Monday, August 29, 2011

How do I decide which treatment is right for me ?

Many infertile couples are confused as to which treatment to select. There seem to be so many choices – and even worse, so many different opinions from different doctors ! It’s hard for them to figure out if IUI is better for them ( as recommended by their gynecologist) or whether they should move on to IVF ( as suggested by their RE) ! This is why it's very important to create a comprehensive treatment plan right from the beginning .

For example, I recently saw a young patient with polycystic ovarian disease . I sat with her and explained her options to her. Step number one would be ovulation induction with metformin , and if that didn't work, then we’d use ovulation induction drugs such as letrozole or clomiphene. If that failed, then one option would be laparoscopic ovarian drilling ; and if that didn't work , then her choices would include artificial insemination ( IUI) with injectibles; and if that also did not work ,then we would consider doing IVF. I created a flowchart to help walk her through her options.

But isn’t it the doctors job to decide what’s best for the patient ? Isn’t the patient likely to get confused when there are so many choices ? How can she decide for herself ?

I feel it’s helpful when you explain things systematically in a stepped care format, because patients learn that we have a lot of tricks up our sleeves and that there is loads of stuff we can do to help them to have a baby. The fact that it’s possible to become more aggressive if simpler treatments fail provides a safety net of reassurance. . However, some patients get upset when we discuss options , because they think this means that the doctor is confused and does not know what to advise !

The reason we use this approach is that all patients carry a certain degree of emotional baggage . Some patients are in a hurry and want to use IVF to have a baby quickly , because of social pressures . Others don’t want to take metformin because they dislike the idea of having to take medicines daily, because it reinforces the fact that they have a medical problem and can't get pregnant in their bedroom on their own. Others are petrified of having surgery ! It’s impossible for me to read a patient's mind , which is why I list all the options and then allow patients to select which one they would prefer . If they ask me for advise, I explain that I am very conservative, and prefer starting with simpler options ; and then gradually escalating over time if these fail,

All options offer different trade-offs between success rates; discomfort ; convenience ; and cost . However, these are decisions which are best left to a patient rather than to the doctor. Of course, if they ask me for advise, I am always happy to provide it . For example , for older patients, I am more likely to be aggressive , but I always make sure that patients have all the information regarding all their choices , so that they are empowered to make the right decision for themselves.

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