Thanks for viewing QAP-online. To our knowledge, the first on-line Quality Assurance Program for the Reproductive Sciences. I created FertAid.com in 2001 to provide Internet support to the many people involved not only in IVF but the reproductive sciences. It is hoped as the site develops the clinical, the research and the animal management spheres will benefit. QAP-online is the cumulation of many years of dealing with issues in the IVF laboratory of comparative assessment of gametes and embryos both within the programs in which I have worked and between clinics. While it is acknowledged that the Internet posed considerable limitations, the spirit of the site is to improve and provide confidence to reproductive scientists and clinicians in their professional capabilities. Welcome to FertAid's QAP-online.

Dr James Stanger PhD.

Director, FertAid

QAP-online should be seen as a tool for both individuals and clinics to improve and maintain a level of interpretative skills associated with the reproductive sciences. It seeks to achieve this goal by providing images and questions which are either educational in nature (e.g. describe each aspect of an individual spermatozoon or embryo) and quantitative (e.g. the % normal forms or % motility or numerically grade an embryo [this one is difficult]). In this way, subscribers may explore where they agree and disagree with other subscribers in how they interpret visual objects, an on-line teaching tool, and then use this as a quality improvement tool to assess their reporting performance in a quality assurance environment. The power of the Internet delivers, with some limitations, the same image to interpret, magnifying the power of the interaction. QAP-online is designed to be available to ALL staff not just one individual.

Since QAP-online allows individual subscribers to link their replies with other subscribers, forming a QAP group such as an IVF laboratory or company (with several laboratories), QAP-online maybe used either as an Internal QAP environment or an external QAP environment. In some ways, QAP-online should be seen as a series on linked QAP groups. It offers the potential for clinics or laboratories to operate a professional development and Internal QAP programs without the need to commit additional human resources.

After 20 years supervising integrated embryology, Andrology, endocrinology, ultrasound  laboratories as well as patient management including nursing and counseling services in a clinical IVF program, it remains apparent that in all these areas expect endocrinology inter-clinical quality assurance is largely absent. In endocrinology (and to a lesser extent Andrology), current QAP systems provide limited quality management albeit in a retrospective manner (results 2-4 weeks after the assay performed). All other areas rely on visual interpretations of images or fresh material on which clinical decisions are made. Yet what one laboratory describes as a "good" embryo, spermatozoon or ultrasound image, another clinic may not. If clinics do not aspire to the highest standards for quality assurance, clinical interpretations of some areas may be rendered of little value not because of biological association but because of sample variability. For instance, excessive variation in sperm morphology between individual staff members or between samples will produce such variation in reporting that a clinic may well argue that sperm morphology is of little value. Yet, if confidence in reproducibility is available between staff, then variations in biological associations may be truly assessed. Reporting of other sample based QAP programs in Andrology have consistently demonstrated wide subscriber variability. Following workshops, the large variability is often significantly reduced, clearly demonstrating that with education,confidence in reporting can be improved.

In current times when single embryo transfers and allocation to ICSI will become increasingly important, the interpretative skills of clinical and laboratory staff will correspondingly also become important.

The Internet provides a unique opportunity to address some of these issues by allowing professional from many areas of various countries the capacity to view and comment on the same embryo, spermatozoon or ultrasound picture. While assessing images does present some limitations, it does not in itself preclude such an endeavor. In fact, the power of inter-clinical assessment far outweighs these limitations.

QAP-online is a nonaligned web area created to provide maintenance of  professional development among experienced workers in reproductive science, educational experience for newcomers to the field, and a learning site for all. In particular, the capacity to view gametes, embryos or research related images in new and different fields makes QAP-online an exciting environment to explore. The concepts created to provide quality assurance to reproductive professional can be used to explore visual images of different, rare or endangered species or to new research. 

QAP-online trusts your participation will rewarding. We welcome your comments suggestions and ideas to expand the limitations of the site to the benefit of all who work and study in reproductive science.

Using real life images ranging from embryos and spermatozoa to ultrasound and clinical observations, QAP-online seeks to provide tools for education and professional development.

Importantly, rather than a single clinic or laboratory submitting an answer to a QAP, the site hopes that all laboratory or clinic personnel, academics and medical professionals may participate in the program.

QAP-online is largely and educational site. Quality Assurance should be 50% education and 50% assessment. The initial feedback capacity of QAP-online is largely a educational function. QAP-online also provides reporting features based upon the questions asked. These reporting functions both bar charts for non-numeric data and standard deviations from the mean plots provide an initial attempt by QAP-online to support an assessment capability.

Realistically priced, QAP-online has been designed to be available to all staff of a clinic or laboratory.

QAP-online seeks to provide a range of QAP schemes which may best reflect your need for continuous improvement. Any scheme which can be visualized by an image or video, or textural scenario can form the basis for a Quality Assurance Program. At present, it is proposed to provide schemes in 

• Embryo Quality

• Sperm Morphology

• Ultrasound Assessment (under development)

QAP-online works on a subscription based system of specific annual QAP schemes. Subscribers may enroll in one or many schemes which comprise of a series of installments or issues. Each issue, usually several per month, delivers an image (of say embryos). Each image has attached to it a series of questions. Multiple choice answers in the form of radio buttons, allow the subscriber to select which choice best answers the question. In other installments, text scenarios are provided. Video options ( of say sperm motility) under review - see free demonstration module for Andrology. Currently you will need to download a Quicktime player to view the videos - and make a cup of coffee while they are downloading!

Some questions and options may be directly relevant to your area of work while questions may be less appropriate. You may respond to any or all of the questions. When you select and submit an option, the number of responses which is the same as the one you selected and the proportion of all the other response is displayed. In this way you can get immediate feedback of how your assessment compares to other subscribers. Since, the scheme is dynamic, the number of responders may change over time but importantly, your response can be evaluated immediately.

Each installment has a date stamp before which it cannot be viewed. You will need to return to the QAP scheme each month to access the issues available in the new month as well as to review how your responses compared to all others received.

In this way, QAP-online aims to provide each subscriber with a quality assurance report of their relative definitions as well as providing some level of education.

One problem with such a scheme is that you do not know the relative competency of the other subscribers. QAP-online attempts to define the status of each subscriber at the time of enrollment. The comparison of your response to other subscribers can be selected to include only those who indicate that the area of assessment is part of their normal work environment or all subscribers.

In addition, a really great part of QAP-online is the capacity for a clinic QAP supervisor to create a record of the clinic or institution (online). Other scientists of the same or related clinic may tag their registration to the clinic using a unique code word. When a subscriber does this (online!), their response may be compared to the other subscribers within their own clinic. In this way, QAP-online allows for the same image to be viewed both internally as part of an INTERNAL QUALITY ASSURANCE PROGRAM and well as part of an external program.

To register, you may either 

• download the registration form available at REGISTRATION FORM , complete and post as instructed together with your payment for the number of schemes desired. When received, you will be added to the site, preliminary personnel information completed and a Subscriber Number, logon code and password assigned. You will be contacted both by surface mail and by e-mail with this information. You can then access the site and the QAP schemes you are interested in.
• OR
• Complete the on-line registration. You will be provided with a Subscriber Number, logon code and password which will be returned to you at the e-mail address you nominate. When received you can then access the site. You may then select a scheme that you wish to participate in by either credit card payment on the Internet or downloading the subscription page and returning it by surface mail as directed.

Future access will be by the logon code and password.

QAP-online seeks to provide continuous improvement and development among many professionals actively working in the area of the QAP scheme while at the same time providing an educational tool for students or newcomers to a discipline.

It is not a scheme just for embryologists or andrologists. QAP-online seeks to provide a quality assurance scheme for many different disciplines within the area of reproductive sciences.

To achieve this, each subscriber's status is  identified at the start of a QAP scheme. For some, the subscriber may actively be involved in that discipline ( e.g. Andrology) while others may be participating to learn. 

The responses to each image is returned as a proportion of professionals or as a proportion of all participants. In this way, professionals may compare themselves to other professionals  without the distortion of the responses from "students".

In many QAP program, say with endocrinology, the instrument is being assessed not the operator. With QAP-online, it is the operator (professional) who is participating. Consequently, while for endocrinology, only one subscription is required per clinic, with QAP-online, every professional has the opportunity to enroll. 

To assist clinics in their internal reviews, QAP-online provides the facility to link subscribers within their own clinic. Where a subscriber has been linked to their clinic, the responses to each question can be compared to other staff members of the same clinic, other professionals and to all subscribers.

In this way, clinics may use QAP-online to run an internal Quality Assurance Program for their staff. Because, it is carried over the Internet, the staff can participate on any computer either at home or at work.

Clinics may subscribe using Company Order Numbers but the subscription will depend on payment of invoice.

QAP-online has created the potential for each staff member in a laboratory service, even if they work in different locations or laboratories, to interact within a common QAP group while at the same time participate in an international QAP scheme. This is achieved by the creation of a QAP supervisor who is responsible for overseeing each staff members activity.

The QAP supervisor than can created a company record of the QAP group with a specific company code.

Any other person who has registered with QAP-online can link their activities to the company by adding this code to their profile. Every member of the group will know who is a member of the group and the QAP supervisor has some capacity to regulate this (under development). The reason for this clearly is that each reply can now be viewed either in relation to other group members or to all other participants in the scheme. A member may withdraw from the group at any time by canceling the link to the company.

Because some accreditation bodies such as NATA may require each laboratory to be enrolled separately, the QAP supervisor can create a record of each laboratory within the QAP group. This means that potentially, each laboratory within a QAP group may still be part of a bigger Internal QAP program and still exist as an individual enrollment in the scheme.

There can only be 1 QAP supervisor per QAP group but there can be several laboratory QAP "managers" if necessary e.g. if there is a separate QAP manager per discipline per laboratory.

QAP-online has 4 levels of subscription available (see fees). These are:

1. Individual Subscription. This allows a single participant enroll in one or more schemes at minimal cost. This may be achieved over the Internet,

2. Clinic Subscription. This allows a clinic to enroll patently all of its staff in a single scheme. Once the QAP supervisor has enrolled, all other staff who are linked to the same clinic may enroll without further payment directly on-line and participate immediately. This may be organism by credit card payment over the Internet.

3. Professional Subscription. This option allows a clinic to enroll potentially all it staff in all the schemes of the same discipline e.g. a pathology laboratory may enroll all its staff in all schemes associated with Andrology.

4. Global Scheme. Under this option, any staff associated with a laboratory may enroll in any scheme for that calendar year.

Payment may be in $US$, $AUD or Euros when made by posting the registration form with your payment.

Options 1 & 2 for subscription to a single scheme (be it as an Individual or a clinic) may be made over the Internet using a secure credit card payment line. Options 3 & 4 can only be made by postal registration at this time.

QAP-online for the Reproductive Sciences seeks a different goal.

Recognizing that the use of static images over the Internet has some limitations, the scheme seeks to ask questions of the same image to all participants, to provide several images at each installment and to provide regular installments. Depending when you participate, the assessment can provide almost immediate answers.

Furthermore, since new participants may continue to enroll, the response to each question will be dynamic. Unlike analytical QAP schemes, the value will continue to increase with time. 

It is proposed that each subscriber may define a preset number of returns before a response can be determined. 

It is recognize that there is no correct answer when visually assessing an image. Yet for many professionals, it is their "assessment" of embryo quality or ultrasound image which forms the basis of their professional experience.

The scheme seeks to support such experience by asking subjective answers on the appearance a particular features of the subject of the image or question. E.g. 

• what is the degree of fragmentation of an embryo?

• what type of sperm abnormality is present?

• is this ovary polycystic?

The response of submitting answers to the QAP scheme is limited because it is non-numeric. In such situations, each professional may use their own terminology to describe their observations. Assessment of variable answers present significant problems.

To overcome these potential problems, each question will have a series of preset answers attached. In this way, the scheme can identify the number of responders who selected the same option. The value is then expressed as a percent of all responders. 

The initial attempt by QAP-online to provide a subscriber with a measure of their "performance" over time will be to calculate an average percentage for all questions for a selection. The mean percentage will attempt to reflect the incidence with which a subscriber concurs with other subscribers. Although each question may have a variable number of options, all subscribers will have attempted the same questions. It is acknowledged that each subscriber may view the image slightly different depending on their Internet/computer system ands their own experience e.g. if a sperm is shown with one type of stain and the subscriber uses a different stain, then their experience will differ to others who routine use the same cellular stain as in the image.

A small space for feedback will be available to provide QAP-online with information to improve the service. Please use this space since information received will be used to improve the nature of the questions and preset options.

QAP-online has created the concept of a Primary QAP question. Indicated by a symbol, the primary QAP question is the question used to produce reports on the staff and clinic QAP performance.

While this may be developed further in the future, at present there is only ONE QAP primary question per QAP Scheme. These are:

1. Embryology: Grade the embryo with a score between 1( very, very worst quality) and 100 ( very, very best quality) -{* see discussion about this below.}

2. Andrology:Sperm Morphology: Estimate the % normal forms

3. Andrology: Sperm Motility: Estimate the % Motility.

Each Primary QAP question is a numeric variable and the reporting features provide for:

1. Each staff member (either within a clinic or as an individual subscriber) can view how many Standard deviations from the mean their answer was for each occurrence of the question.

2. The QAP supervisor can assess each staff members response to each installment within a scheme either between each staff member ( Internal QAP) or against all subscribers.

3. The total schemes performance ( all installments/scheme) is currently under development.

* The concept of allocating a value between 1 and 100 to an embryo will appear foreign to most embryologists since most IVF labs use a 3-5 tier semi-descriptive scheme e.g. B+ or A-. Others use a numeric system of often up to 8-9 points. In reality, both schemes achieve a similar goal of grading an embryo [after all A+ to C- or D is a 9-10 point system. QAP-online has elected to use a 100 point system to essentially try to be independent of your local system and thereby better compare how each embryologist grades an embryo. Its advantage is that a variability in grading can be quantified and presented in a common format with other Primary questions such as in Andrology.

QAP-online is not aligned with any one professional society. Rather, it seeks to support any society whose activities are associated with the various schemes provided. Since QAPon-line is an international QAP scheme, professionals may belong to national and international organizations. If more than one QAP scheme is subscribed to by an individual, they may nominate a different society with each scheme.

QAPon-line plans to support each and every society identified by providing each subscriber with the opportunity to nominate the society they belong to at the time of subscribing to a scheme. QAPon-line will donate $USD 5.00 for each paid subscription to the society annually.

QAPon-line will attempt to gain cognate point recognition where possible to allow subscribers maximum value from subscribing.

If a society wishes to develop a new QAP scheme for its members please contact the site on QAP@fertaid.com .

QAP-online believes that the facilities of the site could be used for educational purposes only. If you work in an area of leading edge technology  or you are engaged in conservation work on endangered species and where you believe others may benefit from reviewing images form your work, please contact the site on QAP@fertaid.com and maybe a free educational QAP scheme could be established for you.

Images used by QAP-online have been with the permission of the clinic or scientist or clinician. Where possible and appropriate, acknowledgment is provided. All images of gametes have been collected as part of a clinics internal quality assurance process and the identity of the material is not know by QAP-online. 

Currently, QAP-online wishes to acknowledge and thank the following IVF clinics or organizations for the supply of Images

Queensland Fertility Group, Brisbane, Australia.

City West IVF, Sydney, Australia

North Shore ART, Sydney, Australia

Oozoa Biomedical Inc, Canada.

QAP-online seeks to provide images and textual scenarios for quality assurance and education purposes. While the site is pleased to provide a measure of each subscribers interpretation, it cannot be held responsible for how that information is used by the subscriber. It is not intended that information be used in a promotional manner of commercial interest. Any such use for this and any other purpose is at the complete responsibility of the subscriber. QAP-online will not reveal the identity of any subscriber within the limits of Internet environment.

QAP-online reserves the right to use information provided for presentation at scientific meetings but in a way which will not identify or imply any comment on an individual or company participating in one or more schemes.

QAP-online adheres to a Policy of Confidentiality. The identification of each subscriber and each company will not be made available to any parties without the specific consent of the individual or company representative.

Some reporting features may provide information on both the performance of an individual subscriber and also the performance of the clinic or laboratory and is intended for internal use only. Any use outside the clinic or laboratory should only occur with the express approval of the QAP supervisor.