How to choose the PMA center to rely on

This decision arises when the diagnosis of infertility or previous failures of other therapies indicate the use of Medically Assisted Procreation (PMA) techniques.

Generally the suggestion comes from the referring gynecologist, the family doctor, from friends who have already experienced this path or from the internet.

Orientation is not easy because you do not have sufficient knowledge of the topic and the cultural tools necessary to evaluate the differences between one center and another.

However, the factors that most come into play in the choice are above all the geographical proximity of a given center to one's residence and the costs to be faced for the procedures to be performed.

While these two factors are immediately perceptible, there are others that are much more difficult to evaluate but which are perhaps the most important for the goal to be achieved: having a baby in your arms.

Let's look at these other factors at play together.

Especially when you don't yet have direct experience, it is common to imagine that PMA techniques are performed more or less in the same way and with similar results in the various centers spread across the country, whether public, private or affiliated.

Therefore it seems logical to rely on the nearest center or a public one in order to reduce costs even if geographically distant.

However, are we sure that this is always the most convenient choice for the objective to be achieved? To answer this question it is necessary to know some numerical data, understand how the quality of the chosen center influences the results of the procedures and also know the effects that these difficult paths can have at a distance on one's emotional state and both personal and couple life.

First of all, it is good to know that in Italy there are 201 active centers that practice in vitro fertilization and that in 2019 over 50,000 cycles were started on over 41,000 couples (data from the National PMA Registry at the ISS (https://www.iss.it/rpma).

The Registry communicated that the average number of births per cycle started (calculated on all IVF cycles in 2019) was 10.2% with an average age of the patients of 36.8 years.

Between 40 and 42 years of age the average number of deliveries for multiple transfers carried out on the same patient (cumulative %) was 5.9% and in women aged 43 and over it was only 1.6%. The Registry also tells us that over half of the cycles performed in Italy (66.8%) come from centers that carry out more than 500 cycles per year, i.e. from the largest centres. Unfortunately in Italy these data are always published in an aggregate manner and it is not possible to trace the results of each center.

In the United States, however, where the results are published center by center, very large differences can be seen between one center and another.

For example, in New York where there are almost 50 centers the cumulative percentages (i.e. of multiple transfers coming from a single pick up) of births in women aged 35-37 ranged from 13.2% (in 2019 this center performed 3435 pick ups and over 6000 PMA cycles overall) to 44.6% https://www.cdc.gov/art/artdata/index.html In our Biofertility center in In 2019, the deliveries per cycle started were 18.2% with an average age of the patients of 37.2 and the majority of these cases, unfortunately, had already failed before reaching us.

In Biofertility patients aged 40 years and over, the cumulative % of transfer deliveries was 13%.

How can these large differences in results be explained? Certainly the different ways in which the same techniques are carried out can have a decisive role and in particular the customization with which they are applied.

In fact, at the same age, couples are very different from each other and when the protocols used take these factors into account, these protocols can be more effective than standard ones.

For example, depending on the ovarian reserve, one patient may respond very differently than another and therefore require an adequate stimulation protocol.

In particular, the dose is increased to avoid poor oocyte collection or reduced to exclude an excessive response which can cause hyperstimulation and damage to the quality of the oocytes.

There are, however, many other factors that should be taken into account to increase the chances of success ( https://youtu.be/fABXdEPpd64 ) with adequate treatments both before, during and after ovarian stimulation.

Among these factors we mention the levels of Progesterone in the blood during stimulation which may require carrying out the pick up on any day, even on the weekend and adequate maneuvers to keep it under control.

However, the more difficult the case is (e.g. advanced age, poor ovarian reserve, endometriosis, PCOS, severe andrological factor) the greater the need to personalize the PMA ( https://www.centroinfertilita.it/blog-e-news/308-pma-industrializzazione-vs-personalizzazione.html ).

As in all human activities, experience and the will to apply oneself to each job, spending all the time necessary, represent the most important factors for success.

Unfortunately, these conditions are not easily verifiable from the outside in the practice of PMA.

There are, however, elements or traces of them that can be directly verified by each couple and which can shed light on these very important factors.

In practice, we should ask ourselves some questions: 1° Are pickups and transfers also available on weekends? 2° Is Progesterone measured during the stimulation and especially on its last day? 3° Are the protocols different from couple to couple or are they standardized? 4° Is the human and relational aspect taken into sufficient account by the centre's team? Are you followed by the same professionals who know your history well? How much time is dedicated to interviews and requests for explanations? These questions, in fact, represent important aspects of the quality of a centre.

On the other hand, the success or failure of such complex techniques often depends on such particular and super-specialized elements that even a normal gynecologist might not be aware of.

A couple often makes a logical reasoning: "let's try these 3 attempts that fall within the convention of the nearby center and then we can possibly evaluate another one".

However, the reasoning does not take into account some important factors. 1) How much time passes from the first contact with the center to the execution of these attempts? Waiting lists are often very long and after the age of 40, we know that time plays a fundamental role. 2) How much physical and, above all, psychological fatigue do failures cause? Let us remember that the average of these failures according to the PMA National Register is 89.8! This aspect is generally not known or appreciated by those who have never experienced the PMA experience.

Yet it is enough to find out from those who have accumulated several failures to realize how much their negative load affects the life of each individual and of the couple. 3) A measure of the degree of personalization implemented by the center can be verified by the differences in the protocols used in the various cases.

Just ask couples who have already done the stimulation or is in progress to realize it ( https://youtu.be/9aokT_ivQYY ) 4) A couple immediately realizes if the center is able to create an empathetic relationship, if it listens, remembers the details of the case and responds coherently. Furthermore, there are many couples who initially appear as a simple case because the woman is young and there don't seem to be too serious causes of infertility.

Any failures reveal, however, that they are often in reality difficult cases that require great personalization of therapies.

Since one cannot know a priori whether it will be a difficult case (and one can unconsciously choose a center that has 5% results or 30%), it would be appropriate for such couples to also be treated by a center where experience and personalization are applied at the highest level precisely to reduce failures to a minimum.

On the other hand, we know that failures are frequent and therefore it is essential to feel listened to and understood.

That is, patients should have the feeling that everyone did their best and will always do so by trying to understand what went wrong.

In this way the couple can start again with the right energy, having done the appropriate in-depth analysis to have a better chance at the next attempt. Another doubt regarding the choice of geographically distant centers is the apparent difficulty of being sufficiently looked after and also the amount of time it takes to reside near the center also due to one's work which may not allow for excessive absences.

Well, this doubt is resolved if, after having identified the ideal center wherever it is in Italy, it guarantees a complete evaluation of the case, maximum personalization of the therapy and continuous listening to individual needs.

To summarize, the relationship with the center can also be seen from two aspects.

The first is the strategy to be applied to the case in question.

It is generally decided during the first interview and with the evaluation of all the exams taken up to that point.

From these things and from some other subsequent tests the center understands the situation well and decides the best path to follow including the ovarian stimulation protocol.

If the first interview cannot be done in person, it is sufficient to gather all the information with an online consultation at the times and days most convenient for everyone, as if the center were coming to your home to find out the story, ask questions and discuss the exams received before that interview.

In other words, this mode is sufficient to set the appropriate strategy which is the most important thing.

The second aspect of the relationship with the chosen center concerns further tests that are recommended and prescribed.

If the places where they are carried out respect the average standard, the results sent to the center will be adequate for the conclusions and final decisions.

After all, the laboratory tests required are generally of a common type (with some rare exceptions).

Ultrasound scans or other tests such as hysteroscopy also belong to the usual normal practice of the average gynecologist.

In some cases the center itself can indicate trusted colleagues for this or subsequent phases for further checks.

What is truly fundamental, difficult and unique is the management of this data which, together with the first interview, is part of the personalization strategy of the best stimulation protocol to carry out and, even before that, of the other drugs or supplements to take.

The same reasoning applies in the period of stimulation when, that is, the patient can carry out ultrasound monitoring by a gynecologist with sufficient experience (there are many who know how to monitor follicular growth and there is no need to be part of a PMA center for this).

Even when hormone tests such as estradiol and progesterone need to be carried out, you can stay at home because medium-level laboratories are able to carry them out and give the results the same day.

All this data can be sent daily to the center which will evaluate them and give the daily therapy to be administered with any corrections to the dose and type of drugs.

When it appears clear from the ultrasound and the tests that the final moment has been reached, the couple can arrive at the center the day before the pick up, carry out the egg retrieval the following day and return home on the day of the transfer.

If, as in our case, it is carried out on the second day, the couple's stay away from home can be 3-4 days.

After the transfer you can be followed equally accurately because the center that works to personalize the therapies is available 7 days a week by telephone or e-mail.

In other words, what's the point of having a center near your home if it's difficult to communicate with it, especially on weekends? For the sake of truth, couples from all regions come to our center and have never encountered distance problems in carrying out the process ( https://www.centroinfertilita.it/testimonianze/casi-di-successo/309-biofertility-la-denziale-non-e-un-problema-la-personalizzazione-e-il-nostro-punto-di-forza.html ) In conclusion, it is sometimes a question of choosing how much you are willing to accept results sometimes modest and with the addition of an important psychological load when the priority falls on the proximity of the center and on the low cost (moreover the latter often turns out to be different because one cannot imagine other expenses which often arise unexpectedly during the journey).

In other words, what is more convenient? Go to a center that presumably has double the results of the average center and get to your child first, or settle for significantly lower results, wasting a lot of time and burdening yourself with considerable anxiety? It is not a question of favoring private or public centers but simply of choosing the quality and customization offered.

Everyone must make their own choices independently and consciously as long as they know all the factors at play well from the start, even those that are not visible.