By Kasey Fuqua
Over the last 40 years, advances in technology have changed the way women get pregnant, deliver babies and receive treatment for conditions ranging from cancer to endometriosis. Gynecologic care has become more effective with fewer side effects, allowing women to experience a high quality of life whether they experience infertility, fibroids or pregnancy.
Minimally Invasive Surgery
Minimally invasive surgery is arguably the largest and most important innovation in gynecologic care. The first minimally invasive hysterectomy was performed in 1989. Throughout the 1970s and 1980s, laparoscopy became safer and more effective, thanks in large part to the work of gynecologists across the globe. By 2016, more than 15 million laparoscopic procedures were performed worldwide each year.
“Anything that moves us toward a smaller incision is an advancement because it allows people to have a faster recovery, less risk of infection, and shorter hospital stays,” says Rachel Lee, MD, a gynecologist with Monarch Women’s Wellness, a Bayview Physicians Group practice.
Dr. Lee primarily performs robotic surgeries as opposed to laparoscopic procedures. She believes the robot is just one more tool to help ensure women can receive laparoscopic procedures and has seen benefits in its use.
“Before I was using the robot, I would have to convert more people to open procedures,” says Dr. Lee. “Part of it is that you have a lot of magnification to see things clearly. Also, the robot rotates just like your wrist does and allows you to maneuver in spaces that may be more challenging for conventional laparoscopy.”
Robotic surgery, which has only been FDA approved for laparoscopy since 2000, is evolving rapidly. Recently, a urologist at the Cleveland Clinic performed a procedure using a new approved single incision robotic platform that could revolutionize single incision surgery.
Still, it’s not clear that robotic surgery has any advantages over conventional laparoscopy.
“I don’t know if there ever will be an answer between robotics and laparoscopy,” says Joseph Hudgens, MD, gynecologist with EVMS Medical Group. “Data supports that both robotics and laparoscopic surgery are superior to conventional open surgery, but there’s not conclusive data that exists that one is superior to the other.”
Dr. Hudgens and Dr. Lee agree that the right approach surgery depends on the surgeon and their experience. With either minimally invasive approach, experienced surgeons offer excellent results.
Robotic surgery is not the only technology improving gynecologic care. Dr. Lee says new devices, such as hysteroscopes that allow for the use of tools inside the uterus, have improved treatment for many conditions.
One device, called Myosure®, allows for quick and accurate removal of fibroids and polyps. The device contains both a hysteroscope and a small vacuum device to remove the polyp.
Dr. Hudgens served as one of the principal investigators for the recently FDA-approved device called Sonata to treat uterine fibroids transcervically with radiofrequency ablation. The breakthrough procedure treats painful fibroids while sparing the uterus and avoiding hysterectomy.
While all these advances benefit patients, they can put a strain on gynecologists who have to keep up with the latest technology.
“Coming out of training now, it’s very hard to keep up with the amount of information and the latest treatment without being focused,” says Dr. Hudgens. “The trend nationally is becoming specialized in treating a particular disease or subspecialty.”
Dr. Hudgens says many OB/GYNs now seek advanced training and sub-specialization in the treatment of certain conditions. This can lead to an increased quality of care for patients, especially those with complex conditions, as surgeons become more comfortable with technology.
“We have come such a long way so fast,” says Dr. Hudgens. “If you look at all aspects of society, technology has revolutionized the way we live. Medicine is probably behind some other industries in adoption of technology, but as our healthcare system evolves, we’re going to get even more specialized.”
Reproductive medicine is one area of sub-specialization in gynecology that has developed quickly over the past four decades. Since the first successful in-vitro fertilization procedure was performed at the EVMS Jones Institute for Reproductive Medicine 37 years ago, assisted reproduction technologies have changed dramatically. The physicians and scientists at the Jones Institute have helped spur those changes, resulting in the births of more than 4,000 babies.
“Drs. Howard and Georgeanna Jones at EVMS were the first to use fertility medication that stimulates the ovaries for in-vitro fertilization, increasing the number of eggs obtained from a single cycle,” says Dr. Laurel Stadtmauer, MD, PhD, of the Jones Institute. “The first IVF treatment actually used no fertility medication. The patient’s eggs were retrieved from a natural cycle.”
Dr. Stadtmauer says the first lab was like a small closet with little technology. IVF treatment focused on women who had blocked or missing Fallopian tubes. Now, the Jones Institute hosts multiple labs and uses IVF and other procedures to treat both male and female factor infertility.
Dr. Stadtmauer says new technology, from intracytoplasmic sperm injection (ICSI) to embryoscopes, has tremendously improved IVF success rates. While success rates in the 1980s were around 10 percent per attempt, they are now between 30 and 50 percent depending on the patient’s age and other factors.
Laboratory technology is key to this increased success. Embryos spend a longer time in the lab, five days as opposed to two or three, giving embryologists more time to determine which are healthy. In the past, an embryologist would check on the embryos about once per day. Now at the Jones Institute, the specialists use an embryoscope to take about 2,000 pictures of embryos over the five days they remain in the lab. They can then select embryos that are growing and dividing normally and have a better chance of survival and implantation after embryo transfer.
The extended time in the lab also allows for pre-implantation genetic testing. This testing may be especially important for women over age 38 who have a higher rate of miscarriage due to chromosomal abnormalities.
“Genetic testing for aneuploidy and for genetic diseases has been a big advancement,” Dr. Stadtmauer says. “About 25 percent of our patients choose to do genetic testing prior to transferring embryos.”
The Jones Institute was the first center to perform pre-implantation genetic testing for Tay Sachs disease in 1994. Today, they can perform genetic testing for dozens of diseases. Between increased monitoring and testing, embryologists can now select the embryos most likely to develop successfully and have the normal numbers of chromosomes, and avoid an affected child in cases where the patients are known carriers of a specific disease. Instead of transferring four of five embryos, physicians today transfer a maximum of two, and a single embryo in many cases, which greatly reduces the multiple birth rate after IVF.
“Another big advancement is the process used to freeze embryos,” says Dr. Stadtmauer. “It used to be inefficient, and maybe 60 percent of embryos would survive. Now with a technique called vitrification, which is a rapid cooling technique, 90 to 95 percent of embryos survive.”
Thanks to vitrification, transfer of frozen embryos is now more common. The break between harvesting eggs and transferring embryos allows patients to achieve an optimal endometrial lining and ideal hormone levels to increase success rates. It also has reduced a patient’s risk for ovarian hyperstimulation syndrome.
Freezing is not limited to just embryos. Physicians can also freeze eggs, providing fertility preservation options for cancer patients. Even ovarian tissue can be frozen and transplanted back after cancer treatment to allow patients to ovulate and conceive naturally. As technology advances and IVF success rates rise, more women will have the opportunity to experience pregnancy and motherhood.
Once women have achieved pregnancy, they can receive more information about their developing child than ever thanks to advancements in technology and knowledge.
“Genetic screening has really changed in the last decade, allowing for noninvasive prenatal testing,” says Laura Cordes, MD, OB/GYN at Tidewater Physicians Multispecialty Group. “Fetal chromosome analysis from maternal blood sample in early first trimester opens up genetic testing to more women and also opens options for management of pregnancy.”
This early, noninvasive testing has far fewer risks than amniocentesis. It also improves the safety of treatment for women who choose to end their pregnancy after the discovery of a lethal genetic abnormality.
“It’s not yet standard of care for 100 percent of women via American College of Obstetrics and Gynecology guidelines, but it’s available to everybody,” says Dr. Cordes. “Certainly for those women in high risk categories, it’s a recommendation.”
In some ways, women are opting to leave technology out of the labor and delivery room. Dr. Cordes says that at her practice, midwives work closely with OB/GYNs to offer personalized and safe care for expectant mothers.
“Midwifery care has really grown in the last decade,” says Dr. Cordes. “Our practice really integrates the midwifery model into the obstetric model. Our six midwives probably do 90 percent of our natural vaginal deliveries.”
This model of care allows patients to receive the care they want and even allows high risk-patients, who normally wouldn’t be appropriate for midwifery care, to still have the pregnancy experience they want. It also frees up OB/GYNs to specialize further in gynecologic surgery.
Whether or not women opt to take advantage of technology, it allows them the opportunity for more personalized care throughout every stage of their life. As new devices, surgical tools, and laboratory techniques are developed, women should expect a continued increase in both their quality of care and their quality of life.