Santa Claus in the fertility clinic: Table I

In 1978, Thomas was the first to describe what we now know as the ‘therapeutic illusion’ (Thomas, 1978). In many cases, the patient who will get better without treatment will also do so with treatment. The risk is that the physician may ascribe recovery to his treatment and consider it a confirmation of his good decision to apply it. To quote Thomas in his imaginative article: ‘In the past this therapeutic illusion has been responsible for many mistaken diagnoses and much useless medication, and is probably responsible for a lot of unnecessary treatment today’. Let me paraphrase Thomas for our speciality, Reproductive Medicine: The majority of the patients who will get pregnant with intracytoplasmic sperm injection (ICSI) will also do so with IVF. The inappropriate use of medical treatments should be abolished, but success of such efforts will be limited by the tendency of human beings to overestimate the effects of their actions, the therapeutic illusion or the ‘unjustified enthusiasm for treatment on the part of both patients and doctors’ (Casarett, 2016). In this issue of the journal we publish the most recent ICMART data, from the years 2008–2010 (Dyer et al., 2016); a wonderful effort for which the authors have to be commended. It offers a benchmark for assisted reproductive technology (ART) treatments in this day and age. Unless the majority of couples’ infertility in the world today is determined by severe male causes, the report offers a sobering confrontation with modern Reproductive Medicine practice. As compared with some 220 000 IVF treatments, more than 455 000 ICSI treatments have been started in 2010 in the world. The ICSI:IVF ratio varied from 1.4 in Asia to 60.3 in the Middle East (Table I). In non-male infertility, ICSI does not offer an advantage over IVF, as demonstrated in one medium-sized randomized controlled trial in 423 patients (Bhattacharya et al., 2001), and—year after year—in the SART CORS (Society for Assisted Reproductive Technology Clinical Outcome Reporting System) reports (SART, 2016). The most recent SART CORS report, over 2013, shows that in the USA, among patients without diagnosed male factor infertility, in every single age group below 43, ICSI resulted in fewer live births than IVF (SART, 2016). The American Society for Reproductive Medicine, in an official statement (COM017) on ICSI for non-male factor infertility (ASRM, 2012), stated ‘Routine use of ICSI for all oocytes does not appear to be justified in cases without male factor infertility or a history of prior fertilization failure’. The statement continues to point out that ‘ICSI for unexplained infertility does not improve clinical outcomes. ICSI for low oocyte yield and advanced maternal age does not improve clinical outcomes’. In routine ART for non-male factor infertility the risk of failed fertilization is low and a similar frequency is found after IVF and ICSI (ASRM, 2012). We clearly overestimate the effect of ICSI. We have arrived in a situation of therapeutic illusion on a grandscale (‘the unjustified enthusiasm for ICSI on the part of patients and doctors’). Intending to improve their patients’ pregnancy probability by preventing fertilization failure, wellmeaning doctors actually decrease their chances. This has to stop. We all have pledged to ‘first do no harm’. But how? By critically appraising the literature, by making rational clinical decisions, by implementing new treatments only if based on robust evidence (and, in the absence of such evidence, by doing the necessary trial), by weeding out inappropriate use of tests and treatments, by contemplating the role of our own beliefs, biases, bigotries and dogmas, and by adjusting our clinical care when and where necessary, we ultimately will serve our patients best. Not by playing Santa Claus and doling out nicely wrapped presents of unnecessary, ineffective and costly care.