Sutton's
law
is named for the bank robber Willy Sutton . When asked
why he robbed banks rather than offices, given the fact
that banks were much better guarded and harder to rob,
he replied "Because that is where the money is".
In medicine, this is the name given to the principle of
going straight to the most likely diagnosis. In simple
terms, this could be paraphrased as “ Go for where
the gold is “ – and for infertile patients,
this often means – “Choose the treatment option
which maximizes your chances of conceiving quickly.”
Traditional treatment
for infertility used a logical step wise approach. First,
make a diagnosis – find out what the problem is.
Then, try to fix it, using a progressively escalating
approach. Try medications first. If this fails, try
surgery. If this fails, then do IUI. If this does not
work, then try HMG superovulation plus IUI; and if this
fails, and the patient is still not fed up, go in for
IVF.
While this is logical, and looks great on paper, the
fact remains that it often does not work out well in
real life. This approach is time consuming, and patients
get fed up and drop out of treatment rather than move
on to the next step. This can be a real tragedy, because
these are often patients who could have got pregnant
with IVF. This approach might be reasonable for some
couples, but you cannot use a “one size fits all”
approach.
The fact is that there is a price you pay for everything
, and the price you pay for this sort of methodical
logical approach is an opportunity cost.
I recently saw a very successful and very busy couple
who was responsible for a dramatic change in my way
of thinking. The wife was 29 years old and said, “
I want a baby quickly. Money is no object and I want
you to do IVF for me. I want to have my first baby by
the time I am 30, and don’t want to waste time.
What can you do to help me achieve my goal ? I know
I may get pregnant in my own bedroom, but I prefer IVF
as I don’t want to waste time.”
This was a very unusual request, and I was surprised,
but in retrospect this approach makes sense. She argued,
“ We all want more control over our life, including
our reproductive decisions. Why should we have to depend
upon Nature’s vagaries when we don’t need
to ? After all, Nature is not very efficient at producing
babies, and if we can give Nature a helping hand , then
why not do so ?”
“There is no risk in performing IVF – either
to me or to the baby. It is safe and effective treatment,
and has no downside, other than the financial risk .
I am willing to spend the money in order to buy time.
For me, this is the perfect time in my life to have
a baby – this is my window of opportunity ! With
my busy schedule and carefully planned out life, the
opportunity cost of NOT doing IVF will be considerable
!”
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Traditionally, we have used IVF for treating infertile
couples. However, it would be equally valid to use IVF
to help couples to achieve their personal reproductive
goals, as long as they make a well-informed decision,
and are aware of the pros and cons. An analogy would
be cosmetic surgery, where surgical techniques are used
to help patients to enhance their self-esteem. Why should
I refuse her ?
Actually, if I had a choice, the only treatment I would
offer would be IVF – after all , I want all my
patients to get pregnant as soon as possible. If they
can do so with IVF, then why not use this as Plan A
rather than as a fallback option when all else fails
? It’s well known that pregnancy rates with IVF
are much better for younger women than for older women,
so it’s much more cost effective to do it when
you are younger. It is true that doing IVF means spending
considerable money. On the other hand, not getting pregnant
has a considerable cost attached to it too – the
drainage of emotional energy and the time spent waiting
and hoping. IVF may be more cost effective and time
effective for many patients.
Equally importantly, IVF gives infertile couples peace
of mind that they tried their best - that they gave
infertility treatment their best shot. This peace of
mind can be priceless !
In the past, IVF was considered to be the treatment
of "last resort" - and was reserved for patients
who had failed all other treatment methods. Today, it
is often the treatment of first choice, because it maximises
the couple's chance of conceiving quickly, no matter
what their medical problem.
I feel the best option would be to allow couples to
choose for themselves. I can assure that I will never
let them make a wrong choice, but when there are options,
the responsibility for deciding depends upon then –
they cannot abdicate it to anyone else.
Everything in life comes back , but time does not –
and kicking yourself afterwards does not help !
“ For of all sad words of tongue or pen,
The saddest are these: "It might have been!"”
Why not do IVF when you are young and can enjoy your
kids, rather than regret not doing it when you are old
?
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