Wednesday, January 20, 2016

Allowing the IVF patient the freedom to make her own decisions

One of the hardest things for me as an IVF specialist to do is to tell an individual patient what to do. This might seem surprising - after all, isn't the  IVF doctor the specialist ? and isn't it our job to help patients to make these decisions ? Isn't that what patients expect - that we will help them to make the right decision by telling them what to do ?

Part of the problem is that I try to be as non-judgmental and non-directive as possible, because I feel patients should make these decisions for themselves. After all the outcome is always uncertain, but if they retain control of such key decisions in their life, they will have peace of mind they did the best, and the treatment process itself will be a happy and a positive one , no matter what the final outcome.

This can be quite challenging for me, because patients in India are still not used to making these decisions for themselves. Many are not sure what to do with this autonomy. In fact, a lot of them get confused and upset when I , the doctor , ask them for their opinion ! They feel that it's my job as a doctor to tell them what to do , rather than ask them for their inputs ! I am sure some of them feel I am incompetent - that it's because I am not very sure as to what I'm doing, which is why I need to ask them for their opinion !

 Thus for example, let's consider a patient who is a poor ovarian responder, for whom I have been able to retrieve only 2 eggs .  I would prefer doing a day 5 transfer, even though she only has 2 eggs, because the value of information I can get from growing the embryos to Day 5 would be far more rather than just going ahead and transferring on day 2.  Thus, if I transfer on Day 2, and if the cycle fails, I will never be sure as to why the cycle failed. Was it because the embryos were of poor quality and they arrested in vivo ? Or was there some other reason for the failed implantation?

On the other hand, If I do a day 5 transfer, I am able to give her much more intelligent information, which can then help her fine tune what to do for the next cycle. Thus, if the embryo arrests in vitro before becoming a blastocyst, then this will cause her short term pain , because I will not be able to do a transfer for her , but she will know on a long-term basis that her major problem is poor egg quality, and that the best option for her next cycle would be to consider using donor eggs. This is invaluable information, which I cannot obtain by any other method.

The reality is that there are not right answers in IVF, and it's important that patients be counseled, so they can make the decision which they feel is right for themselves, because they're the ones who are going to have to live with the consequences of this decision.

It's very easy for me to tell them what to do, and I am sometimes tempted to do so, but I  discipline myself and allow them to decide for themselves. I promise them that I will support them, no matter what they decide. If they are unsure, I tell them to sleep over it. I also promise them that I will never let them make a wrong decision, and I will explain the pros and cons of each option, but that it's in their long-term best interests that they make the decision which their heart tells them is right for them.

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