Saturday, October 10, 2009

Should patients be allowed to decide how many embryos to transfer ?

The major problem with IVF today is that it is expensive treatment with a limited success rate. When patients are paying for their treatment out of their own pocket, they naturally want to maximise chances of success. This is why they want more embryos transferred, in the hope that at least one will implant and become a baby.

Unfortunately, while it is true that transferring more embryos does increase the success rate, it also increases the risk of a multiple pregnancy. Infertile patients are often happy to take this risk, because they want to minimise the chances of what they feel is the worst possible outcome - not getting pregnant.

Today I had a patient who had come to me from the USA and had already failed 4 earlier IVF cycles. She had 5 8-cell Grade A embryos on Day 3 and wanted me to transfer all of them. She did not want to do a blastocyst transfer; and was quite insistent that we transfer all 5 back. Our clinic policy is to transfer 2, but I was willing to transfer 3 since she had already failed so many cycles. I feel that if a patient is not going to get pregnant after transferring 3 embryos, she is not likely to get pregnant by transferring 4 or 5. In fact, in my opinion, transferring more than 3 just increases the risk of a multiple pregnancy, without improving the chances of achieving a prgegnancy.

However, her perspective was quite different. Since she had already failed so many cycles, she was sure her problem was with embryo implantation, and she felt that transferring more embryos would maximise the chances of successful implantation . She was not interested in my logic or the figures; and was adamant that we transfer all five.

I am a big believer in patient autonomy and non-directive counselling and am quite happy to let the patient make the final decision in such matters, since it's her body and her embryos. I did accede to her wishes, but was wondering if I should have put my fut down and refused to transfer more than 3 ?

Did I do the right thing ? Should I have made the final decision ( since I am the medical expert ?) Or did I do the right thing by respecting her desires and treating her as an intelligent adult who could make her own decision for herself ? If she ends up with quads, everyone will criticise me for transferring 5 embryos. On the other hand, could I be sure that the fifth embryo I transferred would not be the only one to become a baby ? When outcomes are so uncertain, what should the doctor do ? Life is much easier in the UK, when these decisions are made by bureaucrats, so that neither tte patient nor the doctor has the freedom to decide !

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