title: Self-operated endovaginal telemonitoring versus traditional monitoring of ovarian stimulation in assisted reproduction: an RCT.
abstract: OBJECTIVE
  Does self-operated endovaginal telemonitoring (SOET) of the ovarian stimulation phase in IVF/ICSI produce similar laboratory, clinical, patient reported and health-economic results as traditional monitoring (non-SOET)?
  
  
  CONCLUSIONS
  SOET is not inferior to traditional monitoring (non-SOET).
  
  
  BACKGROUND
  Monitoring the follicular phase is needed to adapt gonadotrophin dose, detect threatening hyperstimulation and plan HCG administration. Currently, patients pay visits to care providers, entailing transportation costs and productivity loss. It stresses patients, partners, care providers and the environment. Patients living at great distance from centres have more difficult access to treatment. The logistics and stress during the follicular phase of assisted reproduction treatment (ART) is often an impediment for treatment.
  The study was a non-inferiority RCT between SOET and non-SOET performed between February 2012 and October 2013. Sample size calculations of number of metaphase II (MII) oocytes (the primary outcome): 81 patients were needed in each study arm for sufficient statistical power. Block randomization was used with allocation concealment through electronic files. The first sonogram was requested after 5 days of stimulation, after that mostly every 2 days and with a daily sonograms at the end.
  
  
  METHODS
  Inclusion criteria were age <41 years, undergoing ICSI, no poor response and having two ovaries. We used a small laptop with USB connected vaginal probe and developed a specific web site application. Sonographic training was given to all women at the initiation of a treatment attempt at the centre. The website contained demonstration material consisting of still images and video sequences, as well as written instructions regarding the use of the instrument and probe handling. In total, 185 eligible patients were recruited in four centres: 123 were randomized; 121 completed SOET (n = 59) or non-SOET (n = 62), and 62/185 (33%) eligible patients declined participation for various reasons.
  
  
  RESULTS
  Patient characteristics were comparable. The clinical results showed similar conception rates (P = 0.47) and ongoing pregnancy rates (SOET: 15/59 = 25%; non-SOET: 16/62 = 26%) (P = 1.00) were obtained. Similar numbers of follicles >15 mm diameter at oocyte retrieval (OR), ova at OR, MII oocytes, log2 MII oocytes, embryos available at transfer, top quality embryos and embryos frozen were obtained in the two groups, indicating non-inferiority of SOET monitoring. Regarding patient-reported outcomes, a significantly higher contentedness of patient and partner (P < 0.01), a higher feeling of empowerment, discretion and more active partner participation (P < 0.001) as well as a trend towards less stress (P = 0.06) were observed in the S versus the NS group. In the economic analysis, the use of SOET led to reduced productivity loss, lower transportation costs, and lower sonogram and consultation costs (all P < 0.001 but higher personnel cost than NS).
  
  
  CONCLUSIONS
  The study was stopped (no further funding) before full sample size was reached. There were also a few cases of unexpected poor response, leading to a wider SD than anticipated in the power calculation. However, although the study was underpowered for these reasons, non-inferiority of SOET versus non-SOET was demonstrated.
  
  
  CONCLUSIONS
  Home monitoring using SOET may provide a patient-centred alternative to the standard methods. ART sonograms can be made, and then sent to the care provider for analysis at any appropriate time and from anywhere if an internet connection is available. This approach offers several advantages for patients as well as care providers, including similar results to the traditional methods with less logistical stress and potentially bringing care to patients in poor resource settings.
  
  
  BACKGROUND
  Supported by an IOF (industrial research fund) of Ghent University (full protocol available at iBiTech) and as a demonstration project of Flanders Care (Flemish Government). There are no conflicts of interest to declare.
  
  
  BACKGROUND
  EC/2011/669 (Ghent University Hospital), B670201112232 (Belgian registration) and NCT01781143 (clinical trials number).
authors.affiliation: Centre for Reproductive Medicine, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium jan.gerris@uzgent.be.
authors.forename: Jan
authors.initials: J
authors.lastname: Gerris
authors.affiliation: Centre for Reproductive Medicine, Clinique St Vincent, Rue Lefebvre 207, 4000 Rocourt (Liége), Belgium.
authors.forename: Annick
authors.initials: A
authors.lastname: Delvigne
authors.affiliation: Centre for Reproductive Medicine, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600 Genk, Belgium.
authors.forename: Nathalie
authors.initials: N
authors.lastname: Dhont
authors.affiliation: Centre for Reproductive Medicine, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium.
authors.forename: Frank
authors.initials: F
authors.lastname: Vandekerckhove
authors.affiliation: Centre for Reproductive Medicine, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium.
authors.forename: Bo
authors.initials: B
authors.lastname: Madoc
authors.affiliation: Centre for Reproductive Medicine, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium.
authors.forename: Magaly
authors.initials: M
authors.lastname: Buyle
authors.affiliation: Centre for Reproductive Medicine, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium.
authors.forename: Julie
authors.initials: J
authors.lastname: Neyskens
authors.affiliation: Biostatistics Unit, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium.
authors.forename: Ellen
authors.initials: E
authors.lastname: Deschepper
authors.affiliation: Biostatistics Unit, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium Department of Public Health, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium.
authors.forename: Dirk
authors.initials: D
authors.lastname: De Bacquer
authors.affiliation: Department of Health Economics, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium.
authors.forename: Lore
authors.initials: L
authors.lastname: Pil
authors.affiliation: Department of Health Economics, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium.
authors.forename: Lieven
authors.initials: L
authors.lastname: Annemans
authors.affiliation: Centre for Reproductive Medicine, Vrije Universiteit Brussel, Laarbeeklaan 1, 1090 Jette, Belgium.
authors.forename: Willem
authors.initials: W
authors.lastname: Verpoest
authors.affiliation: Centre for Reproductive Medicine, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium.
authors.forename: Petra
authors.initials: P
authors.lastname: De Sutter
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D006080:Ovarian Follicle / Q000000981:diagnostic imaging*; D010062:Ovulation Induction / Q000379:methods*; D011247:Pregnancy; D018873:Pregnancy Rate; D027724:Reproductive Techniques, Assisted; D012648:Self Care / Q000379:methods*; D014463:Ultrasonography / Q000379:methods*
keywords: IVF/ICSI; health-economy; patient empowerment; telemonitoring; vaginal sonography