Friday, May 29, 2015

Making the right decisions in an IVF Cycle

Traditionally most decisions in an IVF cycle are made by the doctor. It's the doctor who decides what dose of injections to use for super ovulation, what treatment protocol to use, when to increase the dose and when to trigger the HCG injection.  And this is what most doctors and patients expect as well. After all , IVF is a medical treatment and it's logical that the decisions will be made by the medical specialist.  However, lots of IVF decisions should actually be made by the patient . Even if the doctor makes them, the doctor should invite the patient’s participation and consider the patient’s preferences when making some of these decisions.

Let’s look at two examples.  One, is a patient who has had a poor ovarian response and who has only grown two follicles . The traditional response is - if you have less than four follicles, your chances of getting pregnant is poor, so let’s go ahead and cancel the cycle and let's use donor eggs in the next cycle. This is especially true for IVF clinic who need to  game their numbers to rank high on the IVF pregnancy rate league tables.  This is what most doctors so, if left to their own devices. 

However, a respectful doctor would ask the patient, “We only have four follicles and therefore the chance of you getting pregnant, if we go ahead with this IVF cycle, are pretty poor. However, would you like continue or not? The advantage of continuing is that we may get eggs and these may become embryos and you may get pregnant . The disadvantage is that we may not get any eggs at all and you may end up spending a lot of money without getting anything in return." 

As you can imagine, this is a complex decision and we need to think about what the patient’s preferences are when making such a complicated decision. There is no "right decision" in this setting. Thus, there will be some older women who will say, “Look Doc, this is all the follicles I’m ever going to grow, so go ahead.  If you get the eggs, great ! And if not , then at least I will have peace of mind I tried my best.”  On the other hand, there will be some patients who will say “You know doing an IVF cycle is too expensive and if my chances are poor, I’d just rather cancel."  The point is, it’s the patient who should decide , and since the doctor cannot read the patient’s mind, the patient should ask to be allowed to participate in these crucial decisions , and the doctor should encourage the patient to provide her inputs.

The same thing applies, for example, at the other end of the spectrum. For example, when patients with occult Polycystic Ovarian Disease, grow too many follicles, the standard response is to cancel the cycle, but this means that the patient will not get pregnant. She then needs to start a new cycle and it’s quite possible she may end up with hyper stimulation ( OHSS) again in the next cycle.  This is why some patients will say, “You know, since I’ve spent so much time and money and energy in growing all these follicles, why don’t we go ahead with the egg collection and freeze all the embryos and I can come back next time for a frozen cycle."  This decision will depend on multiple factors, such as how many cycles the patient has done before; whether she understands what the risks of ovarian hyperstimulation are; how comfortable the doctor is in managing ovarian hyperstimulation syndrome; and whether the patient stays in the town or whether she’s travelling back to her city. Since there are multiple variables, it’s not possible to use a cookbook protocol mindlessly.  These decisions need to be tailored according to the patient’s medical condition as well - for example if the E2 level is exceptionally high, then no matter what the patient wants, the doctor will be forced to cancel the cycle. 

While it’s the doctor who is the final decision making authority, he needs to be respectful and invite patient discussion.  None of these decisions are written in stone and doctors need to be flexible when they do IVF treatment in clinical practice.  This is better, not just for them, but for their patients as well, because their patients feel heard and they are happy that whatever can be done to maximise their chance of getting pregnant, is being done.  Being flexible, of course, doesn’t mean being wishy-washy , and this is why it’s got to be a joint partnership , where the doctor allows the patient freedom to make certain decisions , and then takes the final call himself.

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