By: Gina Edwards

In the last decade, fertility care delivery has had to adapt — to pandemic restrictions, to rapid technology shifts, and to a cultural sea change that has driven more patients than ever before to seek out reproductive guidance.

Dr. Julie Rios heads the Division of Reproductive Endocrinology and Infertility at UPMC Magee-Womens Hospital. Since assuming the division chief role in Summer of 2021, she has guided the department in meeting the evolving needs of patients in a shifting health care climate.

“When I came here, we had over 1,000 patients on the wait list of people getting in to see us,” Dr. Rios says.

Though this backlog of patients from COVID has subsided and there is no longer a lengthy waitlist, that was only one part of the challenge: the adoption and scaling of telemedicine during the pandemic also quickly ushered in a new normal across all health care service lines.

Since then, overall demand for fertility services has skyrocketed, owing to several factors, including new tests and technologies, social media trends, and expanded insurance coverage for certain services.

Changing Conversations in Fertility

Clinical tests developed over the last decade have influenced an increase in demand for some analyses — specifically when it comes to preimplantation genetic testing or evaluating cells from an embryo to identify abnormalities early in the process. Previously, such testing was done on one cell of an 8-cell embryo. Nowadays, the embryo is cultured longer, into the blastocyte stage, which is comprised of hundreds of cells — of which five to 10 cells are tested — offering a higher degree of accuracy.

However, such advances are not without controversy, as Dr. Rios explains: “Should we do [preimplantation genetic testing] for all patients during In-Vitro Fertilization (IVF)? Do younger patients really need it? Are there risks with it? And I think that's still a debate going on in our field.”

A surge of interest in at-home DNA genetic testing a la 23andMe has also resulted in patients requesting services to avoid passing on certain characteristics, for example. Dr. Rios adds that social media has complicated matters, as patients will request specific procedures they have heard about online that may not be evidence-based or likely to succeed. In other cases, patients may be working with a specialist outside of the ob-gyn field, who may recommend treatments that can be costly and have significant risks.

“It is a very expensive and emotional invasive process that patients go through,” Dr. Rios says. “You want to have a shared decision-making model with them, but there must be a balance between patient autonomy and physician expertise.”

When conflicts in courses of action arise, it is a balancing act for providers to ensure patients feel heard but are also counseled toward appropriate medical recommendations. She says that their division uses tools like an online calculator to predict the success of a given procedure like IVF, which can open up conversations about the best courses of action, particularly given the patient’s insurance options.

“I do think insurance coverage comes into account for this. Someone that has a 10% success rate, but it's fully covered is going to take that chance and could be successful. Then, someone else that must pay for two or three cycles out of pocket may not want to spend $60,000 for a 30% success rate,” she says.

While Dr. Rios says that the bulk of the patient volume in the department is for infertility services, she is also seeing an uptick in interest in services like egg preservation.

“Cost comes into everything we do. More and more companies are covering fertility preservation or just covering our services,” she says. “As we see more coverage, we’re going to have more patients doing it. I also think that there’s more interest, and more people understanding that it’s quite successful.”

Collaborating Beyond the Clinic

Beyond her work in the clinical space, Dr. Rios works with researchers at Magee-Womens Research Institute on fertility preservation efforts for specific patients.

“We have a great team that collaborates between [Dr. Kyle Orwig’s] team at the Center for Reproduction and Transplantation (CRT) and our team at the Center for Fertility and Reproductive Endocrinology (CFRE),” Dr. Rios says.

If the patient is interested in egg freezing, they will work with Dr. Rios’ team. If patients are unable to do egg preservation and have ovarian tissue, they can pursue that preservation option through the CRT. Patients with testes primarily work with the CRT, but the CFRE will review the semen analysis and help the patient understand the information about their specimen. If patients cannot bank sperm, they can do the research protocol, which is testicular tissue cryopreservation.

“We also work with Dr. Hwang in our Men's Health Center, who could potentially then see these patients to do other fertility preservation procedures that maybe aren't under a research protocol,” she says. “We essentially have a multidisciplinary team where we're all managing the patient so they can get what they need.”

This sentiment also goes for patients who have had chemotherapy for cancer, or any medical condition requiring gonadotoxic treatment. Through these teams, patients receive information about how their fertility could be affected, and what options they have to preserve it.

“They're going to have potentially lifelong effects: they could go through menopause early and need hormone replacement,” she says. “The clinic is here to support those patients. It's a great checkpoint, so that they understand how they could use their eggs or their tissue.”

Division Directions & Priorities

As leader of the REI Division, Dr. Rios has worked to institute communication protocols so that patients receive continuous care experiences even if their provider is out of the office. Dr. Rios and her team are also working on an FAQ educational series so that the most common questions from patients are already answered before they walk in the door.

“Every patient is an individual, so they're not going to fit into every single protocol,” Dr. Rios says. “But there are some basic standards we can make, and we individualize from there.”

These streamlined processes facilitate another tenet of Dr. Rios’ focus as a leader: provider wellness.

“In general, I'm trying to overall make our staff, our physicians, our providers — everyone to have more wellness. We want to feel like we're taking care of these patients, but also making sure like when you're not here, you're able to spend time with your family,” she explains.

Finding this balance for providers is especially important given the current outpacing of demand to supply of reproductive endocrinologists. More advanced practice providers (APPs) are being trained in certain aspects of care in the REI Division to offset the demand and they work closely with physicians to provide excellent care to patients.

In looking toward the future of the division, Dr. Rios hopes to build for long-term research as well as establishing great patient education and patient relations — to provide great care. As pregnancy rates have risen in the division, she is encouraged by the progress and examining ways to keep them improving.

Dr. Rios says that ultimately, the goal is leading toward patient-specific care:

“We're looking forward to collaborating with our patient population, MWRI, and within industry to contribute to the science and to try to make fertility outcomes better and more individualized for every patient.”