In the world of artificial reproduction (ART), the physician is the visible face to the patient. But treatments would have no success chance without the hidden work done in the embryology lab. There, like in an ex vivo uterus, technology imitates nature and produces the miracle of conception.
This miracle is possible thanks to the silent and precise work of embryologists. A work that, despite all the technology, resembles still more an artisan craft rather than a high tech job. And the same way that the embryologist’s job remains invisible, so does their contribution to patient experience.
A great contribution to patient experience, but hidden
Patients have almost no contact to the laboratory, except may be some informational conversation about embryo development. But the lab has a very direct impact on the patient experience. If any of the lab parameters failed (air, pressure, gas temperature), embryos would get lost. Without both the craft and the scientific know how about embryo culture and selection possibly many couples and women seeking an ART treatment would see how their dream to become parents vanished away. Not to talk about the high professionalism to ensure gamete and embryo traceability in order to ensure that the right embryo gets fertilized with the right sperm and is implanted into the right person.
Precisely this invisibility makes that this very important lab work is almost not mentioned in satisfaction surveys and, to the contrary, that there are almost no complains about the lab. In fact, if anything goes wrong in the lab rather than a complain the clinic will get a lawsuit.
The maturity of robotics, nanotechnology and microfluidics will probably change the force balance that allows the embryology profession to be still a craft in a deskilling world. If they want to produce value to the patient, embryologists will possibly need to become a visible part of the patient experience.
New technologies in the embryology lab
Between 2005 and 2015, the cost of genome sequencing has dropped form 10.000 US$ to only 1.000. Nanotechnology and robotic costs have also fallen so that an old project from the 90s like robotic ICSI (injecting sperm directly in an oocyte) is now feasible. It is also no more science fiction to vitrify (a form of freezing) oocytes automatically. Knowledge can be automated too. Embryo selection is the highlight of the embryologist’s job. Embryos are selected according to morphology and other factors. Experience and know how are key at this point. But algorithms able to predict embryo viability analysing embryo morphokynetics during their cellular division process, like those developed by Auxogyn with the Eeva technology, are more accurate now than a trained embryologist’s eye.
Robotics based on nanotechnologies combined with microfluids (what is called the “lab on a chip”) allow the precise identification of metabolites and other biomarkers, measure oxygen
consumption or to control micro flows of nano pumps and nano valves. Until 2020-2025 it is expected that these technologies can automate liquid manipulation (pipetting), move small volumes horizontally, facilitate computer assisted oocyte retrieval, place and move oocytes securely and detect flagella movement of sperm cells. To know more about, this presentation of Jaques Cohen (pioneer of embryo genetic testing) is very interesting presentation.
Technology is ready now, because technological, biotech and pharma companies have been investing heavily on it. For many embryologists this could probably mean to lose their jobs those that survive will possibly experience deskilling with more and more routine tasks, as it has happened with all other industries; except for those jobs with high added value and lack of specialists in the labour market.
The new embryologists: specialists in patient centred design
How can the job of n embryologist evolve in order to retain or even gain value? In my opinion there are two pathways for change that are complementary: development of better treatments and of technologies on one side and becoming part of the patient experience on the other side.
Nowadays most embryologists do applied research in order to improve pregnancy rates and to contribute to better therapeutic alternative. But very few clinics have the economic capacity to really develop new treatments and technologies. Yet they have the capacity of partnering with pharma or technology companies, like for instance IVF SPAIN does (see living lab for preconceptional testing or piloting Eeva technology). Those clinics that chose the way of innovation will need new profiles in the lab. An embryologist will have to be biologist, but also geneticist, technologist and people centred design.
The patient experience
By patient experience we usually understand meet and if possible exceed patient needs regarding therapeutic results, care and price. It is a vision born from a commercial or marketing perspective (in public systems, remember that return is measured in votes), often managed by quality departments.
But what is the patient’s definition of patient experience? There are patients that act as mere users of healthcare service and there are the so called active patients that manage their disease and also engage and mobilize other patients, mostly over internet. Probably the best known example is David deBronkhart (“e-patient Dave”).
These active patients are able to raise significant funds for research and decide the contents of research. They are also strong parties when talking to physicians, pharmaceutical and technological companies as well as governments.
In fact, it is in the e-health industry where these new kind of patients have gained great influence thanks to user centred design methodologies that helped to co-design clinical and assistive technologies. Their presence is also growing in the co-creation of clinical and non-clinical processes at hospitals. The new Bridgepoint Hospital in Toronto, the awarded futuristic ICU in Utrecht (LINK) or the development of non-technological innovation with patients by the Healthcare Service in Galicia (Spain) are good examples.
Due to their fundraising power, these new patients start to participate in the definition of clinical trials and thus they are considered less and less research objects and more and more research co-subjects. Participatory medicine is not a mainstream tendency, but it gains everyday more influence, as well as the co-participation in medical decision making by so called “empowered patients”.
A new role: participative clinical trials and co-design
True that all these tendencies show success with chronic patients. Fertility patients are certainly not chronic, but they are also not acute patients. Since a women or a couple feels the desire to have child, since it gets the sad diagnosis of infertility soonest one year later until they have a child with a fertility treatment years of trials and failures can go by. Yet, patient associations are very few and powerless since the time –a liminal time- between diagnosis and treatment results is very different for each couple.
So, what adding value role can play the embryologist in this very particular form of patient experience. As we have seen, there is a form of patient experience related to quality and commercial aspects and another one more related to patient engagement. The more the embryologist transforms his/her profile towards a mixture between biology, engineering, genetics and bioinformatics, the more value he/she will have for clinic if he/she works on following three lines.
Engagement in clinical trials is important to achieve personalized treatments that are really patient centred. Mainly because the right patients are included in the right trials at the right moment. More than a cost reduction, that is significant by the way, what we can obtain from this approach are insights on patient context, habits and meanings that are very valuable both to develop adherence strategies and also commercial strategies and arguments. Those high qualified blended profiles of biologist and technologist we are envisaging in this post have a key role to play at this approach because they can combine the biomedical gaze with the ability to obtain patient insights.
This is similar when discussing co-design of medical technologies and services (remember the embryo lab is part of these services). Literature shows that user involvement highly increases the acceptance of a given product or service by reducing the failure rate at product or service launch (3 in 12 in technology, over 40% in other sectors according to Susan Weinschenk); it also increase user satisfaction over 40% und reduces re-programming costs by 50%. Mixed profiles that include patient experience competences are prepared to be excellent lead users, able to test and co-design technologies working with real patients in real environments and real situations: something impossible in the clinical or pharmaceutical lab.
Finally, patient participation in healthcare facility design perhaps does not look like a task for an embryologist, since the way the lab gets organized is not directly related to patients in the sense that these are often not informed don the question and their voice is in this case not as valuable as in other contexts where patients have direct contact. Yet, at the end of all processes of a reproduction clinic must pass through the laboratory and therefore, embryologists have to be present as a fundamental piece when creating new spaces for patients.
As a recapitulation, the future of embryology in artificial reproduction possibly is related to the transformation of current biomedical professional profiles towards innovative and human centred profiles that blend biomedical knowledge with genetics, technology as well as with patient centricity competences, from both psychological and social sciences.
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