Thinking About Ob/Gyn
A fresh and evidence-based perspective of all things related to obstetrics and gynecology. Follow us on Instagram @thinkingaboutobgyn or visit thinkingaboutobgyn.com for show notes and more.
Thinking About Ob/Gyn
Episode 10:9 Fibroids, Facts, False Beliefs, and More!
We challenge long-held beliefs about fibroids, highlight new ectopic pregnancy nuances, and dig into real-world dermoid cyst outcomes. We also unpack the evidence and ethics of 39-week induction after IVF and ICSI, balancing small absolute risks with maternal tradeoffs.
• Evidence overturning links between fibroids and miscarriage, PROM and abruption
• Distinguishing spontaneous versus iatrogenic preterm birth in fibroid pregnancies
• Why myomectomy can raise early delivery and cesarean rates in some patients
• Ectopic care updates: tube-sparing choices, HCG thresholds, two-dose methotrexate
• Experimental adjuncts to methotrexate remain unproven
• Dermoid data supporting laparoscopy, irrigation, and specimen bags over open surgery
• Surgical decision making during pregnancy and avoiding uterine manipulators
• IVF and ICSI timing: late stillbirth risk signals, limits of testing, 39-week logic
• Shared decision making when absolute risks are low but values differ
Be sure to check out thinkingaboutobgyn.com for more information and be sure to follow us on Instagram
1:33 Fibroids And Miscarriage Myths
5:53 Preterm Birth, PROM, And Hemorrhage
9:31 Myomectomy: Risks, Scars, And Outcomes
13:25 Ectopic Pregnancy: What’s New
18:37 Surgery Versus Methotrexate Nuances
22:05 Experimental Add-Ons To Medical Therapy
27:47 Dermoid Cysts: Real-World Data
32:48 Laparoscopy, Spillage, And Pregnancy
36:06 When Open Surgery Makes Things Worse
40:34 IVF, ICSI, And 39-Week Induction
48:05 Stillbirth Risk: What The Data Shows
55:20 Testing, Timing, And Shared Decisions
1:04:10 Practical Counseling And Tradeoffs
Follow us on Instagram @thinkingaboutobgyn.
Welcome to Thinking About OBGYN. Today's episode features Howard Harrell and Antonia Roberts discussing fibroids and more.
SPEAKER_02:Howard?
SPEAKER_00:Antonia?
SPEAKER_02:What are we thinking about on today's episode?
SPEAKER_00:Well, we've got a few articles to discuss that we'll go over, and we didn't have a thing that we do for no reason, but I think if we discuss the articles, we'll be able to come up with one as we go along. So we'll wing that.
SPEAKER_02:That sounds good. This is the time of year again where because of the maintenance of certification cycle, we find even more interesting articles while we're going through our required quizzes that we have to do to stay board certified. And a lot of these articles that are available for us to choose from are ones that we may have already talked about here in the past year or so. But there's always a good handful that wouldn't have otherwise come across my radar at least, or that maybe I saw them, but wouldn't really have thought to read it if I didn't have to. But then now that I had to, I'm glad I did. It's more interesting than I thought. And yeah, so overall, I enjoyed my article time. I still have a few left to go here in the last couple of weeks before the deadline. But I'm excited also to hear which articles you picked and what you thought about them.
SPEAKER_00:Well, we won't have time to do a bunch. I know you and I both came up with a list of several, and there were a ton that we already talked about too. It's surprising the ones that we think are important are also ones that other people think are important. But we did miss some. One of I just I picked my favorite of all the ones that I did. There was an article by Elizabeth Pritz, who's a reproductive endocrinologist in Michigan, that was in the January 2025 Green Journal entitled Uterine Lyomiomas in Reproduction. And I really did just love everything about this article. I don't get excited by many things, but I love the personal way in which it was written. Many science articles today are just boring and stale and so like clinical and abstract. It's a team of thirteen writers. This is written by one author, and she talks about her own thoughts and her experiences in the first person. I love that in medical writing. And I love the approach her approach to evidence. And it's really a story of her own rejection of anecdotal medicine and expertise-based medicine that she grew up in the 1990s, and her embrace of uncertainty about these topics. And now really the science that's evolved and the evidence-based medicine that's evolved and how they go hand in hand with her current understanding and still uncertainty, right? There's still a lot of things unknown, but that's the nature of evidence-based medicine. I think it gets lost. The experts knew what was right, right or wrong never in doubt. We know this is true, and we have all these narrative fallacies and this inertia in thought. And actual science says there's a lot we don't know, and and we're going to collect this information systematically and try to find answers that help people. So I love this article. People should read it.
SPEAKER_02:Yeah, she does have a long career spanning from before when evidence-based medicine was really a thing in OVGYN to the present. And I think a lot of younger physicians, well, like us, I think, take evidence-based medicine as a given. That's all we've really ever known, and don't always realize that it only really began in the mid to late 1990s. So before then, it was, like you said, a lot of expert opinion and anecdote. And a lot of things we talk about on this podcast are they serve to contrast between those prevailing narrative fallacies that were just passed down and passed down by the experts, as opposed to actually looking at empiric science-based medicine. So this author for this article does a nice job giving a portrait of that transition, specifically as it relates to fibroids and our understanding of how they affect human reproduction. The story she tells about fibroids probably could be told about almost any little subsection or a niche in medicine.
SPEAKER_00:Yeah. And we have to be very careful to understand to level set what we know and what we don't know. It reminds me of a story I've heard about Baja Sabai, the maternal fetal medicine doctor who's contributed so much to our understanding of preeclampsia. And the story is that when he was a fellow or a resident, he made a list of some number of things, 20 things, 25 things, whatever it was, doesn't matter, that we know to be true about preeclampsia, about hypertensive disorders of pregnancy. And then he just started working that list in his career. And let's let's actually do a science-based study to see if this is true. And of course, by the end, I know he still has a career, but he's older now, and over his career, he essentially has disproven, as I understand it, most of the things on that list. They were not based upon good data. And this reminded me so much of that. So if anybody knows more details about that Sabai story, I may have just made it up, but that's his that's the rumor I hear. So I think this is a very valuable article in the same way to level set where we're at now scientifically with what meaning of fibroids are for a patient, at least in terms of their effect on pregnancy outcomes and conception. So let me go through some of the points, and again, please see her article for the evidence. She goes through all of the studies, and we're not going to do that. She does a great job of that. Now, so let's do some of them. So previously, we believed that fibroids were linked to an increased rate of spontaneous abortion. And our best evidence today from this article is that fibroids do not increase the risk of miscarriage or abortion. And of course, so many things follow from that. We could extrapolate more, but obviously a lot of work in recurrent pregnancy loss and surgical preparation of the uterine cavity for implantation or for patients with a current pregnancy loss follows on the presumption that fibroids have something to do with the risk of miscarriage or abortion. So it's really important if they don't, and may call some of those things into question. Fibroids have previously been linked to an increased risk of preterm premature rupture of membranes. But again, our best evidence is that there is no increased risk of PROM due to fibroids. Previous meta-analyses of studies indicated that fibroids were associated with an increased risk of placental eruption. And these meta-analyses so often only include retrospective data. We really do have to do an episode about the abuse of meta-analysis. It's extraordinary, even since we started this podcast, how many meta-analyses are being published and the quality is just so low, and of course, even the good ones are only as good as the data that's in them. And the our discussion about telon autism is a great example of that. That stems from a meta-analysis. But if you leave out important data or you're only reviewing quality epidemiologic retrospective data, it doesn't matter that it says meta-analysis, it's still bad data. But in any event, our prospective data about this subject, which largely comes from a Danish National Birth Cohort and other registry data, indicates that there is no increased risk of eruption with fibroids. Now, the data here as almost any area is conflicting. And it could be, of course, that patients with retroplacental fibroids have an increased risk of eruption, which makes obviously a lot of physiologic sense, whereas those with other locations do not have an increased risk. So maybe that's true and explains some of the conflicting data, and that's an area of uncertainty. We've also believed that fibroids are associated with an increased risk of preterm labor. And this one appears to be true. Well, I should say preterm delivery. Careful distinction. That appears to be true. But it may be that the increased risk of preterm delivery is iatrogenic, and that there is not an increased risk of spontaneous preterm birth, and therefore spontaneous labor in itself. And again, very important difference. We conflate those two things all the time. And especially with epidemiologic retrospective stuff, how do you tell the difference when the person delivered 36 weeks and you just have a code for that, whether that was induced or iatrogenic or spontaneous? And interestingly, it appears that neither the size nor the location of fibroids change that risk of preterm delivery, which gets into some causation stuff. You would think that if the fibroids are causing some change in the myimetrium or something like that, that's certainly bigger ones or intramural fibroids, or there would be a difference in those rates.
SPEAKER_02:And that wouldn't be to say that even an iatrogenic preterm delivery in someone that has fibroids wasn't indicated. It may be that if they're having an iatrogenic preterm delivery, that the fibroids were related to certain risks that led to that. It wasn't the fibroids themselves necessarily.
SPEAKER_00:Yeah, hypertension, who knows?
SPEAKER_02:Yeah. But maybe it could be, because we don't really get that from this article or the available evidence that in some cases at least there could be some misconceptions about fibroids and their effects on pregnancies that could lead to an increased risk of unindicated iatrogenic preterm deliveries. So that's just part of an unanswered question at the moment. But yeah, it would be incorrect to just assume that because there are more preterm births, that they are all spontaneous because of fibroids.
SPEAKER_00:Yeah. And you think about when we put people in a pot of high risk or you need extra monitoring or surveillance because you have this fibroid and we're going to do serial ultrasonography on you because we're worried about eruption or we're worried about whatever. Well, then you expose perhaps low-risk pregnancies to higher false positive rates associated with antenal testing. And then you do see as a consequence of that sometimes what appears to be indicated antenatal or iatrogenic preterm delivery. So what how we manage these pregnancies and our thoughts about them is important. And the same may be true with the risk of cesarean delivery in fibroids. So women with fibroids are definitely at an increased risk of cesarean delivery, but this difference seems to be mostly in those patients who had planned or scheduled cesarean deliveries. There doesn't seem to be a difference in the rate of acute cesarean deliveries, meaning the they show up in labor compared to women who don't have fibroids, the section rate seems to be similar. So if the difference is related to a higher rate of planned cesareans, then again, we don't know whether those planned cesareans were always appropriate or not.
SPEAKER_02:One obvious scenario here that I'm sure all of us have seen at least once is that there's a fetus that's persistently breached due to maybe an obstructing fibroid that they can't quite turn into the right position because that fibroid's in the way, or that there's a large fibroid in the lower uterine segment that just completely blocks the head from descending into the pelvis. But if neither of those conditions apply, we do need to be careful not to invent some other reason to plan a cesarean due to our own fears about complications from the fibroid. That may not be even true. I'll say anywhere that I've ever practiced, I've never really seen this to be a thing. It usually is caesareans just for persistent reach or the heads just way behind a ginormous lower fibroid, but I could potentially see how this could happen.
SPEAKER_00:Caesareans give people this perception of control. And so if we believe, for example, that there is an increased risk of postpartum hemorrhage, which is another of the beliefs that she tackles here with fibroids, then you might think that knowing that you're better off going into an operative setting. But once again, she does address that, and there doesn't appear to be much increased risk of hemorrhage when you control for other variables, which is always the problem with retrospective data is there these epidemiologic studies are usually not able to control for the variables we'd like. But as newer studies come out and you get better data with either retrospective with more variables accounted for or prospective data, you can do that. And the author points out that knowing that might lead to fewer planned cesareans, because it seems she suspects that people are worried about hemorrhage.
SPEAKER_02:It would seem very irrational to me for someone to plan a cesarean for any increased risk of postpartum hemorrhage outside of an accreta or a previa. That's already labor's already contraindicated there. But if there's other if there's a prior postpartum hemorrhage, let's do a C-section, or there's a big fundal fibroid, oh no, let's do a C-section, that doesn't really make sense because the average blood loss in a cesarean universally is higher than that for a vaginal delivery, usually something like double at least. And many of the mechanisms of postpartum hemorrhage are the same between vaginal delivery and cesarean. Anea is usually the most common reason. Plus, you add in, on top of that, with a cesarean, the risks of surgical bleeding that you wouldn't get with a vaginal birth. So again, I don't think I've seen someone have a planned caesarean for prior postpartum hemorrhage or something like that.
SPEAKER_00:But yeah, I've definitely seen it. I've definitely seen patients who were told that because they had a hemorrhage due to acne, then they should just have a cesarean. And again, this illusion of control, and we can plan for whatever uterid ligation or B lynch sutures or whatever that might be. So uh but yes, unless the mechanism of hemorrhage that we're worried about is invasive placenta or something of that nature that deliberately needs to be dealt with surgically, then yeah, you're just increasing their risk of hemorrhage universally by doing a surgery associated with a lot more hemorrhage. And even maybe on a non-labored uterus that doesn't have upregulated potasin receptors and doesn't respond as well. Like the risk of acne is higher with C-section than it is vaginal delivery. Okay, then the paper talks about the commonly perceived benefits of myomectomy. So one is to decrease the risk of preterm delivery. And recall, the risk of preterm delivery is higher in patients with fibroids, but that doesn't necessarily and it doesn't seem to equate to spontaneous preterm birth. Still, though, removing the fibroid might remove, let's say, the medical indication for iatrogenic preterm birth. If there's no fibroid, maybe the patient doesn't get the other things we were speculating about. So this idea is prevalent for both reasons. But what the studies show is that prepregnancy myomectomy not only does not decrease the risk of preterm delivery, it may actually increase it, particularly with larger fibroids. When you replace the fibroid that was there with a scar, you may see actually an increased risk of iatrogenic preterm delivery due to the patient having now an incision in the active segment. And of course, they would then need a cesarean in usually early, 36 weeks even, or early term, to avoid a uterine rupture during labor. So a lot of those patients are going to be delivered at 36 weeks subsequently. But you also may see an increased risk of spontaneous preterm delivery as well. There's this idea of also removing fibroids to decrease the risk of delivery complications like hemorrhage, which don't bury the lead is not associated, right? We just talked about that. But women with previous myomectomies, if anything, seem to have higher rates of cesareans and more blood loss with delivery, and don't appear to have any other significant benefits or differences in maternal or neonatal outcomes.
SPEAKER_02:Well, it sounds like the points that are being summarized here so far counter a lot of the common narratives about this in our field and probably should change a lot of the counseling and management of women with fibroids who are still hoping for future pregnancy. So for this author, part of her story is how she trained at a fellowship at Yale in the late 90s, and they were routinely removing fibroids to reduce comp future pregnancy complication rates without necessarily having the scientific evidence to support that what they were doing was beneficial. So yeah, now in the age of evidence-based medicine where she has actual studies and outcomes to look at, we can answer some of these questions more definitively. And this is just another example of how what experts believed to be completely true really doesn't always hold out in the controlled literature. And I don't think this is saying it's never ever appropriate to remove fibroids before pregnancy. But we probably have to look at it on a more individual basis. So obviously, if it's someone that has symptomatic fibroids, like they have bad pain, bulk symptoms, heavy bleeding, that should be addressed for the quality of life, if for nothing else. Don't just make them keep suffering until they're done having babies. And I've also seen more extreme cases where someone came in already pregnant, but they had such a huge fibroid that then after they got pregnant, it it got so much bigger. They had a full-on bowel obstruction and it was like neat like to the level of needing a colostomy because it was so big. So that probably would have been one to benefit from some kind of treatment to reduce the size of that before pregnancy. But that's not really, I think, what the article is talking about, because that's really not that common. And I've also seen how really big fibroids, even though the pregnancy goes well, they can start to degenerate and basically liquefy once the baby starts taking some of that blood supply for themselves. And that can be really painful, and we can't really intervene besides giving them some pain meds throughout the whole pregnancy, just having them deal with it until after delivery. And you had only just at the beginning of this mentioned specifically the little cavity distorting fibroids. And do fibroids even affect getting pregnant to begin with? Do they interfere with the implantation itself? Not even miscarriage, but does it even take? That's still a big belief that I see in the infertility world. And it is still baked into the ASRM guidelines for asymptomatic intracavitary fibroids, even though that acknowledges it's weak evidence, but you can consider removing them. But this paper here that we're talking about is challenging a lot of that based on how weak the evidence really is.
SPEAKER_00:And it may be exactly true that the intercavitary fibroids do interfere s significantly with implantation. The question is whether or not surgical treatment, which is going to leave back some scarification and probably not healthy endometrium in the place of where this fibroid was, whether or not that actually increases the live birth rate. And so I do think, too, that we currently live in a accelerated world of technological solutions to fibroids, meaning both the roboticists who are learning how to do robotic myomectomies, and this is a new skill that they have, and then intracavitary fibroid systems that that folks can do. And so all of a sudden we have a lot of tools to surgically remove fibroids, and that always spawns over utilization. And now we just may be the pathologizing fibroids. And that's the harm here is somebody comes in and they're not symptomatic, but on ultrasound they've got some fibroids, and then somebody has recently learned how to do robotic myomectomies, and they tell them that they should take these out before they get pregnant. I think that's what the article's addressing are those sort of overstated claims. If anything, you may be hurting that patient. Okay. Now you liked a paper from the New England Journal of Medicine on tubalictopic pregnancy that was published back in February of 2020. And we actually had this back then on our list to talk about. These New England Journal of Medicine review articles are always excellent. They do them on female-related subjects every few months. But I think we never got to that one. So why don't you give us some highlights from that article?
SPEAKER_02:Yeah, I agree. I like their review articles. Like most of them that they present, they have a case-based learning with a little vignette, and then they have a review of guidelines and supporting evidence. So we don't have to spend a whole bunch of time reviewing the basics of tubal ectopic pregnancy for our listeners. But I always like going through some of our bread and butter. This is a very basic topic for us. We have to have it mastered from almost the very beginning of our training. So I picked this because I wanted to make sure there weren't any holes in my knowledge because I expect myself to know everything that I'm supposed to know about ectopics. It's one of the basics. And I was pleasantly surprised that there were a few new things that were maybe still experimental, but that it was interesting to see that there's still some new research about it. And then just a little bit of polishing of some of the details that I knew, but haven't necessarily gotten to some of the more extreme cases lately. So I'll just point out some facts that stuck with me as I read this article. So one is that black patients are seven times more likely to die from ectopic pregnancy compared to white patients. The risk of a significant hemorrhage for untreated ectopics is well above 50%. And in the 1970s, before we had ultrasound so widely available, the most common presentation was hypovolemic shock. So certainly that's become a lot less frequent today because we're able to catch a lot of these before they get to that point. It still does happen from time to time. Our goal is to try to identify these before they show up almost dead in the emergency department. In this article, they also spent some time discussing salp injectomy versus salpingostomy for surgical treatment. So that is either removing the entire tube where the ectopic is or splitting it open and basically digging out only the ectopic and then sewing the tube back up and leaving it in place. So this is still an area where there is some variation in clinical practice. Most of us will do a self injectomy by default. And this article again reaffirmed what we've known that future live birth rates are on average the same whether you do salp injectomy or salpingostomy, as long as the patient has another functional fallopian tube. And the reason we don't default to salp angiostomies, even though it might seem more con like you're preserving their fertility more, it doesn't always work as well because there's either uncontrolled bleeding or you can't quite just scrape out all of the ectopic tissue, or you just can't save enough of the tube to actually sew it back up and have anything useful left behind for the patient. But with all that said, there there always is a consideration of trying to preserve the tube if, especially if the other side, which isn't unaffected, is already absent, or if it looks significantly diseased, like it it's not gonna function well. And I've actually done it in a setting where there was so much scar tissue that I could not remove the tube. I just couldn't isolate it from the rest of the pelvis. And I was thankfully able to open the tube and the ectopic came out easily, but that wasn't actually the point. The plan would have been to remove the tube if I could have. They also mentioned a study here that in patients who have baseline infertility or they already have known damage to their opposite tube, in those patients there is a higher future pregnancy rate if they are treated with self-angostomy. So it is something to consider for those select patients. But because of there being a significant rate of some retained tissue, then we still need to follow HCG levels to zero after doing a self ingiostomy and potentially still treat them with methotrexate, even though we've already done the surgery for them. They also discuss some of the pros and cons of single versus double dose methotrexate for medical treatment. And it does appear that the two-dose regimen is probably better for patients whose starting HCG levels are over 3,000, or if they have an adnexal mass larger than two centimeters. But other than that, most patients don't have significant benefits in terms of preventing having to still get surgery, whether you go with one or two-dose regimen. And in this article, they encourage a cutoff of 5,000 for the HCG level for medical management. Like if it's over 5,000, you should really strongly consider surgery. And that is something we still see varying a little bit in guidelines and discussion, but it makes sense that if it's over 5,000 and you just give them methotrexate, there's a much higher chance that'll fail and they'll need surgery anyway.
SPEAKER_00:Yeah, numbers all over the place in some of the commentary about this. And obviously what really happens is of course the success rate of methotrexate just declines more and more. And at some point, if you're only 80% successful or only 70% successful, and they're out there with that risk of ectopic rupture, which is much, much higher with those larger numbers, it just makes sense to do surgery. So it's hard to argue against 5,000, but if you have a select stable patient who lives five minutes from the hospital and is very reliable and it's 7,000 and you want to give methotrexate, go ahead. So the 3,000 is based on some newer data that's accumulating, so that number may be a little bit different than what people have heard or if you've thought about that. The other thing I was going to say is the article talks about salpingostomy and salpingotomy, or I want to say salpingotomy when I say that. Salpingostomy, salpingotomy. The G can be soft or hard, I don't know. But technically, ostomy, you cut it open, and as you said, you can put some interrupted sutures in there and close it back, but you don't have to. And I think that people previously have distinguished that as being the difference between salpingostomy and salpingotomy, where the automy is just an incision.
SPEAKER_02:I don't sew it back up if it's not bleeding.
SPEAKER_00:And I may have those terms people use them almost interchangeably, and they used them they tended to use them interchangeably, but I think really the difference there is do you sew it back up or not. Most people just use a salpingostomy term and they talk about whether you sew it or not. But in in how they distinguished them in there, they didn't see a difference in whether you did that or didn't. So in my mind, I do that cut for bleeding rather than something that you should always do. You don't have to sew it back up. They also discussed some case series in an open label trial using epidermal growth factor receptor inhibitor called gefitnib, and that's added to the methotrexate treatment. And the thought is that this would potentially improve outcomes, reduce the need for surgery, things like that. This disrupts ectopic pregnancy implantation since there is a high expression of epidermal growth factor receptors in placental tissue. But they also refer to a randomized trial showing that a seven-day course of this medication combined with single dose methotrexate didn't demonstrate really any difference in the number of patients who subsequently needed surgical intervention. So I'm sure there'll be more studies to come, maybe a study that looks at two-dose methotrexate protocols with that medicine, things like that. There could be different doses of the medicine itself used or different courses. So you may see more about that. They also discussed adding methapristone to methotrexate with the same thought in mind. And there has been an open label trial that suggested that the combination was more efficacious, but they left that at we still need larger trials to understand whether there's value in adding methapristone to the methotrexate.
SPEAKER_02:Yeah, so that'll be interesting to keep an eye out for and see if that ever becomes, especially in those cases where the starting HCG is high. Could that could that help make medical management more successful for them too? But remains to be seen.
SPEAKER_00:Yeah, and I'll put uh I'll put a link and we can put on the Instagram a uh algorithm of a protocol that has recently been updated and validated at the University of Tennessee Memphis that helps you walk through the evaluation of a pregnancy of unknown location. So take a look at that, and it can be something useful for you as you go through a pregnancy of unknown location and try to understand when you should treat and when you shouldn't, and things like that. So we'll we'll put that up.
SPEAKER_02:I think most interns and residents probably have their own, like they they have an algorithm in mind, but I would still encourage you guys to look at this. That this was really brilliant, like very detailed and very straight, like detailed but still straightforward. And unfortunately, I I have to lament that I've learned that not all emergency departments, even in more bigger cities, seem to have ultrasound available, which would have sounded crazy to me before where I'm at now. But in my corner of the world, patients are getting transferred from well, really from more rural ERs, but from one ER to another just to have an ultrasound. And ultrasound obviously is a pretty big part of working up pregnancy of unknown locations. So some places may have to modify this algorithm on the fly depending on what resources they have. But even so, I think it's something every ER and OBGYN office should just take a look at. You could benefit from having some kind of algorithm already on hand. It answers a lot of questions, especially for the ER doctors. And this is a great algorithm. So Yeah.
SPEAKER_00:And it and I believe it's gonna be submitted for publication with the results of their implementation study. So we'll come back to it when it gets published, but to pre-release view here. So okay. Well, I was gonna pick another article that you happen to also pick. So we'll do one that we both picked. This is a study from October of 2024. It was in the Gray Journal last year, and it was a review of a little bit over a thousand cases at a single institution, someplace in mass called Harvard or something. I've never heard of them. But it was their their experience with dermoid cysts.
SPEAKER_02:Yeah, I did like that one. And so they had a thousand. Cases of dermoid cyst removals at their one facility running from 2004 to 2015. And they just tabulated all the data about all the different presentations and surgical approaches and outcomes. And I like this paper too because it helps us set our assumptions about dermoids. What are they and how do we counsel patients and manage them? It's a little bit like the fibroid paper we just talked about, where you know having a real life series, large series like this gives us real quality data to understand these cysts in a little more detail.
SPEAKER_00:Yeah, and it's not all earth-shattering, but again, how we counsel patients. We need good data in our heads if we kind of counsel patients about what to expect in the approaches to management. So they found that 10%, of course, which is a number we already know, of these cysts were bilateral. They diagnosed 10% of them during pregnancy, of which they managed 10% during the first trimester, 10% in the second trimester, and 80% at the time of cesarean delivery.
SPEAKER_02:Well, that seems easy to remember. Like a rule of 10 going there.
SPEAKER_00:Aaron Ross Powell There's so many of these rules. I I can't keep up with them all, but the rules of two and sevens and I don't know. But yeah, we'll let the we'll let some med students come up with a rule. Also, 5% of these masses presented initially as torsions, a presentation. Size-wise, only eleven percent were bigger than ten centimeters. So ninety percent n 89% were smaller than centimeters.
SPEAKER_02:Round it down to ten, ten percent bigger than ten centimeters.
SPEAKER_00:You're adding to the ten rule.
SPEAKER_02:Yeah.
SPEAKER_00:Seventy percent of them were treated with a minimally invasive approach, which did ex expose patients to a higher spillage rate than oak procedures, but only one out of three hundred and ninety-four cases had chemical peritonitis of the spills.
SPEAKER_02:Yeah, I really liked that little fact. And if I remember correctly, that's even more rare than the risk of these being cancerous, which is already rare. So that's really reassuring to know that every time you do these laparoscopically, the fear has been drilled into our heads that if it spills before you get it out of the body, you're gonna either see the cancer everywhere or get the chemical peritonitis. But it turns out that chemical peritonitis is very rare and it is quite manageable. And the rate of spillage during laparoscopy is, we know it's fairly high. So it's reassuring that even so, it's almost never turns into chemical peritonitis. And as you said, most of these were minimally invasive, most of those being straight stick laparoscopy. There were some of them that were done robotically, and they had some so it was a little more than half of all the cystectomies that they did had spillage. But even 8% of the oporectomies, where you go in and you say, I'm not even gonna try to dissect this out. I'm gonna just take the whole ovary to prevent spillage, even 8% of the time it still spills then. So probably shouldn't do an ophorectomy just to avoid spillage. And the other thing is that that is a lower rate of chemical peritonitis than what has previously been reported. And in this article, they speculated that might be due to our modern specimal specimen removal bags, especially if maybe someone tries to put the bag in and then do the dissection in the bag, which is difficult, but either that way or just by getting it in the bag and before it has a chance to spill during the removal from the body. They they also talk about really copious irrigation. So if you can irrigate liters and liters until the water is completely clear, there that's a really low chance of getting peritonitis then. They also make the point that during pregnancy, surgical removal can be done in any trimester. And I wonder if there might have been any patients in the third trimester who had a cesarean only for the fact that they had this dermoid cyst and it seemed opportune to remove the baby and the cyst at the same time. I know that it is more difficult to do laparoscopy in the third trimester, and it's it's generally not the most ideal just size and angle wise to do that.
SPEAKER_00:But you could do that as part of them.
SPEAKER_02:Yeah, exactly. Vaginal birth and then Yeah. But I was glad to say to see that they didn't arbitrarily say we should avoid surgeries in the first trimester. We know that everyone always gets a little antsy about doing surgeries at any point in pregnancy, even early first trimester, let alone when they're further along, even though we've known for a long time that there is no demonstrated harm to the fetus from surgery or from general anesthesia, it really is just the fear that there's going to be a spontaneous miscarriage that happens to occur sometime after surgery, and then they blame the surgery. And obviously, if we do this, if we do a dermoid cystectomy removal at any point in the pregnancy, we're not putting in a manipulator in the uterus or cervix. So that would be the only thing that could harm the pregnancy.
SPEAKER_00:Yeah. And I wouldn't use a uter manipulator even in a non-pregnant patient personally to do these, so it's not necessary. And maybe there's the thing that we do without evidence is avoiding minimally invasive surgical management of dermoids for fear of spillage, or avoiding management of fibroids in early trimesters for fear of surgery during surgery, surgery during pregnancy. So we said we'd find one. There it is. The other thing was a difference in blood loss. So the thing we do without evidence is an open case to have more control over spillage and the dissection, and maybe less blood loss, right? But they actually found their open cases had a higher average blood loss than in the laparoscopic cases. In fact, 30% of the patients who had an open management approach had an EBL of greater than 500 milliliters versus only about 1% of those who had an endoscopic approach. And the open surgeries had more bowel injuries, oddly enough. So this is something that almost always should be managed minimally invasively. And if you don't feel comfortable doing it, you'll have a colleague to refer to who does.
SPEAKER_02:That was a very interesting fact. And my theory is that it it points to those being more complicated cases from the outset, like maybe if they were really big dermoids, or maybe if they knew the patient has a lot of prior adhesions and it's going to be very difficult to do it endoscopically. Because if all the case, yeah, if all things are equal, it would be it I can't see how just the open incision itself would cause those problems, especially the bowel injury.
SPEAKER_00:But I'll say a lot of times people do open approaches on patients that they're worried about, and these might tend to be very obese patients or things like that. And you've got an obese patient with a five-centimeter dermoid, and you're struggling to pack bowel away, you're getting retractor injuries, you're getting small bowel pitched up in your retractor, it's deep in a cavity. Honestly, I cannot stand doing open cases. And so it could be a factor of both of those.
SPEAKER_02:Yeah. Yeah, that's a good point. So I think the takeaway is people should not be afraid to do dermoid cystectomies or ophrectomies, for that matter, laparoscopically, and also should not consider themselves a failure if they do a laparoscopy in the cyst ruptures. They should just copiously irrigate. There were a lot of other really interesting, thought-provoking papers that that we both looked at. Some of the other ones I read were a positive trial about IUD insertion and pain relief for that. There was a much more disheartening trial about amnioinfusions to save babies who have bilateral renal agenesis in utero, which that is still generally considered fatal. There was a review on previable membrane rupture. There was one about the inconsistencies in pre-implantation genetic testing of embryos for IVF. And there were many more. But at this point, we also have an interesting listener question that we should get to before we wrap up.
SPEAKER_00:And I'll say if folks are doing their MOC right now and they found an article that they thought was interesting or just have questions about, send them to us and we'll get to them. And if you found it interesting, other people will too. So what's our listener question?
SPEAKER_02:Okay. So this listener will call them birthing in Boston. This, I believe, female is Adula, and she has a question about the role of induction of labor for patients who have had IVF with ICSI, the intracytoplasmic sperm injection. Apparently, she's had several of her clients be told by their OBGYNs that they because they had ISI or even just the conventional IVF. So just briefly, the difference is conventional IVF, they put the eggs in a petri dish, they put the sperm there, and they just let the sperm swim and fertilize. The ICSI is where they take a needle and filled with sperm and they inject the sperm directly into the egg, bypassing the whole need for the sperm to swim. So those are the two different ways an egg can be fertilized in the lab. So her clients have been told that if they've had one of those done, especially the ICSI, they need to go through a 39-week induction or a plant cesarean if they need a cesarean. And she's wondering what's the source of this recommendation and is it evidence-based? She already brought up that she's aware of the SMFM consult series number 60 that says, quote, in the absence of studies focused specifically on the timing of delivery for pregnancies achieved with IVF, we recommend shared decision making between patients and healthcare providers while considering induction of labor at 39 weeks. And she notes that there is a suggestion, at least, that the stillbirth rate is higher with pregnancies achieved by IVF or ICSE.
SPEAKER_00:Yeah, this is a good one. I always like questions for the type of question, because the answers to me are less important than the sort of methodology to arrive at the answer and then you can apply it more generally. But so it is true, unfortunately, that pregnancies that result from assisted reproductive technologies in general, but certainly including IVF and ICSE, have an increased risk of stillbirth. The difficulty is understanding whether or not that increased risk is due to the baseline characteristics of the patients who need those technologies in the first place to become pregnant, and then also whether or not induction at 39 weeks or at any other specific time actually prevents perinatal deaths. You also need to know when those deaths happen to understand whether, you know, how impactful that is. And of course, another question would be whether or not the addition of antenatal testing at starting at some point on that population of patients would sufficiently reduce the risk so that inducing patients at those gestational ages ends up serving no purpose as long as the testing's normal. So there's several things you have to understand to appreciate how you'd make a recommendation.
SPEAKER_02:Yeah, a lot of our recommendations about timing of delivery or antenatal testing are not based on randomized controlled trials. So generally we have nothing showing that those interventions are beneficial. They're really based on theoretic benefits of those interventions. So whenever the risk of fetal demise rises above a certain threshold above the baseline, then we do antenatal testing, even though that testing hasn't necessarily shown to reduce the rate of fetal demise. And we also, along with that, often recommend delivery earlier than when those demises tend to occur for that particular risk factor or group of patients. But we know that patients who use IVF or other advanced reproductive technologies are not the same as patients who don't use it and get pregnant. So it's important to control for as many possible variables as we can, both known and unknown.
unknown:Yeah.
SPEAKER_00:So let's get into the murkiness here. Again, I think going through this is very illustrative of what kind of data we have to inform these decisions and what the thought processes are. So classically, there was a 2010 Danish prospective study that compared the stillbirth rates in women who conceived after IVF and ICSE with women who did not. And they found in that prospective cohort that the risk of stillbirth in the IVF ICE group was 16.2 per 1,000 pregnancies compared to just 3.7 per thousand in the control group. So that's a fourfold, a little bit over fourfold, increased risk of stillbirth. In that study, they controlled for the usual suspects, things like age, BMI, educational status, smoking habits, alcohol and coffee intake. And even after controlling for those variables, they still had a slightly higher, it was lower, but it was still a slightly higher than fourfold uh increased risk of stillbirth.
SPEAKER_02:Well, that sounds scary, especially on the surface. Of course, those those people went through a lot to get pregnant, and obviously those are desired pregnancies because they got pregnant very much on purpose. And so with that background, also having a higher risk of loss even late in the pregnancy is obviously distressing. So uh around what gestational ages did those stillbirths occur?
SPEAKER_00:Right, that's important because if they occur early, then inducing at 39 weeks may not may be negligible. So and they don't fully answer that in that data set. They do say that stillbirth with IVF IXE pregnancies peaked, the rate was highest at 32 weeks compared with the highest rate for the spontaneous pregnancy group occurred at an average of 36 weeks. But of course, those are peaks doesn't mean that they don't occur across a span of gestational ages. But it does look like they occur earlier than in spontaneous pregnancies on average. So again, the issue is are there either uncontrolled other uncontrolled variables to account for this increased risk, like hypertension or other medical problems or things like that? And for the majority who obviously go past 32 weeks, is the actual demise risk at 39 weeks and at 40 weeks ongoing, is it the same? Is it the same as the low risk by that point? Is it still higher by some margin? Or have many of the at-risk pregnancies already been culled out because they had hypertension or they had diabetes or something else and they're not even in the group of ongoing pregnancies? So in other words, if you make it to 39 weeks with a spontaneous pregnancy, or you make it there with an IVFXE pregnancy, and you don't have any other indications, any normal indications for delivery or extra anenatal testing, does induction for that low risk group of women still pregnant, does that prevent any stillbirths?
SPEAKER_02:Aaron Powell And we're not even getting to questions about maternal outcomes yet, which is important. But even with stillbirths, we have to also think about the what's on the other side. So total perinatal mortality, how does the risk of early neonatal death change when we start intervening to prevent stillbirths? It could be possible that some, I wouldn't say obviously all, but maybe some fetuses that die at 39 or 40 weeks in utero might have survived birth if they'd been induced earlier, like induced at 37 instead, but then gone on to die anyway within the first month of delivery, maybe from complications related to more of a prematurity type syndrome, or maybe there's some underlying issue like is with SIDS or the sudden unexplained infant death, that could be also at play with those late-term stillbirths as well. We don't know that, but I'm just saying that just because we induce earlier to prevent a stillbirth, it doesn't mean that we're also preventing an early neonatal death necessarily. So, really, when we consider these issues, we have to consider perinatal mortality that all includes from the last trimester of pregnancy through maybe the first month of life. And of course, some of these papers only look at the first week of life. So you have to look really into the details here. And more specifically, if we're thinking about inducing at 39 weeks rather than 40 or 41, we have to look at the last week or two of pregnancy, add to that the first 28 days of life, and then see if the total rates of stillbirth plus neonatal mortality are different. I think there is a prevailing understanding at the moment, at least that 39-week births have the lowest perinatal mortality overall, that earlier births might have slightly more early infant deaths, maybe from prematurity type syndromes, but then the later births might have slightly higher cumulative stillbirths and maybe also a post-maturity type syndrome. I have an image of a survival chart in my head from some study. It may have been the arrived trial or something else, where at 39 weeks, that is the peak survival for the baby. It's less before and it's less after. So I think that's why 39 weeks is so broadly accepted, even for completely elective inductions with no other medical reasons. But that's why we don't go earlier for elective inductions.
SPEAKER_00:Right. No, that's true. We're talking about low absolute risks, but that is absolutely true. And as pregnancy progresses past 40 weeks, certainly past 41 weeks, due to placental senescence, you start to see increased rates of just placental insufficiency, meconian-stained fluid, meconian-stained aspiration syndrome, and neonatal deaths from pulmonary hypertension and the meconian aspiration syndrome sequence, and they're much higher at 41 weeks and 42 weeks than they are at 40 weeks and 39 weeks. So that logic is true. But but that's why we look at even the arrived trial, which we've talked about, it looks at the aggregate of perinatal, and they didn't see a difference. I think that's one thing people forget about the arrived trial is at least for how it was powered, they did not see a difference in perinatal outcome, but they used the right methodology. They looked at the last bit of pregnancy and the included neonatal deaths in there, because you have to weigh that. And this particular study didn't give us the information to make that assessment. Now, there was a 2021 systematic review and meta-analysis that we can put a link to, and it looked at 19 studies, and this was published in the British Journal of Obstetric Synecology, and they found that pooled data in their analysis showed an odds ratio of fetal demise of 1.82 for stillbirth in the IVF Ixy pregnancies compared to spontaneously conceived pregnancies, so a lower number.
SPEAKER_02:Yeah, that so that's at least a little better than that earlier 2010 study, 1.8 versus fourfold. It's still elevated, but a lot less so.
SPEAKER_00:Yeah. And we should also note that in about half the studies that they included, there wasn't a statistically significant difference in at all in the mortality at the in the IVFX pregnancies compared to the spontaneous pregnancies. Most of the weight that contributed to that 1.8 risk came from the study we just talked about in 2010, because that's the study that's shown the largest difference in the two. And so if you remove that study from the pool, if you just accept that they didn't control for things like hypertension and other things that some of the other studies did, and majority of studies found no difference, right? If you remove that from the pool, then that risk drops from 1.8 to an even smaller number approaching one. The authors of this review definitely suspect some of the studies are biased because they also don't differentiate between intended terminations and spontaneous terminations. So a lot of pregnancies have intended terminations and and they may not happen until 22 weeks or something like that after you find out about an anomaly, and they're often included in the fetal demise numbers. And so the numbers drop when you use a methodology that excludes them.
SPEAKER_02:Yeah. Yeah, I think that maybe they forget that even with IVF, there can be a yeah, they can there can be a severe anomaly, or there can be severe preeclampsia that could kill the mother. So there are reasons for terminating even IVF pregnancies. But the authors of that review concluded that the risk it is increased, but that the reasons for that risk and the confounders are still unclear. The British Medical Journal 2021 study also did stratify for risks related to diabetes, hypertensive disorders, which the other earlier study did not. So that may account for why the risk is lower, because they're controlling for some confounders that are not the IVF itself, but maybe factors that run along together with IVF that could contribute to stillbirths. But even controlling for those, there was still some residual risk. And for some reason, I didn't quite agree with this, but they on purpose excluded studies looking at perinatal or postnatal deaths because they they said those happened for different reasons and they, I guess, didn't know how to include them in the analysis. They said it would be interesting to know that. Well, you should have looked at studies and included that. But yeah, having those studies too, I think would even better answer the question of whether inducing at 39 weeks is beneficial or not.
SPEAKER_00:Yeah, and I looked at the references for the studies that they excluded for that reason. And honestly, they don't really, I don't think they are they're helpful to answer that question either. We just don't have the data. They were looking at other issues in those studies, and the IVF Ixyprecies were part of those studies, but they weren't the theme of those studies. They were a subset, and so not a lot of number contribution to the analysis anyway. Now, from other studies, we do know that the risk is highest in the mid-trimester. So maybe the best study of that answers this question is a Nordic study from the Con Artis group, and they they looked in that study at ART pregnancies in general, so this wasn't IVFXE specifically, and compared those to spontaneous conceptions, and they found that singletons conceived by advanced reproductive technologies had an increased risk of early neonatal death by an odds ratio of 1.54 and a similar risk within the first year of life. And they had double the risk of stillbirth, but this risk was even earlier from the Danish cohort. It was before 28 weeks. And after 28 weeks, they found no difference in the risk of stillbirth between ART and spontaneously conceived pregnancies.
SPEAKER_02:Well, that's another scary factoid for us, especially for us IVF people. I'll have to read that paper and see if they had any common themes of why these babies were dying. But yeah, as I mentioned, I IVF kind of feels a little more, even more higher stakes as far as pregnancy loss. There was always that stereotype in my training that IVF patient patients are going to be so anxious about losing their pregnancies, if they call with a concern and you don't call them back right away, they'll call like 20 more times and that kind of unfortunate stereotype. But if there's this kind of information out that like there's there's a higher risk of just stillbirth, then why wouldn't they be anxious? And I think the current ACOG guidelines and SMFM, they still suggest starting antenatal testing of I all IVF pregnancies at 36 weeks. But if you're looking at this Con Artis study, even if you backed it up to 32 weeks, if their real risk was before 28 weeks, then that's not beneficial either. And I don't think anyone out there is suggesting start antipartum testing like 20 weeks or 24 weeks, for example, as if that would really save any stillbirths anyway. But I think the big thing is that we unfortunately don't understand why this risk is increased, let alone how do we reduce this risk.
SPEAKER_00:Yeah. And many times the testing isn't associated with a reduced risk for those pregnancies anyway. So that's a whole separate issue. But we don't start typically testing until 32 weeks, except in the in the most extreme high-risk pregnancies, we'll occasionally start at 28 weeks, primarily because the false positive rates of these tests are so high that we end up harming more pregnancies with iatrogenic preterm delivery, like we talked about a few minutes ago with fibroids, when the test comes back with some concerning finding, but the tests aren't that good. So we try to restrict that at least to a gestational age that if we end up delivering the baby like post-32 weeks, we're not exposing that baby to the risks of extreme prematurity. There is a 2019 Danish cohort study that looked at term pregnancies and did find still a 2.4 fold increased risk of fetal demise beyond 37 weeks in IVF IX pregnancies compared to spontaneous pregnancies. So this is one small sliver of support for doing testing starting at 36 weeks and beyond, but it still doesn't prove that the testing itself reduces the risk of fetal demise.
SPEAKER_02:Aaron Powell So it's becoming like a ping-pong match. One says 28 weeks, the other says 32, 37. So which, yeah, which is it?
SPEAKER_00:That's why we need to drill down on what the causes are. You would think that the earlier the 28-week demises are structural anomalies or things like that. And obviously the demises past 37 weeks are probably more likely to be related to the normal causes that we think of with fetal demise, maybe placental issues or stuff like that. So beyond 37 weeks, they found a 1% risk of stillbirth in the spontaneously conceived pregnancies and a 3-ish percent risk of stillbirth in the IVF IXE pregnancies. Now, this was 35 stillbirths out of 10,235 pregnancies that they had in the data set. And this difference was statistically significant for the IXE pregnancies, but it actually washed out of statistical significance for the IVF pregnancies that didn't have IXE. And I think that brings us back then to the specific concern about ICSE pregnancies brought up by our birthing in Boston listener. And it's really from this study in particular has been the main push for the 39-week induction.
SPEAKER_02:Okay. And I'm sure there's speculation of what about IXE could make the pregnancy higher, higher risk than regular IVF, but we don't have answers, like solid answers. But either way, it sounds like it's still rare enough that probably a few individual occurrences one way or another determined whether this was a significant risk or not. And it was from a retrospective register register-based cohort study. So it's weak evidence, but it's really all we have right now.
SPEAKER_00:So that gets us to how these recommendations are made. So in the post-arrive trial world, where we generally act there's no downside to a 39-week induction, then even a hint of a downside to the ongoing pregnancy will always be met with a recommendation for 39-week induction or delivery. So as listener said, the Society for Maternal Fetal Medicine doesn't mandate delivery at 39 weeks, but it does recommend, as you mentioned, weekly surveillance beginning at 36 weeks, which ACOG endorses, as you mentioned, and it seems to really strongly encourage delivery at 39 weeks, even though they know that uncomplicated singleton IVF pregnancies with reassuring testing could be managed up to 41 weeks. There was also a published in JAMIN Network Open in August of 2023 that sought to answer the question about optimal timing of delivery for patients who had undergone infertility treatments. And this again was a cohort study that looked at nearly 180,000 singleton-term pregnancies conceived with infertility treatment, and they found that the risk of delivery at 39 weeks in terms of neonatal morbidity and infant death was lower than the risk in subsequent weeks of gestation. So they favored the 39-week delivery timing for that reason. And this data is really the data you mentioned before, that graph in your head. This is a graph in that paper, because again, you almost in all cohorts, you're going to see that the per week fetal demise rate and neonatal survival ability rate is best at 39. So you can label the patients anything you want, but you're usually going to see that result. And they did in that study in JAMA use a perinatal definition that included neonatal aggregated neonatal aggregated morbidity mortality and compared that to the fetal demise and neonatal deaths compared to the spontaneous pregnancies. So that would tend to support, again, 39-week induction if you don't see a risk of doing the induction to the mother.
SPEAKER_02:And those absolute numbers all across the board are still so low for perinatal death that it does leave room to actually consider the mother as well and what are her risks.
SPEAKER_00:Aaron Powell Yeah. That's really the thing about understanding the arrived trial is how you contextualize the risks to the mother. So but this is where joint decision making comes into play. People who choose vaginal birth after cesarean deliveries with a risk of uterine rupture, or people who choose home births for that matter, with even in low risk pregnancies, well, they're taking more risk for their fetuses and newborns than are women who have IVF Ixy pregnancies who choose if they're otherwise low risk, who choose to continue on to 41. So they calculated a number needed to treat of only 64 inductions at 39 weeks to prevent one excess neonatal morbidity or infant death. Most of those are morbidities, not deaths. And morbidity has a definition that includes NICU admission or low apgar score and things like that. And of course, it's a retrospective cohort. But it makes sense, right? Empirically, it we do know that 39 weeks is better than 40 is better than 41. The actual number to treat to prevent a death, I couldn't calculate. So the task is to balance these risks and benefits for the patient. And in in the past, patients who've undergone artificial reproductive technologies, as you mentioned, the uh things like IVF and IXE, they were thought of as having these VIP pregnancies, this very important pregnancy. And it was unconscionable to go past 39 weeks. You wanted to get that baby out of there as soon as it was ready.
SPEAKER_02:Yeah, like I how I was alluding to before. It's like they're more anxious, there's higher stakes. Some of them have waited years and had maybe a lot of losses, and they've gone into debt over this, and this might be their last chance to ever have a baby. So then the attitude managing them is don't let any baby die if you can help it, but especially don't let this baby die.
SPEAKER_00:Yeah. And which is understandable, obviously, you're pregnant with an IVF pregnancy. It's understandable. We're torturing you with this data right now. But if you follow the logic all the way through, the implication is that pregnancies that are achiefu infertility treatments are somehow more valuable or more important than other pregnancies, which of course is insulting to the other pregnancies. So we don't use the terms VIP anymore for IVF pregnancies. That was actually in the literature in the 1980s. If people are interested, I'll find it. But it has influenced the routes of delivery and the extra care and attention and all that patients with these sorts of pregnancies have received in the past. And this includes a higher rate of cesarean delivery as well. We're not going to take any risk at all. We're not going to tolerate any decelerations at all. Just a general sense of, again, let's we fought so hard to get here, let's take no risk. And C-section is viewed as the riskless alternative. So my guess is most OBGYNs still have this bias underlying, implicit bias. And why take a risk? You spent$30,000 getting pregnant. You tried for X number of years. Let's get to 39 weeks and get out of here and not risk anything. And the evidence does seem to support that you'll get perhaps a few bad outcomes out of many thousands of pregnancies, but that has to be weighed against maternal risks. And none of these studies really address that. They focus on just the neonatal risk. So in a context of shared decision making, where patients understand the risks and the benefits, they should still be free to make decisions because we do a job where sometimes we put one part of the dad at greater risk than the other part of the dyad, and we're trying to optimize risk management for both. And so women should be allowed to make those decisions in the context of their own values after being fully informed.
SPEAKER_02:Of course, always. And patients need to know this information to understand and actually make that decision. They need to be educated that 39-week induction is not a horrible thing if it's done responsibly, but also that it's often perfectly okay to go past 39 weeks. The arrive trial that we've talked about on here so much supposedly, ostensibly showed that induction did not increase the rate of cesarean delivery compared to expectant management. But that at least was in a setting with a high baseline rate of cesareans. So it doesn't necessarily apply across the board. And still, the pendulum can swing the other way, sometimes too far, where people are wanting to avoid inductions and interventions at all costs, even if they get to 42 weeks and beyond. You and your guest, Anna, who Anna, oh, pardon me, who represented a lot of these people who're skeptical about our interventions. You talked about some of that on the episode about natural birth claims. Patients should not be afraid of indicated inductions. We induce patients, for example, with cholestasis of pregnancy for very similar increased rates of perinatal mortality. And in general, where people are very accepting of that practice.
SPEAKER_00:Well, they're probably itching like crazy, so yeah. They're begging. But we know that anenatal testing in that case doesn't help those patients either. And so we have a pretty definitive understanding that certain select patients with cholestasis, we are saving neonatal lives, and we're we can't help them with extra anonatal testing, and so those inductions clearly benefit some children. Despite everything we've talked about, because we have only these retrospective cohort studies, we still really don't know that patients who have IVF ICXE who undergo weekly testing at 36 weeks, if that makes a difference, if it would decrease those numbers. We don't know how much testing was applied in these cohorts and how good a job they did as sorting out otherwise high risk pregnancies. So this is why it's still a conversation with the patient.
SPEAKER_02:Well, my IVF IXE pregnancy last time around just made the decision for me because I was about to start a busy day of clinic at 38 weeks and my water broke. So so that was it.
SPEAKER_00:Yeah. But would you have gone with a 39-week induction if that happened hadn't happened? Are you in team induction?
SPEAKER_02:Yeah, yeah, I would have, and I will with my current one too, but but it's not because I'm universal, like everyone needs it at 39 weeks. It's because I was supposed to return to work six weeks after that date, and that was going to happen no matter what. So I didn't want to eat into any days of my maternity leave. I already had blacked out.
SPEAKER_00:Yeah, and that's okay because we understand that induction can be done safely, and that you're not hurting you know it's certainly not hurting the newborn by having a 39-week induction. That that's clear. Yeah. And I say that because Anna might disagree with me. But but yeah, if it's pragmatically helps you get your maternity leave and all that. Which reminds me, I think we need to do an episode about burnout. I think I have just the person.
SPEAKER_02:Sounds good.
SPEAKER_00:We'll do that in two weeks.
SPEAKER_02:Okay. I'm looking forward to that.
SPEAKER_00:All right. We'll see you guys then.
SPEAKER_01:See you then. Thanks for listening. Be sure to check out thinking about obgyn.com for more information and be sure to follow us on Instagram. We'll be back in two weeks.