Sunday, September 28, 2008

IVF - the best path to a baby for infertile couples ?

Patients and doctors perceive illness and treatment from completely different perspectives. Let's look at infertility, for example. Most doctors look at the world through a biomedical perspective. They want to diagnose the problem; and then come up with solutions to help the couple to conceive. This is traditional in medicine, where the first step is making a diagnosis; after which we create a treatment plan. Text books will talk in terms of treatments based on correcting an underlying problem; and will usually offer a sequence of treatment steps which progress from simple to complex; and less expensive to more expensive. This is the stepped care approach, which makes a lot of sense from a societal perspective.

However, the patient's perspective is completely different. They don't really care as to whether the reason they can't have a baby is because he has a low sperm count or she has blocked tubes. All they want is a baby, so they can move on with their lives.

This often creates a lot of tension between patients and doctors. From a patient's perspective, rather than waste time, money and energy on ineffective treatments which have a low success rate, it makes sense for them to move on directly to the treatment which gives them the best chances of success - and this is IVF - the final common pathway, which allows us to bypass all medical problems !

However, most doctors do not share this point of view. Many are not very empathetic and do not understand the emotional pain infertile couples suffer from. They would prefer taking a text book approach to the problem . Many are tied down by treatment guidelines published by Gynecology Societies or the government, which limits the options they can offer to patients.

Also, doctors often tend to be quite arrogant. They take the approach that they know what's best for the patient, because they are the experts; and often will not take the patient's viewpoint into consideration at all.

Let's look at a 35 year old couple who want a baby. They are very successful; very well off; and need a baby to complete their life . Traditionally, doctors would do a workup to find out what the problem is; and then start treatment to correct this problem. Unfortunately, this sort of approach can be very time consuming - and not very efficient. Patients will often get fed up - and they simply do not have the time or energy to keep on going back to the doctor for repeated followups, all of which exact an emotional toll. Not only is there the pain of failure; there is also the opportunity cost; and the waste of time. From a doctor's view point, this is par for the course, but I feel doctors need to be more flexible, and to tailor treatments to suit the patient's perspective.

For this couple, the bottleneck is much more likely to be the time and energy they can devote to their baby making project, rather than money. It would make much more sense to just do IVF for them to maximise their chances of having a baby quickly. Now I understand that a lot of doctors will feel this is too aggressive and is overkill. I used to think so myself. However, I now feel we should let the patient decide, rather than make decisions for them. If the trade-off is between time and money, many will decide to go for the most efficient route, even if this is more expensive, as this may be the most cost effective for them !

Not only are we saving the couple a lot of time by giving them a baby quickly by IVF; we are also helping to improve the quality of their parenting, so that they can spend quality time with their baby when they are young and have energy - rather than waiting till they turn 40 before moving on to IVF !

In a fee for service setting, I feel decisions as to which treatment option to explore are best left to patients, rather than to doctors. A good doctor will explain all the options to the patients; the trade-offs involved; and then allow the patient to decide for themselves !

Unfortunately, especially in the UK, most GPs are not very empathetic towards infertile couples; and they while away a lot of the couple's valuable years in ineffective treatments before referring them to a specialist. This represents hundreds of years of wasted opportunity and heartburn for thousands of infertile couples, causing enormous private pain .

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