Wednesday, April 20, 2016

The IVF specialist's quandary

One of the problems I still grapple with, even after 25 years of doing IVF, is how optimistic to be with my patients. It's always a hard call, because while it's easy to be hopeful, I'm worried that if I'm excessively optimistic , patients will start assuming they will definitely get pregnant , especially when they have great quality blastocysts; a good endometrium, and a smooth transfer. However, if they don't get pregnant ( and because this is a biological variable and IVF is full of uncertainty, we still can't predict for the individual patient whether or not a particular cycle will work for her), my fear is that they'll go to pieces , and it'll be very hard for them to cope with their broken heart and their shattered expectations.

This is why I try to be as realistic as possible , and explain to them that there's a good chance that they will get pregnant, but they need to be prepared for failure.

Lots of patients don't like this. They feel I'm being too negative, and too pessimistic. Most patients want a doctor who's all pumped up , and who charges them up - someone who provides them with a lot of optimism and support. Many patients believe that being hopeful increases their chance of getting pregnant.

It's not hard for me to smile and be cheerful  - I am an optimist by nature. However, I do need to think about the long-term consequences, so that if I'm excessively optimistic and the cycle fails, and then the patient comes back and asks me, "Doctor, you said everything was going well, so why did the cycle fail," and how can I answer the question at that point?

This is why I try to prepare patients as best as I can , so that they know that even though we've done our best, the final outcome is not in our hands. We educate them about the process itself , so they have peace of mind they have received high quality care.

The problem is that there are lots of different kind of patients we have to treat.  Some are intelligent, some are educated, and some aren't. It's very hard to know how to individualize the degree of optimism for each patient - and how to titrate the information  and the way I provide it to these patients.

The problem is that one size can't fit all, but it's very difficult to know what the individual patient sitting in front of me needs. This is a challenge which I still struggle with. I want to give my patients hope, but the one thing I don't want to do is to  give them false hope - and this is a hard balance to find.

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