Dr David Adamson Discusses How Professional Guidelines Impact Reproductive Care Outcomes

There are many legitimate differences in opinion between patients when it comes to reproductive care that physicians need to be aware of when considering professional guidelines in fertility care, says David Adamson, MD, FRCSC, FACOG, FACS, reproductive endocrinologist, surgeon, founder and CEO of ARC Fertility.

Adamson is set to discuss the importance of professional guidelines in reproductive medicine, as past president of The American Society for Reproductive Medicine (ASRM), at the ASRM 2023 Scientific Congress & Expo being held October 14-18, 2023, in New Orleans, Louisiana.

Transcript

How has adhering to professional guidelines in reproductive care resulted in improved patient outcomes or helped prevent adverse events, and how do these guidelines impact daily clinical practice?

The guidelines have really been extremely helpful. Most of the guidelines I’m referring to, or thinking about, are the American Society for Reproductive Medicine, practice guidelines, laboratory guidelines, and ethics guidelines. But it's important to note that there are other guidelines from other organizations, such as the European Society for Human Reproduction and Embryology, and also the International Federation of Fertility Societies, and other organizations.

There are also some excellent guidelines that have come from United Kingdom services. So there are different groups in different areas that have produced guidelines. In general, I'll be thinking more about the American Society for Reproductive Medicine, because they're more applicable to the United States. But it's important to note that a lot of people are interested in these. I’ll also just mention that the World Health Organization, with whom I’ve fortunately been able to work, is also now embarking on guidelines in certain areas.

The reason it's important to note that different groups are doing this is that guidelines, when properly done, are difficult to do. There's a lot of evidence out there that has to be considered; some of the evidence is better than others. And it's certainly true that not only in different parts of the world but even within our country, depending on the socio-economic status of the people being treated, obviously, based on gender and race, it's important that guidelines have to really apply to everyone.

Just a little bit of a sense about guidelines–they're not that easy to do. They're difficult to do well, but they're really, really important because they do help people do the right thing. The first is that, I think the most important aspect of guidelines is that people who are really knowledgeable about the field do a very extensive research of the literature. And all the people who are involved have to be unbiased; they have to disclose any potential conflicts of interest that are assessed. So that what you're getting is people really committed to the best possible care, who are knowledgeable about the evidence, really coming up with the guidelines that you do see and do come up.

And so the first big benefit for both patients and physicians, when guidelines come out from the types of organizations I've discussed, is that they can really count on them as state-of-the-art, fact-based information. As we all know, these days, that's not trivial at all, because there are a lot of sources of information today.

Not only are some people, without much knowledge, putting out opinions, but there are others who are quite knowledgeable but who have commercial interests, or other reasons for putting out opinions, that may not be completely unbiased and may not take a really objective look at what the evidence tells us. I think the first and most important thing about how guidelines improve quality is that people can count on them when they come from these organizations; you can have confidence in them. And because you have confidence in them, you can depend on them more, so that's the first thing.

The second aspect is, certainly with the American Society for Reproductive Medicine—and some of the guidelines there have also come from the Society for Assisted Reproductive Technology, which is an affiliated society really focused on in vitro fertilization and assisted reproductive technologies, and sort those guidelines with ASRM also—that these guidelines really do pertain to a very broad and comprehensive aspect of medicine. So, the second big value of the guidelines is that they're really not hit-or-miss, is something here or is something there. The ASRM has tried to address, certainly, the most important issues, and a very broad set of issues, and so, the second attribute of the guidelines is that they cover almost all important aspects of clinical care, which means they can be used in many, many different situations.

The third attribute or characteristic of these guidelines is that they're constantly being evaluated and reevaluated, because as new science, new evidence comes along, new technologies come along as types of patient care come along. Then, there's a need for either newer guidelines or a revision of older guidelines as we get newer information.

These guidelines are also up-to-date, generally speaking, and they're revised. So, these guidelines can be used with confidence, they cover most of what we do, and they're up-to-date. This is very valuable to get this kind of information for both patients and doctors in a very complex area.

Probably the single biggest benefit of guidelines that we've seen in the United States with respect to infertility and IVF [in vitro fertilization] has been the Society for Assisted Reproductive Technology guidelines on the number of embryos to transfer. The reason that this is important is that most people think that twins are a great idea. I happen to be an identical twin. So, I think twins are okay. Not sure what my brother thinks about it, but I think twins are okay. But the reality of it is that twins have twice the risk of serious permanent physical and/or mental disability or death for each baby—which means the risk of a baby having a bad outcome in a twin pregnancy is twice as high for Baby A plus twice as high for Baby B, which means it's 4 times as high that you're going to end up with an outcome that's not good.

In addition to that, there's approximately twice the risk of having a pregnancy complication that's going to affect the mother. And so, that's why trying not to have twins on purpose is a good idea. What happened was, when IVF got started back in 1978, Louise Brown was born. But when it really started to get more available in the 1980s, the technology in the labs was still not that good; we were still learning about embryo culture and how to assess embryos and what have you. It was absolutely routine to put several embryos back because the chance of any one of them implanting and becoming a baby was not very high.

Then what happened was in the early 1990s, the laboratory technology—in particular, embryo culture—improved a lot, very quickly. And so doctors continued, putting more embryos back because patients wanted the baby, the doctors wanted the patient to get pregnant. But the embryo culture and the technology got so much better, all of a sudden more embryos started implanting and we had a huge multiple birth rate. In fact, the twin rate was well over 30%—it was 35% to almost 40%—an unbelievably high twin rate.

The triplet rate actually reached 7% or 8%; it was really unexpectedly high. Of course, this wasn't realized for a year or 2 later, because people were doing all this and then it wasn't until a couple years later that all the results got published and people said, “Heavens, look at these rates.”

So the Society for Assisted Reproductive Technology, being very concerned about this, started putting out guidelines about how many embryos you should put back, and it reduced the number very dramatically. And over the years, as the technology has improved in the lab, that number has gone down and down, so that now single embryo transfer—putting only 1 embryo back—is basically recommended for almost every patient. Not every patient. If you have a woman who's in her 40s and she only has a couple of embryos and neither one looks to be very good quality, there are situations you can justify putting a couple of embryos back. But by and large, 1 embryo is the number that should be put back in almost all patients.

As a result of this, over the years, the twin birth rate now in the US is down to somewhere around 5%, or maybe a little bit less, which is only a little bit more than the naturally occurring twin rate, which is somewhere in the 1% to 2% range. So, I think the guideline about reducing the number of embryos transferred has had a huge and positive impact on the practice of IVF and can help many people not just have a baby, but have a healthy baby.