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Assisted Reproductive Technology:
Recommendations for the Future of the Registry
Assisted Reproductive Technology: Recommendations for the Future of
the Registry
Title:Profiling assisted reproductive technology: outcomes and
quality of infertility management
Author: E. Steinberg et al.
Address:Baltimore, MD
Source: Fertility and Sterility 69:617-623
Summary:A comprehensive look at current assisted reproduction
technologies (ART), performance evaluation of ART and performance enhancement
suggestions are covered in this article, as well as a critical review of
the American Society for Reproduction (ASRM) / Society for Reproductive
Technology(SART) Registry. The registry is an initiative of a "proactive
performance assessment" by a clinical specialty society (ASRM/SART). To
be a member of ASRM/SART, an ART program must report their procedure activity
data to the registry. Data validation is accomplished by a committee that
performs site visits to ensure proper data collection. In the year 1994,
SART acquired reported data on 42,509 ART treatment cycles at 249 centers
in the US and Canada. The authors point out that a performance evaluation
must focus on ÒprocessÓ and ÒoutcomesÓ of care.
"Process" refers to the compliance with established standards or preferred
patterns of practice. While providing for an acknowledgement of the diversity
of physicians involved in infertility treatment, ASRM/SART guidelines neglect
to define patient selection criteria or provide guidelines for diagnostic
evaluation or ART procedure selection. ASRM/SART does attempt to address
ÒoutcomesÓ by first addressing immediate outcomes such as:
retrieval rates and fertilization rates and by reporting the "ultimate"
outcomes of delivery, clinical pregnancy, abortion, singleton vs multiple
birth etc. The weakness, the authors point out, is that "the failure to
adjust for patients treatment history results in misleading indications
as to the effectiveness of particular ART's and of the comparative effectiveness
of particular centers". These outcome measures can be improved upon using
the patient as the denominator by adjusting for the variation in patient
characteristics such as: age, duration of fertility, presumed cause of
infertility, treatment history and DES exposure. They also suggest that
statistical significance of observed differences in events rates be indicated
and that maternal age is recognized as a continuous, rather than dichotomous,
variable in the case mix adjustment. This adjustment will help answer the
key question for couples considering ART, "Of the women who undergo ART
treatment, who are like me, what proportion deliver a healthy baby?"
In this article, ASRM/ SART are commended for their efforts to obtain
standardized data on ART treatment procedures and outcomes in the registry
initiative The value of these efforts will be recognized, according to
the authors, if the above mentioned suggestions are implemented and when
the necessary ÒprocessÓ portion or the guidelines currently
lacking for ART treatment, are developed, allowing for a critical appraisal
of the particular aspects of infertility management. Comment: In the next
three weeks, there will be a series of "What's Up Doc?" addressing
the issues of success rates, SART, and reporting. These are pivotal issues
in the further development of this technology.
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