Tuesday, January 03, 2012

Should IVF doctors refuse to treat patients who have a low chance of success ?

Sometimes patients come to me with unrealistic expectations of success , and my initial knee-jerk reflex and first response is to simply say no , because their chances are so poor .

This is what happened recently when a patient with a high FSH level asked me to do IVF treatment for her. I suggested that she’d be better off using donor eggs, but she then countered by asking me an interesting question. She said , “ Doctor , why are you refusing to treat me ? This is my money which I am choosing to spend . I'm not asking anyone for any help or any assistance - I'm not placing a burden on anyone else. I understand fully well that my chances are extremely poor. I'm not asking you to raise false hopes or do anything unethical or do anything wrong. All I’m asking you to do is help cooperate with me so that I can achieve my goal, which is that I have peace of mind that I tried whatever options were available to me. I'm an intelligent woman . I understand exactly what I'm capable of doing and equally what you're capable of doing. I understand that I have ovarian failure and that my chances of success are poor but I don't want to kick myself later on that I did not give myself the best shot possible and therefore I would be grateful if you would accept my request and take me on as the patient. “

I think this was a reasonable request from a perfectly intelligent patient. She was autonomous , and was making a decision for herself. She was intelligent. She had realistic expectations. This was a treatment which didn't carry any harm. It wouldn't hurt anyone else in the process , because she wasn't using anyone else's money or consuming scarce resources to go through with her treatment . Equally , it would help her. Perhaps it would not give her baby , but would still benefit her from her perspective because it would help her to achieve emotional closure that she had tried whatever treatment options were available to her , given today’s technological limitations that we cannot create artificial eggs in the lab.

Since she needed assistance from an IVF specialist to do this treatment , I actually felt it would be unfair on my part to refuse such a reasonable request. I was pretty certain that she wouldn't grow any eggs - or that even if she did , the chances of success were practically zero. But as long as I was honest with her and explained the facts to her; and she understood this , and in spite of that chose to go on with the treatment, I concluded that I would not be fair in my part to refuse her.

One of my colleagues was quite critical of my decision. He said as a medical professional, it’s important that you decide what patient’s requests are reasonable and what requests are unreasonable. This is not the kind of patient whom I think you should treat because your ability to be able to help her to have a baby are extremely slim. You know that and it's your job as a Doctor to tell her that so she doesn't pursue this foolhardy course.

I agreed with him that from a purely medical perspective , his stance was correct and that my ability as a medical professional to help her have a baby was very slim , given her high FSH level and her poor ovarian reserve. However, my ability to help her as a professional , not just in the limited perspective of giving her a baby , but of helping her to achieve her heart’s desire and emotional closure that she'd given it her best shot were something which I felt I could not in all fairness refuse.

I think it is my job as a doctor to counsel patients and offer them advice and my personal perspective. However, I also think it's perfectly acceptable for them to override my decisions and come to their own conclusions. As long as these will not harm them, I'm quite comfortable with allowing them to follow their hearts desires. After all I can never walk in her shoes ! Going through the IVF cycle would help her to come to terms with the fact that she would never be able to have a baby with her own eggs and that technology could not help her. Even if the cycle failed, she will still be better off than if she never tried at all.

In fact, going through the cycle would change her as a person hopefully for the better a) because she'd given it her best shot and b) because it might help her to then consider alternative options for carrying on with her life, which could perhaps include either being contented living a child free life ; or considering adoption, or even donor eggs.

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1 comment:

  1. Anonymous9:56 AM

    Yes. Finally, a Dr. that gets it. Infertility is an emotional journey for women! We do not like being treat as if we don't know what we want and what the risks are!

    Once informed we should be given the choice to try or not.

    If there is no harm in trying. Then why not?


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