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• W3217551454 abstract "Following the advent of in vitro fertilization (IVF), the field of assisted reproductive technology (ART) has seen a dramatic increase in success rates along with an increasing number of developments, techniques, and add-ons. However, there remains considerable variability in pregnancy rates among clinics reporting to national databases. These variabilities could be due to differences in patient populations, but advancements in clinical care as well as laboratory techniques certainly play a pivotal role in a clinic’s success.Following the Fertility Clinic Success Rate and Certification Act of 1992, all ART clinics were mandated to report success rate data in a standardized manner to the federal government, which opened the door for transparency in reporting clinical outcomes. The creation of these large databases offers ART practices the opportunity to use the data to model after and improve their individual outcomes. Although most would argue that high-quality randomized clinical trials are the most ideal studies to advance clinical care, it is important to understand that some facets, such as the best clinical practices, are not amenable to these study designs. Over the past decade, several high-impact articles have been published in this area. However, the unanimous incorporation of these advancements into practice has yet to be done.In this month’s issue, Knudtson et al. (1Knudtson JF, Robinson RD, Sparks AE, Hill MJ, Chang AT, Van Voorhis BJ. Common practices among consistently high-performing in vitro fertilization programs in the U.S.: 10-year update. Fertil Steril 2022;117:42-50.Google Scholar) sought to evaluate similarities and differences in clinical and laboratory practices among what are considered high-performing fertility clinics that are all members of the Society for Assisted Reproductive Technology. A cross-sectional survey encompassing 61 questions was conducted across 13 (deidentified) IVF programs with high cumulative singleton live birth rates that perform at least 100 cycles per year. Several important points are brought to light regarding daily IVF practice patterns among these clinics.According to the investigators, many high-performing fertility clinics have similar practices, but there also are some variations. Several consistencies across all programs included the combined use of follicle-stimulating and luteinizing hormones in IVF protocols, intramuscular progesterone in frozen embryo transfer cycles, ultrasound-guided embryo transfer, and requiring that semen analysis be performed before IVF treatment. Additionally, these high-performing clinics focus primarily on the improvement of singleton pregnancies. According to the presented data, most clinics did not routinely recommend preimplantation genetic testing for aneuploidy (PGT-A), but recommended it in patients aged >38 years and still maintained high pregnancy rates. This corroborates the notion mentioned throughout the article that other factors, such as consistency, attention to detail with laboratory staff, teamwork, and regular communication (and not necessarily PGT-A for all patients), are the pillars of clinical success.Additionally, 3 of the 13 clinics perform only frozen embryo transfers, whereas 10 perform embryo transfers in a “fresh” cycle. Most of the clinics perform fresh embryo transfers, and the progesterone level used to advise a “freeze all” approach instead of performing a fresh transfer ranged from 1.5 to 2 ng/dL. Endometrial receptivity was performed rarely by any clinic, but if it ever was offered, it was only in the setting of recurrent implantation failure. Most clinics discouraged routine use of metformin, aspirin, and testosterone. Additionally, clinics were split on the use of dehydroepiandrosterone, coenzyme Q10, and growth hormone in patients with diminished ovarian reserve. None of the laboratories routinely perform sperm DNA fragmentation. Many other important aspects are evaluated, such as laboratory techniques, air quality control settings, media types, and assisted hatching, that are important to review.Over 10 years ago, Van Voorhis et al. (2Van Voorhis B.J. Thomas M. Surrey E.S. Sparks A. What do consistently high-performing in vitro fertilization programs in the U.S. do?.Fertil Steril. 2010; 94: 1346-1349Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar) also aimed to identify consistencies among the top high-performing IVF programs. Despite an increase in new ART technologies such as PGT-A, in the last decade, much of what high-performing clinics report as pertinent to their success remains the same: assessing all patients for endometrial defects, semen analysis before IVF cycle start, ovarian reserve testing, mixed luteinizing hormone and follicle-stimulating hormone stimulation protocols, and ultrasound-guided embryo transfers. Common laboratory practices in both surveys included selective use of intracytoplasmic sperm injection and blastocyst embryo transfer. Most importantly, there were 25% and 18% increases in the singleton live birth rate for women aged <35 and 35–37 years, respectively, compared with 10 years ago.As noted by the investigators, this study has the inherent limitations of a cross-sectional survey design: only 1–2 providers or laboratory personnel per clinic completed the questionnaire, and no comparison group was included in the study. It also is important to note that the survey used was not validated, and the sample size of the IVF programs that they surveyed may not be representative of all IVF clinics. On the other hand, it would be of interest to the readers to include common practice patterns for those aged >37 years, such as day 3 vs. day 5 transfer among patients who have a lower likelihood of blastocyst progression. This group of patients often can be the most challenging, and IVF “add-ons” may be sought after commonly, especially in states with nonmandated IVF coverage. It also would have been of interest to know if these practices have a maximum gonadotropin dose used in their IVF protocols.There are many thought-provoking practice patterns that reproductive endocrinology and infertility physicians can take away from this article. However, focusing on IVF “add-ons” or supplemental medications that few to none of these clinics partake in (endometrial receptivity assay, DNA fragmentation, antibiotics or corticosteroids at transfer, sperm selection aids, time lapse imaging) is an important aspect to consider. Although high-quality randomized controlled trials often are hard to come by with these practice patterns, we must ask ourselves the following question: if the highest performing IVF clinics in the country are not using these “add-ons,” should we be offering interventions lacking clear evidence of benefit? Although we do have data from a recent high-quality randomized controlled trial that an endometrial receptivity assay should not be performed routinely (3Doyle N. Jahandideh S. Hill M.J. Widra E.A. Levy M. Devine K. A randomized controlled trial comparing live birth from single euploid frozen blastocyst transfer using standardized timing versus timing by endometrial receptivity analysis.Fertil Steril. 2021; 116: E101Abstract Full Text Full Text PDF Google Scholar), data from articles, such as that of Knudston et al. (1Knudtson JF, Robinson RD, Sparks AE, Hill MJ, Chang AT, Van Voorhis BJ. Common practices among consistently high-performing in vitro fertilization programs in the U.S.: 10-year update. Fertil Steril 2022;117:42-50.Google Scholar) can help guide our practice patterns in areas where high-quality data may be lacking. As the investigators so eloquently alluded to, this creates added challenges to our practices in balancing our recognition of patient autonomy and our duty to provide cost-effective and safe care. Instead, we should be following the leaders. Following the advent of in vitro fertilization (IVF), the field of assisted reproductive technology (ART) has seen a dramatic increase in success rates along with an increasing number of developments, techniques, and add-ons. However, there remains considerable variability in pregnancy rates among clinics reporting to national databases. These variabilities could be due to differences in patient populations, but advancements in clinical care as well as laboratory techniques certainly play a pivotal role in a clinic’s success. Following the Fertility Clinic Success Rate and Certification Act of 1992, all ART clinics were mandated to report success rate data in a standardized manner to the federal government, which opened the door for transparency in reporting clinical outcomes. The creation of these large databases offers ART practices the opportunity to use the data to model after and improve their individual outcomes. Although most would argue that high-quality randomized clinical trials are the most ideal studies to advance clinical care, it is important to understand that some facets, such as the best clinical practices, are not amenable to these study designs. Over the past decade, several high-impact articles have been published in this area. However, the unanimous incorporation of these advancements into practice has yet to be done. In this month’s issue, Knudtson et al. (1Knudtson JF, Robinson RD, Sparks AE, Hill MJ, Chang AT, Van Voorhis BJ. Common practices among consistently high-performing in vitro fertilization programs in the U.S.: 10-year update. Fertil Steril 2022;117:42-50.Google Scholar) sought to evaluate similarities and differences in clinical and laboratory practices among what are considered high-performing fertility clinics that are all members of the Society for Assisted Reproductive Technology. A cross-sectional survey encompassing 61 questions was conducted across 13 (deidentified) IVF programs with high cumulative singleton live birth rates that perform at least 100 cycles per year. Several important points are brought to light regarding daily IVF practice patterns among these clinics. According to the investigators, many high-performing fertility clinics have similar practices, but there also are some variations. Several consistencies across all programs included the combined use of follicle-stimulating and luteinizing hormones in IVF protocols, intramuscular progesterone in frozen embryo transfer cycles, ultrasound-guided embryo transfer, and requiring that semen analysis be performed before IVF treatment. Additionally, these high-performing clinics focus primarily on the improvement of singleton pregnancies. According to the presented data, most clinics did not routinely recommend preimplantation genetic testing for aneuploidy (PGT-A), but recommended it in patients aged >38 years and still maintained high pregnancy rates. This corroborates the notion mentioned throughout the article that other factors, such as consistency, attention to detail with laboratory staff, teamwork, and regular communication (and not necessarily PGT-A for all patients), are the pillars of clinical success. Additionally, 3 of the 13 clinics perform only frozen embryo transfers, whereas 10 perform embryo transfers in a “fresh” cycle. Most of the clinics perform fresh embryo transfers, and the progesterone level used to advise a “freeze all” approach instead of performing a fresh transfer ranged from 1.5 to 2 ng/dL. Endometrial receptivity was performed rarely by any clinic, but if it ever was offered, it was only in the setting of recurrent implantation failure. Most clinics discouraged routine use of metformin, aspirin, and testosterone. Additionally, clinics were split on the use of dehydroepiandrosterone, coenzyme Q10, and growth hormone in patients with diminished ovarian reserve. None of the laboratories routinely perform sperm DNA fragmentation. Many other important aspects are evaluated, such as laboratory techniques, air quality control settings, media types, and assisted hatching, that are important to review. Over 10 years ago, Van Voorhis et al. (2Van Voorhis B.J. Thomas M. Surrey E.S. Sparks A. What do consistently high-performing in vitro fertilization programs in the U.S. do?.Fertil Steril. 2010; 94: 1346-1349Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar) also aimed to identify consistencies among the top high-performing IVF programs. Despite an increase in new ART technologies such as PGT-A, in the last decade, much of what high-performing clinics report as pertinent to their success remains the same: assessing all patients for endometrial defects, semen analysis before IVF cycle start, ovarian reserve testing, mixed luteinizing hormone and follicle-stimulating hormone stimulation protocols, and ultrasound-guided embryo transfers. Common laboratory practices in both surveys included selective use of intracytoplasmic sperm injection and blastocyst embryo transfer. Most importantly, there were 25% and 18% increases in the singleton live birth rate for women aged <35 and 35–37 years, respectively, compared with 10 years ago. As noted by the investigators, this study has the inherent limitations of a cross-sectional survey design: only 1–2 providers or laboratory personnel per clinic completed the questionnaire, and no comparison group was included in the study. It also is important to note that the survey used was not validated, and the sample size of the IVF programs that they surveyed may not be representative of all IVF clinics. On the other hand, it would be of interest to the readers to include common practice patterns for those aged >37 years, such as day 3 vs. day 5 transfer among patients who have a lower likelihood of blastocyst progression. This group of patients often can be the most challenging, and IVF “add-ons” may be sought after commonly, especially in states with nonmandated IVF coverage. It also would have been of interest to know if these practices have a maximum gonadotropin dose used in their IVF protocols. There are many thought-provoking practice patterns that reproductive endocrinology and infertility physicians can take away from this article. However, focusing on IVF “add-ons” or supplemental medications that few to none of these clinics partake in (endometrial receptivity assay, DNA fragmentation, antibiotics or corticosteroids at transfer, sperm selection aids, time lapse imaging) is an important aspect to consider. Although high-quality randomized controlled trials often are hard to come by with these practice patterns, we must ask ourselves the following question: if the highest performing IVF clinics in the country are not using these “add-ons,” should we be offering interventions lacking clear evidence of benefit? Although we do have data from a recent high-quality randomized controlled trial that an endometrial receptivity assay should not be performed routinely (3Doyle N. Jahandideh S. Hill M.J. Widra E.A. Levy M. Devine K. A randomized controlled trial comparing live birth from single euploid frozen blastocyst transfer using standardized timing versus timing by endometrial receptivity analysis.Fertil Steril. 2021; 116: E101Abstract Full Text Full Text PDF Google Scholar), data from articles, such as that of Knudston et al. (1Knudtson JF, Robinson RD, Sparks AE, Hill MJ, Chang AT, Van Voorhis BJ. Common practices among consistently high-performing in vitro fertilization programs in the U.S.: 10-year update. Fertil Steril 2022;117:42-50.Google Scholar) can help guide our practice patterns in areas where high-quality data may be lacking. As the investigators so eloquently alluded to, this creates added challenges to our practices in balancing our recognition of patient autonomy and our duty to provide cost-effective and safe care. Instead, we should be following the leaders. Common practices among consistently high-performing in vitro fertilization programs in the United States: 10-year updateFertility and SterilityVol. 117Issue 1PreviewTo evaluate similarities and differences in clinical and laboratory practices among high-performing fertility clinics. Full-Text PDF" @default.
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