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• W3035244911 abstract "Like all industries, fertility clinics should identify and follow reference markers of its activity—key performance indicators (KPI)—to allow assisted reproductive technology outcomes to be monitored and compared. Clinical KPIs revolve around following set parameters of the patient population, procedures, and outcome data. Moreover, KPIs should also include identified protocols and standard operating procedures followed in daily practice and should keep track of multiple pregnancy rates, a ruthless confounder of assisted reproductive technology outcomes. Like all industries, fertility clinics should identify and follow reference markers of its activity—key performance indicators (KPI)—to allow assisted reproductive technology outcomes to be monitored and compared. Clinical KPIs revolve around following set parameters of the patient population, procedures, and outcome data. Moreover, KPIs should also include identified protocols and standard operating procedures followed in daily practice and should keep track of multiple pregnancy rates, a ruthless confounder of assisted reproductive technology outcomes. Discuss: You can discuss this article with its authors and other readers at https://www.fertstertdialog.com/users/16110-fertility-and-sterility/posts/30366 Discuss: You can discuss this article with its authors and other readers at https://www.fertstertdialog.com/users/16110-fertility-and-sterility/posts/30366 Since the inception of assisted reproductive technology (ART), the results have hovered between 0 and 100%. If ART pregnancy rates remained around 0, as was the case in the very early days, the whole process would have been long forgotten. Conversely, if ART results now regularly 100%, we would have little to discuss because positive outcomes would be the rule for all attempts. Because ART results have been notable throughout its 40-year history yet clearly remain below 100%, all infertility clinics strive to constantly optimize their care by improving their processes and/or adding new measures. This constant drive for better results in ART is the basis of the need to establish markers for outcomes, known as key performance indicators (KPIs). The imperfections of ART results may be due in part to shortcomings in the clinical treatments or laboratory processes. But beyond the technical issues—clinical or biological—the less-than-100% outcomes of ART also stem from the inherent limitations of human reproduction. Contrary to other human functions (such as digestion, for which 100% efficacy is expected), human reproduction does not work all the time, even when conditions are optimal. Of 100 young couples trying to conceive, 70 are bound to succeed within 3 months or so. Because these couples conceive rapidly, they are naturally considered to be perfectly normal in terms of reproduction; yet not all these normal young women and men will conceive during their first or even second month of trying. It is normal for human reproduction to not work 100% of the time, unlike the reproductive conditions prevailing in other animal species (such as rabbits). Logically, the natural limits of human reproduction apply in ART as well. Although ART may slightly outperform natural conception (courtesy multiple ovulation and various methods of embryo selection), it remains limited by the inherently poor efficacy of human reproduction. When assessing the ART results of a given center, we must distinguish what depends on the quality of the ART process, clinical and biological, from what is inherent to the limitations of human reproduction. These problems underscore the need to identify markers or KPIs that allow monitoring the efficacy of ART so that the results can be compared between different centers and also the outcomes of a given center over time. This monitoring process implies following the laboratory work and clinical steps of ART. The former is addressed by Gemma Fabozzi and colleagues (1Fabozzi G. Cimadomo D. Maggiulli R. Vaiarelli A. Ubaldi F.M. Rienzi L. Which key performance indicators are most effective in evaluating and managing an in vitro fertilization laboratory?.Fertil Steril. 2020; 114Abstract Full Text Full Text PDF Scopus (13) Google Scholar) in another article in the present series, and we will discuss the clinical management of ART. Thus, in practice, monitoring clinical ART—that is, defining the KPIs—implies assessing three sets of parameters that define the patient population; various ART procedures; and adequate ART outcome indices (Table 1).Table 1The patient characteristics and procedure and outcome (PPO) parameters of KPIs in clinical ART.KPIPatient characteristicProcedureOutcome parameter1Female ageAge limitMean age% <37 y% 37–40 y% ≥40 yOS% Cancelled retrieval% Retrieval failure (no oocytes)% OHSSBiological parametersNumber of oocytesMII oocytes rateFertilization rateDay-5 blastulation rateThawing survival2Poor ovarian reserveAMH <1 ng/mLInferior AMH limitSuperior FSH limitAFC inferior to limitRetrieval% Hemorrhage% Pelvic infection% Other complication requiring hospitalization% Oocytes retrieved/mature folliclesClinical outcomeCPR, OPR, SIRMiscarriage rateLBRC-LBRTwin PR3Prior ART attemptsEmbryo transferRetained embryosDifficult transfers4Duration of infertility (mean)5% Uterine factors6% Severe male factor7% Surgically retrieved spermNote: AFC = antral follicle count; AMH = antimüllerian hormone; ART = assisted reproduction technology; C-LBR = cumulative live-birth rate; CPR = clinical pregnancy; FSH = follicle-stimulating hormone; KPI = key performance indicator; LBR = live-birth rate; MII = metaphase-2; OHSS = ovarian hyperstimulation syndrome; OPR = ongoing pregnancy; OS = ovarian stimulation; PR = pregnancy rate; SIR = sustained implantation. Open table in a new tab Note: AFC = antral follicle count; AMH = antimüllerian hormone; ART = assisted reproduction technology; C-LBR = cumulative live-birth rate; CPR = clinical pregnancy; FSH = follicle-stimulating hormone; KPI = key performance indicator; LBR = live-birth rate; MII = metaphase-2; OHSS = ovarian hyperstimulation syndrome; OPR = ongoing pregnancy; OS = ovarian stimulation; PR = pregnancy rate; SIR = sustained implantation. The efficacy of ART greatly depends on the characteristics of the patient population being treated, such as, notably, the age of the female partner, the duration of infertility, and the number of past ART attempts. Irrespective of the progress accomplished by ART over time, its results—pregnancy rates (PR) and miscarriage rates—remain greatly affected by the age of the female partner (2Cimadomo D. Fabozzi G. Vaiarelli A. Ubaldi N. Ubaldi F.M. Rienzi L. Impact of maternal age on oocyte and embryo competence.Front Endocrinol (Lausanne). 2018; 9: 327Crossref PubMed Scopus (133) Google Scholar, 3Demko Z.P. Simon A.L. McCoy R.C. Petrov D.A. Rabinowitz M. Effects of maternal age on euploidy rates in a large cohort of embryos analyzed with 24-chromosome single-nucleotide polymorphism-based preimplantation genetic screening.Fertil Steril. 2016; 105: 1307-1313Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar). We now know that the decrease in PR and increase in miscarriages that become progressively preponderant in women aged ≥37 years are mainly due to an increase in embryo aneuploidy rates (4Jansen R.P. Spontaneous abortion incidence in the treatment of infertility.Am J Obstet Gynecol. 1982; 143: 451-473Abstract Full Text PDF PubMed Scopus (80) Google Scholar, 5Franasiak J.M. Forman E.J. Hong K.H. Werner M.D. Upham K.M. Treff N.R. et al.The nature of aneuploidy with increasing age of the female partner: a review of 15,169 consecutive trophectoderm biopsies evaluated with comprehensive chromosomal screening.Fertil Steril. 2014; 101: 656-663.e1Abstract Full Text Full Text PDF PubMed Scopus (489) Google Scholar). By contrast, donor egg ART has provided evidence that the uterine function does not decline with age (6Stolwijk A.M. Zielhuis G.A. Sauer M.V. Hamilton C.J.C.M. Paulson R.J. The impact of the woman’s age on the success of standard and donor in vitro fertilization.Fertil Steril. 1997; 67: 702-710Abstract Full Text PDF PubMed Scopus (68) Google Scholar). Recent data have shown that although older women may have fewer euploid embryos (5Franasiak J.M. Forman E.J. Hong K.H. Werner M.D. Upham K.M. Treff N.R. et al.The nature of aneuploidy with increasing age of the female partner: a review of 15,169 consecutive trophectoderm biopsies evaluated with comprehensive chromosomal screening.Fertil Steril. 2014; 101: 656-663.e1Abstract Full Text Full Text PDF PubMed Scopus (489) Google Scholar), their implantation chances and miscarriage risks are similar to those of younger women (7Forman E.J. Hong K.H. Franasiak J.M. Scott Jr., R.T. Obstetrical and neonatal outcomes from the BEST Trial: single embryo transfer with aneuploidy screening improves outcomes after in vitro fertilization without compromising delivery rates.Am J Obstet Gynecol. 2014; 210: 157.e1-157.e6Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar). The number of prior ART attempts also impacts further ART chances, with decreased outcomes in women who have had multiple prior failures. Past ART failures select out women who have persistently impaired ART outcomes. Patients with recurrent pregnancy losses, previous in vitro fertilization (IVF) failures, and prior aneuploidy have a statistically significantly higher, age-independent aneuploidy rate compared with patients without infertility (8Kort J.D. McCoy R.C. Demko Z. Lathi R.B. Are blastocyst aneuploidy rates different between fertile and infertile populations?.J Assist Reprod Genet. 2018; 35: 403-408Crossref PubMed Scopus (22) Google Scholar). The role of the male partner is more difficult to assess, notably since the advent of intracytoplasmic sperm injection (ICSI). Although the effects of paternal age on ART outcomes have been questioned (9Sharma R. Agarwal A. Rohra V.K. Assidi M. Abu-Elmagd M. Turki R.F. Effects of increased paternal age on sperm quality, reproductive outcome and associated epigenetic risks to offspring.Reprod Biol Endocrinol. 2015; 13: 35Crossref PubMed Scopus (188) Google Scholar), it is acknowledged that extreme male factors, including surgically extracted sperm, may adversely affect embryo euploidy rates but not the sustained implantation of such embryos (10Tiegs A.W. Sachdev N.M. Grifo J.A. McCulloh D.H. Licciardi F. Paternal age is not associated with pregnancy outcomes after single thawed euploid blastocyst transfer.Reprod Sci. 2017; 24: 1319-1324Crossref PubMed Scopus (11) Google Scholar). The impact of the patient population characteristics on ART outcomes is so important that KPIs aimed at assessing results also should closely monitor the patient population. Indeed, subtle changes such as different sources of patient recruitment leading to differences in the patients’ ages might occur surreptitiously in an ART program and thereby affect ART outcomes. For these reasons some have advocated following the results (KPIs) of a reference population consisting of women younger than 37 years who are undergoing their first or second ART attempt. Today, however, this is better replaced by following the outcomes of euploid embryo transfers (ETs) (11Simon A.L. Kiehl M. Fischer E. Proctor J.G. Bush M.R. Givens C. et al.Pregnancy outcomes from more than 1,800 in vitro fertilization cycles with the use of 24-chromosome single-nucleotide polymorphism-based preimplantation genetic testing for aneuploidy.Fertil Steril. 2018; 110: 113-121Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar). Assisted reproduction procedures encompass both laboratory and clinical steps. As previously discussed, the laboratory process is addressed elsewhere in this series (1Fabozzi G. Cimadomo D. Maggiulli R. Vaiarelli A. Ubaldi F.M. Rienzi L. Which key performance indicators are most effective in evaluating and managing an in vitro fertilization laboratory?.Fertil Steril. 2020; 114Abstract Full Text Full Text PDF Scopus (13) Google Scholar). The clinical steps are essentially three: ovarian stimulation (OS), oocyte retrieval, and ET. The quantitative response to OS can be predicted to a certain extent from ovarian reserve parameters such as antral follicle count (AFC) scores and antimüllerian hormone (AMH) levels (12La Marca A. Ferraretti A.P. Palermo R. Ubaldi F.M. The use of ovarian reserve markers in IVF clinical practice: a national consensus.Gynecol Endocrinol. 2016; 32: 1-5Crossref PubMed Scopus (30) Google Scholar). The OS results are assessed via the number of follicles obtained, plasma estradiol (E2) levels achieved, and ultimately the number of oocytes and mature or metaphase-2 (MII) oocytes harvested. Ovarian stimulation consists of artificially maintaining elevated follicle-stimulating hormone (FSH) levels at the intercycle rise in FSH levels, thereby preventing the midfollicular phase drop in FSH levels (13Jones Jr., H.W. Acosta A. Andrews M.C. Garcia J.E. Jones G.S. Mantzavinos T. et al.The importance of the follicular phase to success and failure in in vitro fertilization.Fertil Steril. 1983; 40: 317-321Abstract Full Text PDF PubMed Scopus (143) Google Scholar). In a natural cycle, the latter is the normal mechanism whereby a single dominant follicle is selected for ovulation. The pathophysiology of OS is well understood, preventing the midfollicular drop in FSH (13Jones Jr., H.W. Acosta A. Andrews M.C. Garcia J.E. Jones G.S. Mantzavinos T. et al.The importance of the follicular phase to success and failure in in vitro fertilization.Fertil Steril. 1983; 40: 317-321Abstract Full Text PDF PubMed Scopus (143) Google Scholar), but the link between actual FSH levels (the amounts of exogenous FSH administered) and the magnitude of the OS response remains controversial (14Paulson R.J. Introduction: Contemporary approaches to alternative ovarian stimulation strategies for in vitro fertilization.Fertil Steril. 2017; 108: 555-557Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 15Siristatidis C. Dafopoulos K. Vrantza T. Salamalekis G. Basios G. Vogiatzi P. et al.Mild versus conventional antagonist ovarian stimulation protocols in expected normal responders undergoing IVF/ICSI: a case-control study.Gynecol Endocrinol. 2017; 33: 553-556Crossref PubMed Scopus (5) Google Scholar, 16Orvieto R. Vanni V.S. Gleicher N. The myths surrounding mild stimulation in vitro fertilization (IVF).Reprod Biol Endocrinol. 2017; 15: 48Crossref PubMed Scopus (10) Google Scholar). The actual “tailoring” of the FSH dose according to the patient’s parameters such as weight and AMH level—for maximizing outcomes while curbing risks such as ovarian hyperstimulation syndrome (OHSS)—sounds logical. However, the results speak otherwise. In an RCT the tailored approach did not effectively prevent severe OHSS: two severe cases were encountered in the tailored group (17Nyboe Andersen A. Nelson S.M. Fauser B.C. Garcia-Velasco J.A. Klein B.M. Arce J.C. et al.Individualized versus conventional ovarian stimulation for in vitro fertilization: a multicenter, randomized, controlled, assessor-blinded, phase 3 noninferiority trial.Fertil Steril. 2017; 107: 387-396.e4Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar). Today, one greatly prefers preventing OHSS by avoiding human chorionic gonadotropin (hCG) when triggering ovulation and using gonadotropin-releasing hormone agonist (GnRH-a) instead (17Nyboe Andersen A. Nelson S.M. Fauser B.C. Garcia-Velasco J.A. Klein B.M. Arce J.C. et al.Individualized versus conventional ovarian stimulation for in vitro fertilization: a multicenter, randomized, controlled, assessor-blinded, phase 3 noninferiority trial.Fertil Steril. 2017; 107: 387-396.e4Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar). Conversely, a meta-analysis examined the claim that a standardized FSH dose of 150 IU/day is as efficient for ART outcomes as doses tailored to ovarian reserve testing (18Lensen S.F. Wilkinson J. Leijdekkers J.A. La Marca A. Mol B.W.J. Marjoribanks J. et al.Individualised gonadotropin dose selection using markers of ovarian reserve for women undergoing in vitro fertilisation plus intracytoplasmic sperm injection (IVF/ICSI).Cochrane Database Syst Rev. 2018; 2CD012693PubMed Google Scholar). The meta-analysis concurred that ovarian reserve testing facilitated dose reductions in women with a predicted high response (18Lensen S.F. Wilkinson J. Leijdekkers J.A. La Marca A. Mol B.W.J. Marjoribanks J. et al.Individualised gonadotropin dose selection using markers of ovarian reserve for women undergoing in vitro fertilisation plus intracytoplasmic sperm injection (IVF/ICSI).Cochrane Database Syst Rev. 2018; 2CD012693PubMed Google Scholar). Hence, although parameters of OS outcome such as number of retrievals, MI and MII oocytes, and day-5 blastulation rate are also part of clinical KPIs, the actual gonadotropin doses used for OS do not need to be, as detailed in Table 1. Protocols and standard operating procedures (SOPs) must guide the actual OS process selected in each clinic, as discussed in a later section of this article. There are two types of OS complications: insufficient and excessive responses. An insufficient response of fewer than two to three maturing follicles leads to OS and oocyte retrieval cancellation, a parameter that needs to be reported in clinical KPIs. It is interesting that diminished ovarian response associated with oocyte retrieval represents a quantitative but not qualitative reduction in performance. Indeed, patients with a reduced response to OS have similar blastulation, euploidy rates, and live-birth rates per euploid ET as age-matched controls who have a normal response to OS (19Morin S.J. Patounakis G. Juneau C.R. Neal S.A. Scott R.T. Seli E. Diminished ovarian reserve and poor response to stimulation in patients <38 years old: a quantitative but not qualitative reduction in performance.Hum Reprod. 2018; 33: 1489-1498Crossref PubMed Scopus (69) Google Scholar). If the oocyte quality of women who have a poor response to OS is on a par with that of age-matched controls, the number of oocytes retrieved still positively impacts ART outcomes and notably cumulative PRs (20Drakopoulos P. Blockeel C. Stoop D. Camus M. de Vos M. Tournaye H. et al.Conventional ovarian stimulation and single embryo transfer for IVF/ICSI. How many oocytes do we need to maximize cumulative live birth rates after utilization of all fresh and frozen embryos?.Hum Reprod. 2016; 31: 370-376PubMed Google Scholar, 21Law Y.J. Zhang N. Venetis C.A. Chambers G.M. Harris K. The number of oocytes associated with maximum cumulative live birth rates per aspiration depends on female age: a population study of 221 221 treatment cycles.Hum Reprod. 2019; 34: 1778-1787Crossref PubMed Scopus (32) Google Scholar). By contrast, an excessive response to OS can lead to OHSS. One of the most dreadful (at times, fatal) complications of ART, OHSS with ascites formation, hemoconcentration, risk of deep vein thrombosis, and prerenal kidney failure occurs in 1% to 4% of cases (22Gomez R. Soares S.R. Busso C. Garcia-Velasco J.A. Simon C. Pellicer A. Physiology and pathology of ovarian hyperstimulation syndrome.Semin Reprod Med. 2010; 28: 448-457Crossref PubMed Scopus (85) Google Scholar, 23Banker M. Garcia-Velasco J.A. Revisiting ovarian hyper stimulation syndrome: towards OHSS free clinic.J Hum Reprod Sci. 2015; 8: 13-17Crossref PubMed Scopus (15) Google Scholar). Our current understanding of the pathophysiology of OHSS and the role played by hCG has allowed us to practically eradicate the risk of OHSS by triggering ovulation with GnRH-a instead of hCG and deferring ET (24Mourad S. Brown J. Farquhar C. Interventions for the prevention of OHSS in ART cycles: an overview of Cochrane reviews.Cochrane Database Syst Rev. 2017; 1CD012103PubMed Google Scholar) whenever OHSS is feared. Insufficient and excessive responses remain the two complications of OS that should be reported in the KPIs that monitor the activity of a given ART center (Table 1). The oocyte retrieval procedure has become fairly standardized since the introduction and rapid global adoption of transvaginal ultrasound-guided oocyte retrieval (25Ozaltin S. Kumbasar S. Savan K. Evaluation of complications developing during and after transvaginal ultrasound-guided oocyte retrieval.Ginekol Pol. 2018; 89: 1-6Crossref PubMed Scopus (5) Google Scholar). A meta-analysis failed to identify the superior mode of pain relief to cover the procedure. Patients generally are allowed to choose between conscious sedation and analgesia, light anesthesia with propofol or local paracervical anesthesia, based on the preferences of a given program (26Kwan I. Wang R. Pearce E. Bhattacharya S. Pain relief for women undergoing oocyte retrieval for assisted reproduction.Cochrane Database Syst Rev. 2018; 5CD004829PubMed Google Scholar). Fentanyl can also be used: when the levels were measured in follicular fluid, no embryo toxicity was found (27Soussis I. Boyd O. Paraschos T. Duffy S. Bower S. Troughton P. et al.Follicular fluid levels of midazolam, fentanyl, and alfentanil during transvaginal oocyte retrieval.Fertil Steril. 1995; 64: 1003-1007Abstract Full Text PDF PubMed Google Scholar). Complications of oocyte retrieval can occur and ought to be monitored carefully and reported as part of KPIs (Table 1). The most common complication is pelvic hemorrhages; >50% of cases require hospitalization. These are most commonly intraperitoneal with an ovarian origin but also can be retroperitoneal in cases of pelvic vessel injury (28Levi-Setti P.E. Cirillo F. Scolaro V. Morenghi E. Heilbron F. Girardello D. et al.Appraisal of clinical complications after 23,827 oocyte retrievals in a large assisted reproductive technology program.Fertil Steril. 2018; 109: 1038-1043.e1Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar). Levi-Setti et al. (28Levi-Setti P.E. Cirillo F. Scolaro V. Morenghi E. Heilbron F. Girardello D. et al.Appraisal of clinical complications after 23,827 oocyte retrievals in a large assisted reproductive technology program.Fertil Steril. 2018; 109: 1038-1043.e1Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar) reported the incidence of complications per oocyte retrieval at 0.4%, of which hemoperitoneum constituted the majority with an incidence of 0.23%. In their analysis, the experience of the surgeon (>250 retrievals for safest outcomes) played a role in the risk of retrieval complications as well as the number of oocytes retrieved (28Levi-Setti P.E. Cirillo F. Scolaro V. Morenghi E. Heilbron F. Girardello D. et al.Appraisal of clinical complications after 23,827 oocyte retrievals in a large assisted reproductive technology program.Fertil Steril. 2018; 109: 1038-1043.e1Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar). Pelvic pain, a common complication of oocyte retrieval, is generally managed by minor pain killers. Other complications of oocyte retrievals include tubo-ovarian abscesses, with ovarian endometriosis being a recognized predisposing factor (29Villette C. Bourret A. Santulli P. Gayet V. Chapron C. de Ziegler D. Risks of tubo-ovarian abscess in cases of endometrioma and assisted reproductive technologies are both under- and overreported.Fertil Steril. 2016; 106: 410-415Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar). Rarer complications include ureteral injuries (30Gurbuz A.S. Cenker A. Iatrogenic ureteral obstruction during transvaginal oocyte retrieval.Int Braz J Urol. 2019; 45: 396-399Crossref PubMed Google Scholar). As illustrated in Table 1, the incidence of retrieval complications should be included in clinical KPIs. The efficacy of oocyte retrieval—the number of oocytes retrieved per large follicles present—remains a matter of controversy and is likely impacted by the doctor’s experience (28Levi-Setti P.E. Cirillo F. Scolaro V. Morenghi E. Heilbron F. Girardello D. et al.Appraisal of clinical complications after 23,827 oocyte retrievals in a large assisted reproductive technology program.Fertil Steril. 2018; 109: 1038-1043.e1Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar). Meta-analysis data suggest little or no difference between follicular flushing and simple direct aspiration with respect to oocyte yield, total embryo number, or number of cryopreserved embryos (31Georgiou E.X. Melo P. Brown J. Granne I.E. Follicular flushing during oocyte retrieval in assisted reproductive techniques.Cochrane Database Syst Rev. 2018; 4CD004634PubMed Google Scholar). In addition, follicular flushing probably makes little or no difference in the clinical pregnancy rate. The evidence was insufficient to allow any firm conclusions with respect to adverse events or safety (31Georgiou E.X. Melo P. Brown J. Granne I.E. Follicular flushing during oocyte retrieval in assisted reproductive techniques.Cochrane Database Syst Rev. 2018; 4CD004634PubMed Google Scholar). We do not support including the number of oocytes retrieved in relation to the expected retrieved as a routine KPI because of excessive variability. Other parameters of oocyte retrieval such as number of oocytes retrieved, global MI and MII oocytes retrieved, and fertilization and day-5 blastulation rates are part of routine KPIs, although these overlap with the laboratory KPIs addressed in a special article of this series. In Table 1, the third and last clinical procedure of ART is ET. The last step of the ART process, ET should be most delicately conducted to avoid undoing the joint efforts put forth by the patient and the clinical and biological teams for optimizing results (32Schoolcraft W.B. Importance of embryo transfer technique in maximizing assisted reproductive outcomes.Fertil Steril. 2016; 105: 855-860Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar). This technical gesture also requires the most balanced hormone environment. Recent data suggest that progesterone elevation (P4 >1.5 ng/dL) during the late follicular phase of ovarian stimulation for IVF can negatively impact ART outcomes, causing advanced endometrial maturation and a direct negative effect on endometrial receptivity (33Lawrenz B. Labarta E. Fatemi H. Bosch E. Premature progesterone elevation: targets and rescue strategies.Fertil Steril. 2018; 109: 577-582Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar). This kind of situation requires cycle segmentation with a freeze-all policy (34Stormlund S. Schmidt L. Bogstad J. Løssl K. Prætorius L. Zedeler A. et al.Patients’ attitudes and preferences towards a freeze-all strategy in ART treatment.Hum Reprod. 2019; 34: 679-688Crossref PubMed Scopus (21) Google Scholar). Canceling ET for hormone anomalies should be part of KPIs. There is overwhelming evidence that ET ought to be performed under ultrasound guidance not just for the sake of efficacy (35Schoolcraft W.B. Surrey E.S. Gardner D.K. Embryo transfer: techniques and variables affecting success.Fertil Steril. 2001; 76: 863-870Abstract Full Text Full Text PDF PubMed Scopus (210) Google Scholar) but also to allow everyone present to witness the proper placement of the embryo, thereby lowering the stress level (36Garcia-Velasco J.A. Isaza V. Martinez-Salazar J. Landazabal A. Requena A. Remohi J. et al.Transabdominal ultrasound-guided embryo transfer does not increase pregnancy rates in oocyte recipients.Fertil Steril. 2002; 78: 534-539Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar). Soft catheters are less traumatic and provide better outcomes (37Abou-Setta A.M. Al-Inany H.G. Mansour R.T. Serour G.I. Aboulghar M.A. Soft versus firm embryo transfer catheters for assisted reproduction: a systematic review and meta-analysis.Hum Reprod. 2005; 20: 3114-3121Crossref PubMed Scopus (90) Google Scholar). The number of so-called difficult ETs that take twice the normal time and thereby are known to adversely affect outcomes should be reported in KPIs (38Plowden T.C. Hill M.J. Miles S.M. Hoyt B. Yauger B. Segars J.H. et al.Does the presence of blood in the catheter or the degree of difficulty of embryo transfer affect live birth?.Reprod Sci. 2017; 24: 726-730Crossref PubMed Scopus (7) Google Scholar). Likewise, KPIs ought to follow ET outcomes for each doctor of the team on a regular basis. Low performers should be notified and their techniques reviewed until their results are on a par with the others, taking the patient population characteristics into consideration. The ultimate outcome of ART is the live birth of a healthy baby. This should be kept in mind when assessing ART success rates with various metrics. The primary outcome parameters of ART are sustained implantation (SIR), clinical pregnancy (CPR), ongoing pregnancy (OPR), and live-birth rates (LBR), which all need to be part of clinical KPIs. All ART programs should compute SIR, CPR, OPR, and LBR at time intervals of every 1 to 2 months to assess the quality of performance in relation to the number of OS cycles initiated, oocyte retrievals, and ETs. The difference between the results calculated per OS initiated and oocyte retrieval represents the number of cancelled OS cycles generally for poor performance during OS or intercurrent events leading to OS cancellation. Generally, OS cancellation for poor performance affects 5% to 15% of cases, depending on stringent OS criteria and/or population characteristics. Ovarian stimulation cancellation is more frequent in older women and ART repeaters. The advent of high-performance, high-yield embryo cryopreservation through vitrification has led to an increased number of cycles in which all embryos are cryopreserved and transfers are deferred through what is called segmented ART (39Shapiro B.S. Daneshmand S.T. Garner F." @default.
• W3035244911 created "2020-06-19" @default.
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• W3035244911 title "Which key performance indicators are optimal to assess clinical management of assisted reproduction cycles?" @default.
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