Thursday, September 18, 2014

The exception which proves the rule in IVF

It’s true that medicine is a complex biological system , and this is especially true of IVF . However , there are certain rules of thumb ( also called heuristics) which are extremely useful when we practice reproductive medicine .

Thus, we know that if the patients embryos fail to implant, 90% of the time the problem is with the embryo rather than with the endometrium . Similarly, when we encounter the distressing problem of failed fertilization after IVF, the problem is because of sperm dysfunction, rather than an egg problem. WE also know that the patient’s embryos are all of poor quality in a good IVF lab, the problem is much more likely to be with her eggs rather than with her sperm.

These heuristics are extremely useful when counseling patients when things don't go well. They help us to plan our next action steps , and we can be confident that we are providing good advice , even though we don't have specific evidence for that particular patient . These rules are based on experience with many other patients , and empirical evidence is quite reliable since medical science has so much experience with IVF today.

However , there will always be exceptions to these rules. The problem arises because doctors love these exceptions . They are fascinated by complicated cases – by patients who are outliers. This is because doctors get bored by the routine, run-of-the-mill problems. They are always on the lookout for the new and the unusual – something who can challenge their curiosity and perhaps results in a paper they can publish !

They believe that not only can they learn a lot more from these exceptions, they can use this knowledge to advance medical science- after all, how much more can you learn from the ordinary case ? They treasure their exceptions, and this is why doctors are fascinated by zebras !

However , as regards patients , it's much more important for them to know what the rules are , because their problem is much more likely to be what occurs commonly , rather than something which is extremely rare . Unless patients are willing to be guinea pigs, they should assume that their problems are similar to everyone else’s.

Because doctors are fascinated by what is uncommon , they love ordering extensive tests, in order to pinpoint the particular problem for that individual patient . This is especially true for clinicians who are also research scientists. While this may be acceptable in a university setting, or during a trial, this is inappropriate in a clinical setting. It often represents a waste of time and a drain of that patient’s resources, because these tests are exotic and expensive . Infertile patients can’t afford to go to doctors who enjoy chasing red herrings to satisfy their intellectual itch !

Not only is this wasteful, it does not help the patient either , because it doesn't usually change her treatment options . Hunting for zebras is an intellectual challenge for doctors. They love playing a game of one-upmanship and treasure these war stories to show how much better informed they are than their colleagues. However , this may not always be in your best interests !

Not sure if your problem is the exception which tests the rules ? Please send me your medical details by filling in the form at so I can guide you sensibly ?

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