‘Tailor-made’ treatments a truth or fallacy in reproductive medicine?

One of two keynote lectures to open this annual meeting explored the promise of personalisation in reproductive medicine. Unless based on the evidence of ‘published knowledge’, and without the input of genotype information, a personalised approach can be little more than intuition.

With more than 10,000 registered for this 38th ESHRE annual meeting and around 80% attending in person, it was just like old times for another session of two opening keynotes lectures, with a packed house once again and a renewed atmosphere of anticipation.

Endocrinologist Stratis Kolibianakis, in an age now embellished by ‘tailored treatment’ and ‘individualised’ approaches, set many of them thinking with his own personalised view on the truths and fallacies of personalisation in reproductive medicine. The bottom line of his argument – his version of the truth – was that personalised treatment is only feasible through the application of ‘solid knowledge’ derived from relevant published literature. Without that, personalisation is no more than a best estimate – or at worst ‘pure intuition’.

Kolibianakis had started his presentation by proposing that the medical model for personalised medicine lies at an interface of individual phenotype and genotype, but the latter, he said, were still lacking in reproductive medicine. Examples of studies in search of a genetic basis for female infertility – in endometriosis or early menopause – were still largely inconclusive. Complicating these studies anyway are the complex etiology of infertility, population bias and standardisation, and the difficulty of applying genetic biomarkers with so many candidate predictors.

So it seems easier to say what is not personalisation in reproductive medicine than what actually is – in whatever way it’s presented. So setting treatment goals by respecting patient wishes is not personalisation, said Kolibianakis, nor even may be decisions on type of treatment, type of stimulation, or progress after oocyte retrieval.

So personalised treatment will depend on the physician’s extent of expectation. ‘We do or don’t expect a treatment to work,’ explained Kolibianakis, ’ we expect that a specific medication dose is the appropriate one.’ And the basis of those expectations remains the literature of published knowledge, ranging from systematic reviews and RCTs to the isolated expert opinion expressed in an editorial. Without that knowledge, he said, we’re left with ‘cognitive bias’, intuition and ‘fallacy’. Thus, treatment personalisation is ‘simply the way to apply science in clinical practice’, illustrated in the development of scrupulously prepared guidelines with evidence from replicated and validated studies.