ASRM/NRAC Practice Survey: IVF in the United States

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Hans van der Slikke, MD: "It's the 23rd of October, and we're at the ASRM in Orlando. Next to me is Steve Corson from Philadelphia - welcome."

Stephen Corson, MD: "Thank you, nice to be here."

Hans van der Slikke, MD: "Yesterday there was a session about the results of IVF Survey in the United States. You were one of the presenters and you told us about the survey which was done between the representatives in the United States. How was this survey set up?"

Stephen Corson, MD: "In the fall of 1999, Serono sponsored a conference between the pharmaceutical industry, clinicians, and the insurance representatives. The general consensus from the insurance side was that their underwriters could not begin to address the issues associated with funding infertility care because they had no idea what we were doing. That was essentially the germination portion of the study, and ASRM then authorized a practice survey to be conducted by the National Regional Advisory Counsel. To make a long story short, this was a representative in each state and we looked at this on a geographic basis to see if there were differences from one area in the country to the other. We got replies from 31 states and we had 583 valuable replies so that was our database. The survey was actually very difficult in that the respondents - the physicians - had to follow the first twenty patients who entered their practice as of January 1st the year 2000 until they were pregnant, until they dropped out of the practice, or until a year had gone by. They had to record all of the history, the testing procedures, and therapy so it was quite a bit of work, and we are very lucky to have good people out there who were willing to do this."

Hans van der Slikke, MD: "Because you have a lot of valuable results."

Stephen Corson, MD: "Yes."

Hans van der Slikke, MD: "What do you think was the most important results you got?"

Stephen Corson, MD: "We first found that there were geographical demographic differences, for instance, the women in the central portion of the country were younger by about three years than the women in the north-east and the south-east. That doesn't sound like much except that John Collins had done a previous survey and demonstrated that for each increasing year of age in a female the pregnancy prognosis decreased by 9%. His survey was done with a mean age of 26.8 years in the female population and our mean age was considerably older so that was an important finding. Another geographical difference was that patients in the west were referred directly more often to reproductive endocrinologists without any workup than in other parts of the country. In other parts of the country, two-thirds of the patients had previous investigation or therapy so it was a slightly different population base. This may demonstrate differences in philosophy of care and they also illustrate differences in the manner in which the insurance companies approach this so far as referrals are concerned, they may limit what the generalist does. Another interesting finding was that we corroborated the complaints of the urologists who have been telling us for years that we underutilized their services. One of the questions was - if you diagnosed a male factor did you send that patient to a urologist. Only about one-third of the time was the male sent to a urologist when there was a male factor at play, and we can certainly do much better than that. In some communities there might be a situation where there was nobody who was really interested or competent but a lot of our respondents were in large urban centers so this is really not the case. Another area in which we can all do better has to do with the multiple gestation issue. Whether patients are receiving clomiphene citrate in the office or gonadotropics stimulation or IVF, the problem of multiple gestation and high order multiple gestation exists. Our respondents were not very good at discussing this issue with the patients up front which is when it should be discussed rather than after the ultrasound shows the presence of three sacs."

Hans van der Slikke, MD: "Did you also ask in your survey how many embryos they transferred?"

Stephen Corson, MD: "Yes, we did, and in general the ASRM Guidelines were followed but it's interesting the percentage of multiple pregnancy is greater with IVF than with office ovulation stimulation but the numbers with the latter are so much greater than the former that 80% of all the twins are a result of office stimulation cycles rather than IVF."

Hans van der Slikke, MD: "Were there regional differences in the IVF multiple pregnancies because you may know that in Europe the big research by Karl Nygren showed that in the northern part of Europe the embryo transfer was often only one embryo and in southern Europe some more with the same results in pregnancy. How is this in the United States?"

Stephen Corson, MD: "We showed no regional differences but of course the story in the United States is much, much different. Here you have real competition; in one city you may have nine or ten centers and they're all competing for patients. The patients always ask - what is your pregnancy rate and it's a different ball game. An interesting fact that we uncovered with respective results was that the pregnancy rate was essentially constant per month, the constancy rate through the year. When you look at the curves for individual therapy such as clomiphene citrate or gonadotrophins, you know they go and they flatten out. What this showed was that as the entry level therapeutic modality didn't work, the clinicians were correct and quickly ratcheted up to the next level so that the actual pregnancy rate was essentially the same each month, and I think that's a good point. With respect to pregnancy by diagnosis, the big three diagnoses of male factor, endometriosis, and ovulation disturbance all had about the same yield so far as pregnancy is concerned. We then dropped down and patients who had tubal disease or adhesions had a lower pregnancy yield, and in many cases that's because their finances would not allow them to go and do IVF which is, as we all know, the ultimate cure for tubal disease. That was the first indication for IVF. An interesting finding was when we looked at the pregnancy rate with use of gonadotrophins alone or gonadotrophins with IUI there was no difference. The general feeling is that their synorchism and that the ovulation induction rate has increased if you add to that IUI but this was not our finding."

Hans van der Slikke, MD: "Most striking was the percentage of dropouts, you did research on that as well."

Stephen Corson, MD: "If we eliminate the people who got pregnant, the dropout rate at the end of the year was about 40% with no real difference by region. Now did those people drop out because they were frustrated or because they ran out of money or their insurance stopped? We don't know, and we didn't ask the question because what the patient tells the physician is not always reflective of what's really going on. She may be embarrassed to say - we ran out of money or she may be embarrassed to say - I want to do this but my husband has lost his desire to do this. All I can do is to report that the dropout rate approached 40% at the end of one year but I can't tell you why. The conclusions reached were that in general, I think, we're doing a good job with respect to moving the patients along when one therapy doesn't work, and not leaving them for ten cycles of clomiphene citrates so we're doing that well. I think we're following the ASRM guidelines for the SART guidelines for embryo replacement well. We need to do better with urological consultation, we need to do better with discussion of unpleasant subjects such as fetal reduction, and of course we need to get the insurance people in on discussions as to how we can better fund our patients."

Hans van der Slikke, MD: "This was interesting, and you started your talk saying the survey was initiated by Serono but I learned that all three major companies supported this survey."

Stephen Corson, MD: "Not so."

Hans van der Slikke, MD: "Not so?"

Stephen Corson, MD: "No, not so - only Serono. The respondents were not paid anything, Serono paid for the statistician. They totally paid for the statistician and the mailings, the other companies did not participate."

Hans van der Slikke, MD: "Thank you very much."

Stephen Corson, MD: "Thank you."