Given the choice between a medical procedure that uses the newest technology and one that was performed by Greek physician Soranus of Ephesus 120 years after the birth of Christ, which would you choose?
For most, it’s no contest. Aren’t robots, laparoscopes, and nearly imperceptible incisions hallmarks of better outcomes? Often, yes. However, when it’s not indicated, defaulting to the latest technology simply because it’s the latest can drive up costs, reduce efficiency, and restrict access to care. Doctors in Yale School of Medicine’s Department of Obstetrics and Gynecology have been focused on improving what already works as a path to better outcomes.
When less is more
The global assisted reproductive technology industry was valued at $21 billion in 2017. Forecasters expect it to continue to grow at a rate of 10% per year. New technologies—in the form of diagnostic tests, imaging, and purported fertility-enhancing procedures—are added to reproductive medicine’s armamentarium year after year.
When couples and individuals visit a fertility specialist, many have reached the point that they are willing to try anything to have a child. It’s tempting to believe that employing all the newest tech, regardless of the cost, could only improve the odds.
“Many of these are ‘add-ons’—unproven technologies added on to treatments—but many centers use them as a part of routine care,” said Pasquale Patrizio, MD, professor of obstetrics, gynecology, and reproductive sciences, and director of Yale Medicine Fertility Center and Fertility Preservation Program.
The controversial freeze-all method of embryo transfer, for example, is a widely used strategy with a weak evidence base. Here, all embryos from a cycle are frozen for later transfer rather than transferring any fresh embryos during the same cycle. A large randomized Danish trial recently added to a growing body of unremarkable findings: Frozen transfer was no better than fresh.
New incubators for embryos are outfitted with cameras that continuously snap pictures of their development. Spliced together to create one unbroken film, the images take baby monitoring to the next level by allowing round-the-clock surveillance of delicate embryos without the need to handle them. But there’s no evidence that the costlier, newfangled method beats existing incubation and selection techniques.
TheThe same goes for uterine scratching, in which a doctor scratches the uterine lining purportedly to improve the embryo’s ability to implant. A recent trial involving 1,300 women at 13 clinics in five countries found no benefits of the practice.
“These add-ons are expensive and can delay care,” said Patrizio. “At centers that use them, the cost will have to be absorbed into the cost of the treatment cycle.”
In his practice, Patrizio emphasizes the use of the minimum effective dose of ovary-stimulating medications, genetic tests only when indicated, and single-embryo transfer whenever possible to lower the odds of high-risk, costly multiple pregnancies.
When the old way is best
At the other end of the reproductive spectrum, hysterectomy is another practice in which high-tech approaches are still lagging behind longer-standing methods.
“Vaginal hysterectomy does not require any high-tech instruments. All you need are simple, traditional surgical instruments—needle holders, pickups, clamps—like in old-fashioned surgery,” said Oz Harmanli, MD, professor of obstetrics, gynecology, and reproductive sciences, and chief of urogynecology and pelvic reconstructive surgery.
But this least-invasive method has languished in the shadow of minimally invasive laparoscopic methods, which were intended to cut down on open abdominal surgeries. The method without any visible incision, however, brings fewer complications and a shorter recovery time—and is the first choice of the American College of Obstetricians and Gynecologists.
“Many women are unaware that a vaginal hysterectomy is even one of their options,” Harmanli said. Because unlike robotic surgery, which many patients ask for by name, Harmanli said, “there is no company behind vaginal hysterectomy. There is no product to sell. So, we have to increase awareness of this approach that eliminates any incision on the abdomen, even those little ones.”
Not only are prospective patients less versed in the method that started with Saronus of Ephesus in ancient Greece, providers are, too. “Resident training programs want to increase exposure to vaginal hysterectomy, but there are fewer teachers now.” Since arriving at Yale, Harmanli has led efforts to increase rates of this method relative to others.
“We still have a long way to go,” he said. “We need to make a deliberate effort to consider this approach over others when possible. In most cases, it is possible.”