Transparency in IVF: Why We Share All Treatment Choices with Patients

In our clinic, we will often discuss the possible medical options in front of our patients with each other. Dr. Anjali and I will try to describe all the available choices because the truth is is there are no black-or-white answers to something as complicated as IVF. It’s important that patients be aware of what their options are - and why we've decided to suggest a particular option. Discussing this in front of patients actually gives them a lot of relief. They can see we are being transparent, and the fact that we are weighing the pros and cons of all the options reassures them that we have considered all possibilities, and then come to a conclusion that we think is right.

Because we do this in front of patients, it actually inspires more trust! Many doctors worry that if they discuss alternatives openly in front of patients, patients will feel that they are confused or are not sure what course of action to recommend. However, the reality is that patients are intelligent and they understand that there is no certainty in medicine. They appreciate the fact that the doctor is applying their mind; thinking about all the possibilities; and explaining all their alternatives to them. We discuss the risks and uncertainty in front of our patients, and by deliberately disagreeing, patients get a better understanding of the risks and benefits of each of their options. This allows patients to make their own well-informed decisions, because they have all the information they need, and the advice is not skewed or biased.

We prefer patients who apply their own minds, and we encourage patients to tell us what their personal preferences are so that we can incorporate this into the decision-making matrix. We also explain to them that while there may seem to be a lot of choices, many of these are theoretical, and not very helpful in real life.

Let’s look at the distressing situation where the patient ends up with a poor-quality embryo, even though the lab is high quality. Now we understand that the problem could be either with the egg or the sperm. The best way of finding out, on a purely scientific basis, is to do a split test. This is logical and rational, and we split the eggs and the sperm and fertilize half the eggs with donor sperm, and the other half with the husband's sperm, and compare the results.

Now this is all very well when you're talking about a mouse lab, but you can't really do this in a human IVF clinic. This means that even though we understand theoretically how to explore the different scenarios scientifically to come up with the right option, often this is not very helpful, because it's not clinically actionable information.

We explain to patients how limited our medical knowledge about IVF often is. There are still too many unknown unknowns for us to come up with simple answers – and we don’t like over-simplifying facts. We tell them how we could have theoretically analyzed the problem on a scientific basis, but given real-life constraints, the choices we can offer them are limited. We then give patients a “cooling off” period, to allow them to make their own decisions. Many patients appreciate our openness, and like the fact that we treat them as intelligent adults who are capable of making their own decisions for themselves. As professionals, our job is to give them a framework and allow them to be heard, so they can make a decision that feels right to them. This allows them to come up with a choice that they are happy with - after all, they need to live with the consequences of their decision!

Unfortunately, most Indian doctors are still very paternalistic and think they know what's right for the patient. This is not an approach we subscribe to, because ultimately all IVF care is elective and we are not mind-readers. Yes, we are empathetic and kind, but it's always the patient who needs to decide for themselves what to do because they're the ones having a baby. We are just facilitators who are helping them to achieve their goals. Unfortunately, some patients misinterpret our willingness to offer them choices. They think that we're confused, or we don't know what to do! The reality is that because we know what can be done, we're sharing our knowledge, and inviting patients to provide their inputs. We think this is a much healthier way of practicing IVF.

Authored by : Dr Aniruddha Malpani, MD and reviewed by Dr Anjali Malpani.