“Understanding Infertility”: A CME Course in Reproductive Medicine August 12-14th, 2011 New Delhi, India

1. Strategies to Reduce Patient Dropout from ART Treatment “Understanding Infertility” – New Delhi, India – August 2011 SandroEsteves, MD, PhD Director, ANDROFERT Center for Male Reproduction and Infertility Campinas, BRAZIL

2. Learning Objectives A critical analysis of “quality” in IVF Unravel IVF dropout Numbers Root causes Dropout hotspots Learn strategies to improve patient’s adherence to IVF treatment

3. Is your IVF program good? Pregnancy rates = Quality??????? 50% is really better than 30% ? Pregnancy rates Esteves, 3

5. >1,000 babies born

6. Lots of credentials/experience

7. Several publications

8. All treatment options available

9. Individualized approach

10. Rare errors/patient complaints

11. Low multiple PR

12. Educational marketing

13. Established 2005

14. 100 babies born

15. Few credentials experience

16. No scientific publications

17. IVF first treatment line

18. No poor responders

19. Record of errors/patient complaints

20. High multiple PR

21. Advertise a lot Esteves, 4

22. IVF Results Esteves, 5

23. So, what makes a high quality IVF Center? Satisfied customers who return for treatment Esteves, 6

24. The dropout of patients undergoing IVF is huge! In a 2005 IVF study from the UK, per-cycle discontinuation rates ranged from 25-42% and increased with each subsequent cycle Adapted from Rajkhowa et al. Reasons for discontinuation of IVF treatment: a questionnaire study. Hum Rep 2005;21:358-363

25. Root Causes of Treatment Dropout IVF events women find stressful7 Up to 65% of couples dropout from IVF without achieving pregnancy before they complete 3 cycles1-5 Reasons1,5,6 1. Olivius K t al, Fertil Steril 2004;81:258; 2. Land JA et al, Fertil Steril 1997; 68:278; 3. Schroder AK, et al, RBM Online 2004; 5:600; 4. Osmanangaoglu K et al, Hum Reprod 2002; 17:2655; 5. Rajkhowa M et al, Hum Reprod 2006; 21:358; 6. Brandes M et al, Hum Reprod 2009; 24:3127; 7. Hammarberg K et al, Hum Reprod 2001; 16:374. Esteves, 8

26. Root Causes of Treatment Dropout Financial/cost issues are NOTprimary cause High dropout rates in countries with national healthcare programs covering IVF Domar AD. Fertil Steril 2004;81:271

27. Strategies to reduce dropout Make IVF more patient-friendly is the key issue Esteves, 10

28. Location Campinas, Sao Paulo, Brazil Complexity Category Private Center Foundation Urologist/Andrologist Gynecologists, Anesthetists, Embriologists, Lab Technicians, Nurses, Psychologist, Pharmacist, Nutricionist, Acupuncturist, Administrative personnel Staff Workload Our method Tertiary Center for Male Reproduction Stress reduction Intensive nursing care Education Total quality management 1997 over 1,200 couples per year Esteves, 11

29. Reduce Patient Dropout from ART Lesson 1: Stress reduction Some IVF difficulties Understanding treatment steps/expectations Several medications, documents, orientation Excessive monitoring Blood, ultrasound Learning about injections FSH/LH/hCG Antagonist/agonist OCP (pain, anesthesia) Esteves, 12

30. Reduce Patient Dropout from ART Lesson 1: Stress reduction Medication Strategies sc rFSH/rLH (pen devices) Antagonist (vs agonist) Combine meds (antag + rLH) sc prefilled hCG Vaginal progesterone 1x/day (vs IM) Minimize blood tests Esteves, 13

32. Sperm retrievalEsteves, 14

33. Reduce Patient Dropout from ARTLesson 1: Stress reduction Complementary Health Care Program Integrated team of health professionals: - psychologist - nutritionist - acupuncturist Weekly sessions Goal: Reduce Stress Rejane Ganzaroli Psychologist, ANDROFERT Esteves, 15

34. Reduce Patient Dropout from ARTLesson 2: Intensive nursing care Each patient assigned to a nurse (~20-25 couples per nurse) Teaching (IVF steps, medication) Individualized patient agenda Medication plan Schedule appointments Hotline (24h/day; 7 days/week) Follow-up: Up to live birth (Registry report) Return visit (non-pregnant) More attention less stressed, happier patients Esteves, 16

35. Next employee: Nurse A high quality IVF program has excellent nurses Esteves, 17

36. Reduce Patient Dropout from ARTLesson 3: Education IVF education on site but preferable via Web Esteves, 18

37. ART Education IVF education on site but preferable via Web Material for download Medication timetables Consents Procedure instructions Medication instructions Esteves, 19

38. Reduce Patient Dropout from ARTLesson 3: Education IVF education on site but preferable via Web Material for download Medication timetables Consents Procedure instructions IVF orientation Goals:  Patient visits  Nursing time Cost savings IVF orientation guide

39. ART Education Video Medication Instructions Cetrotide 02:31 Learning how to administer injections via Web Tutorial Videos on the Web Available for download Crinone 01:11 Gonal 75 02:16 Gonal Injector 02:39 Luveris 02:15 Ovidrel 00:55 Synarel 01:08 Subcutanea 01:57 Esteves, 21 Intramuscular 01:56

40. Reduce Patient Dropout from ART Lesson 4: Quality Management How do you know you are doing a good job? How do you measure your interventions/processes? Are your patients satisfied? Esteves, 22

41. The IVF Clinic:a very complex organization Esteves, 23

42. Reduce Patient Dropout from ARTLesson 4: Quality Management ISO 9001:2008 A well-organized workflow will guarantee good quality of work Quality Management = Process management Define what you want to do, how you want to do it, and how you can ensure it’s being done that way Esteves, 24

43. Reduce DropoutLesson 4: Quality Management ISO 9001:2008: requirements Control of documents Control of records Internal Audits Control of nonconformity and corrective action Preventive action Esteves, 25

45. 90-96% of unhappy customers never lodge a complaint.Marketing for keeps, John Wiley, New York 1993 Esteves, 26

46. Understanding our customers- Surveys Esteves, 27

47. Understanding our customers- Surveys

48. Improve adherence to IVF Lesson 4: Quality Management Total Quality Management A high quality IVF program focuses on how the business is managed Focus on patient Improve communication Continual improvement Leadership Esteves, 29

49. Reduce Patient Dropout from ARTLesson 4: Quality Management Leadership Established unity of purpose and direction of the internal environment Create an environment where people are fully involved in achieving the organization’s objectives Fabiola Bento, MBA Quality Manager Esteves, 30

50. Our method Stress reduction Intensive nursing care Education Total quality management Source: Androfert, 1999-2009 Esteves, 31

51. Reduce Patient Dropout from ART Practical Points Quality in IVF involves technical issues and patient satisfaction Dropout in IVF is mainly related to stress Reducing stress will improve adherence and decrease dropout. Make IVF patient-friendly is a key issue

52. Reduce Patient Dropout from ART Practical Points Infertile patients need education and support throughout the infertility journey Invest in nurses and web-based educational tools A quality system aid IVF Clinics to focus on the needs of the customer (patient): these includes medical, scientific and emotional needs.