
  • 29. 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.
  • 30. Reducing bias and random errors
    Adequate sample size
    Having a control group
    Randomization
    Allocation concealment
    Blinding
  • 31.
  • 32. Internal Validity: If the conclusions are reliable
    External validity: If the conclusions are applicable to a different population
  • 33. Synthesize the evidence:
    Reviews
    Meta analysis
  • 34. 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
  • 35.
  • 36.
  • 37. 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
  • 38. Absence of evidence or evidence of absence?
  • 39. There is absence of evidence to recommend giving HCG as ovulation trigger.
    Financial aspect
  • 40. Ask
    Acquire
    Appraise
    Apply
    Analyze
  • 41. Apply results to your clinical practice.
    Find more evidence
    Generate more evidence
    Financial aspect
  • 42. Ask
    Acquire
    Appraise
    Apply
    Analyze
  • 43. 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?
  • 44.
  • 45.
  • 46. Innocent until proved guilty?
    Guilty until proved innocent?
  • 47. Primum Non Nocere…….
    First do no harm!
  • 48.
  • 49. What is Evidence based healthcare?
    Integration of research evidence, clinical expertise and patient values.
  • 50. 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
  • 51.
  • 52. "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."
  • 53. Thank You….