Wednesday, May 18, 2011

Back in the Top 25/Why we are different

Someone sent me a link to a company that maintains a Web site which pulls IVF success rates off the SART Web site (which includes the statement “programs should not be compared …”), compares them, and publishes lists of the “top 25 programs” in the country. We’ve shown up on that list twice now. Of course, it’s better to be on the list than not, but the first time we were listed I pretty much ignored it. Small programs like ours are more likely have a high (or a low) success rate than bigger programs in any given year. After all, it’s possible for a good baseball player to hit three home runs in a row, but no one has ever hit 30 in a row. As numbers go up, success rates regress toward a mean. But if you show up twice, maybe there is something to it …
The first time we were listed in the “top 25”, a friend who runs a fertility clinic in another state called me. “Michael, what’s your secret? Blast transfer, 5% oxygen in the incubators, assisted hatching on everyone?” No, we don’t do any of those things routinely. I told him it was due to good staff, good patients, and good luck. I suppose there might be more to it than that, though. Here are some things that make our IVF program different from others:
1. We do IVF cases in series. This isn’t all that uncommon, but we batch our patients more than most other programs. – we only do IVF for one week every quarter. Some IVF programs are afraid they will lose “impatient patients” to other clinics by doing this, and that might be true. However, there is nothing like a short, intense run of IVF cases to focus your mind on the treatment. The lab is spotless, the culture medium is tested and fresh, and the staff can concentrate on one task. We bring in a good embryologist who works hard for one week and isn’t around afterwards to twiddle her thumbs while waiting for more IVF cases to dribble in (you other IVF program directors know what I’m talking about here). Doing IVF in series also forces our patients (and our staff) to rest a bit between cycles, and I think this is a good thing. We’ll do four series this year; next year we might do five.
There are some disadvantages to this approach, though. It puts more responsibility on me to keep up with freezing embryos at the end of a series, maintaining lab accreditation, following up on laboratory upkeep, etc.; but I have some technical staff who are good at that, and I don’t mind opening up the back of our laminar flow hood to see why it isn’t working (the damned thing is made in Denmark, and sometimes you have to call Copenhagen if you have a problem, but it’s a sweet machine – the embryology techs love it). Also, our nurse coordinator has to be able to launch people’s stimulation cycles so that the retrievals fall on the right day; and we basically use one stimulation protocol (OCP/long Lupron/FSH/Menopur) on everyone because we have gotten comfortable programming these cycles. No antagonist cycles here (and every time I look at the antagonist data, I’m convinced the protocol we are using is right for us).
2. We have a good IVF lab. If you see cheap furnishings in our waiting room, it’s because the furnishings in the IVF lab are really expensive. When we set up the lab, we got HVAC design specs from an IVF air quality guru and ordered the best equipment we could get. I originally wanted to stock the IVF lab with equipment made in the USA, but I wound up buying a laminar flow hood made in Denmark (see above), an embryo freezer made in Australia, and microscopes made in Japan (the incubators are US-made, however). I think US IVF programs are generally better than foreign ones, but some of the best IVF equipment is made outside the US. I occasionally visit or inspect other IVF labs, and I’ve never seen one nicer than ours. Our contract embryologist says the same thing. We also pay a lot of attention to getting the pH of our culture media just right; I have found that a surprising number of IVF labs don’t do this.
3. We do have a great staff. Front office, financial, nurses, lab techs, my medical assistant – they are all dedicated and caring. Most days we all eat lunch together in the break room. It may be what matters most, and it can be the hardest thing to fix if it isn’t right.
4. We let the husband be in the room during the egg retrieval. I’ve never seen another IVF program that does this. I doubt that it affects the success of the treatment, but I do think it relaxes the wife a bit to have the husband there, and it gives the husband an appreciation for what is going on. I’ve been allowing husbands to watch the retrievals for over 15 years and have never had a problem with it. Part of the reason why other programs don’t do this is they use deep sedation (basically general anesthesia) for the retrievals, and the anesthetists don’t like having the spouse around. We use lighter sedation (given by a nurse or a doctor). It works for us.
5. We don’t do ICSI (sperm injection) on everyone. If you look at US statistics, about 30% of the IVF cases are done because of a male factor, but over 60% of the cases employ ICSI, and some programs do ICSI on all their IVF cycles. While I don’t think doing ICSI necessarily lowers the success of IVF (it certainly doesn’t in our program), I am uncomfortable doing unneeded procedures. There are two things going on here: One is that some of the male fertility tests (like strict sperm morphology and SCSA) label many semen samples as abnormal when they really aren’t, so ICSI gets recommended. The other issue is that some IVF programs are fearful of having an IVF cycle end up with no fertilization, so they just ICSI all the cases. Around here ICSI adds about a thousand dollars to an IVF cycle, so why do it if it isn’t needed? (Hmm, on second thought, maybe that’s a third reason why ICSI is so popular. After all, that microinjector equipment is quite expensive.)
6. Free parking!