Go for where the gold is - infertility, IVF and Sutton's law

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 !


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 ?


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

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