Wednesday, November 22, 2017

When IVF Patients Make Irrational Decisions

Infertility presents a number of unusual challenges for doctors.  It is caused by a medical problem -  for example, blocked fallopian tubes,  or a low sperm out - and this means we can offer medical treatment for it, but the truth is that childlessness is a social label. This is why treatment for infertility is elective - and patients have to decide for themselves if they want to do IVF or not.

This is why there really is no right answer or wrong answer as to what kind of treatment IVF patients should be taking. For example, the medical treatment which would give the highest chances of success for an older woman with poor ovarian reserve (a reduced AMH level and a low antral follicle count ) would be to do donor egg IVF.  In all other areas of medicine, the doctor would advice her to do the treatment which maximises the chances of a good outcome. However, if she wants to try IVF with her own eggs, how can you refuse her this option ?  As a doctor you know that her chances of getting pregnant with her own eggs are extremely poor , but if she still insists that she wants to use her own eggs , you have to respect her personal choices. You know there's a high probability that both the quantity and the quality of her eggs will be  poor, so you try to explain to her that her chances of having live birth chances are low, but she is still the final decision maker, since it's her baby. She is using you to provide her with technical assistance , and wants to make her own choices for herself.

 Now from a purely scientific point of view, this may be an irrational decision, because using donor eggs will increase her chances of having a baby enormously , and after all isn't that what she wants - a baby ? So why not suggest that she uses only donor eggs?  However, for something which is so personal and private as reproduction , these are decisions which patients need to make for themselves. These are usually emotional decisions, which they then justify for themselves by using logic, saying, "Well, even a 1% chance is better than a 0% chance. So why don't I at least give it my best shot?"

This can be very hard for a doctor . Where does one draw the line between offering what seems to be futile treatment , as compared to respecting the patient's autonomy and allowing her to decide for herself ?
There are no easy answers , and this is a bit of a problem , because there are greedy doctors who will take advantage of the patient's desperation . They are happy to offer any kind of treatment the patients wants , because they're quite happy to charge the patient an arm and a leg for fulfilling her desires , even though they know that the treatment is doomed for fail, and she will just end up wasting a lot of money.

However, when there is so much money at stake, it's sometimes hard for a doctor to stick to the higher moral ground. It's very tempting for him to say, "Yes. I know the chances are poor, but after all, I need to do what the patient wants me to do. Why should I discourage her ? If I say no, I don't earn anything at all - so why refuse the income ?  In any case, even if I say no, she'll just go to some other doctor, so isn't it better that I offer her the treatment myself, rather than reject her and send her to my competitor?"

Reproductive medicine is not just science - it also involves art and commerce , and this is why it can be extremely challenging for doctors to make the right decisions for their patients. This is why respecting the patient's decisions can be so difficult - especially when you know that they are just deluding themselves, and you don't want to be a party to offering them false hope.

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