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Panminerva Medica 2019 March;61(1):11-23

DOI: 10.23736/S0031-0808.18.03549-8


lingua: Inglese

A quality management approach to controlled ovarian stimulation in assisted reproductive technology: the “Fischer protocol”

Robert FISCHER 1 , Fabiana Y. NAKANO 2, Matheus ROQUE 3, Fabiola C. BENTO 2, Vera BAUKLOH 1, Sandro C. ESTEVES 2

1 MVZ Fertility Center Hamburg, Hamburg, Germany; 2 Andrology and Human Reproduction Clinic, ANDROFERT, Campinas, Brazil; 3 Origen Center for Reproductive Medicine, Rio de Janeiro, Brazil

BACKGROUND: Ovarian stimulation (OS) is crucial for pregnancy success in assisted reproductive technology (ART) treatments. The possibility of programming the OS cycle and oocyte pick-up (OPU) is advantageous to Fertility Centers operating under quality management systems (QMS) as it might increase efficiency and safety. Moreover, cycle programming is patient-centered as it might help IVF patients to most optimally manage domestic and work commitments. In this study, we describe the so-called “Fischer protocol” to IVF cycle programming and present the clinical results of using this approach in two independent Fertility Centers certified according to DIN EN ISO 9001 standards.
METHODS: Cycle programming was achieved in normo-ovulatory women with pretreatment administration of norethisterone acetate, followed by OS using individualized doses of recombinant human FSH and recombinant human LH in a fixed 2:1 ratio in association with a flexible GnRH antagonist regimen. The final oocyte maturation was attained with use of GnRH agonist trigger. The oocyte pick-ups (OPU) were scheduled approximately 40 days ahead of the programed OPU date. The cycle outcomes of 647 patients treated using the “Fischer protocol” in the Center where the method was developed (study center 1) are presented. The model was then tested at an independent Fertility Center (study center 2), and the first clinical results using the Fischer protocol in 216 patients are presented and compared with that of 516 patients undergoing conventional OS without cycle programming.
RESULTS: The duration of ovarian stimulation was 9±1 day in all treated patients. No OPU was scheduled during weekends or had to be re-scheduled due to issues related to cycle programming. In the study center 1, the highest and lowest mean number of oocytes retrieved was 11.7 (95% confidence interval [CI]: 4.5-22.1) in patients of ≤30 years and 7.7 (95% CI: 1-19) in those aged 40 years and over. No cases of OHSS were recorded in this series. The mean number of embryos transferred was 1.5 and the overall clinical pregnancy rates (CPR) and live birth rates (LBR) were 52.7% and 43.5%, respectively. In the study center 2, patients treated using the Fisher protocol achieved statistically higher oocyte output rate (94.6% vs. 85.0%), number of oocytes retrieved (9.8±7.7 vs. 7.9±7.2), and blastulation rates (55.1% vs. 49.4%) than those treated using conventional OS. The CPR (50.6% vs. 41.1%) and LBR (44.7% vs. 33.2%) also favored the group of patients subjected to cycle programming using the Fisher protocol, although this data mainly resulted from the increased frequency of patients subjected to preimplantation genetic testing for aneuploidy (PGT-A).
CONCLUSIONS: An optimal distribution of both clinical and laboratory workload was achieved by using the Fischer protocol. Moreover, oocyte pick-ups were eliminated on weekends and holidays without jeopardizing the quality of care provided to couples. The Fischer protocol is consistent with the quality management philosophy and focusses on improving the quality of care by increasing safety, efficacy, and patient-centeredness without harming treatment effectiveness.

KEY WORDS: Assisted reproductive techniques - Quality of health care - Ovulation induction - Norethindrone - Gonadotropins - Total quality management

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