When talk about the different options in the field of the assisted reproduction, it is almost impossible to enumerate all the available alternatives. There are lots of options that vary in its complexity, cost and effectiveness. Not all are useful for everybody and everyone doesn’t choose the same option, still when they have similar clinical scenarios.
Patients’ values and preferences
Patients sometimes ask me: “if you were in our shoes, what would you do? That is a very good strategy to understand what the specialist would have chosen in a similar situation, but it doesn’t help to take a good decision. The reason is that decisions should not be taken based only on the best available scientific evidence or just based on the professional experience. Although these two aspects are necessary to make a good decision, they are not enough. We should consider patients’ needs and their available resources. Economical and emotional resources are very important. Although some only pay attention to the economical ones, emotional resources are also finite, and not considering them to make the decisions could be dangerous. When we help patients to choose among the options, we should help them thinking actively about their values and preferences, and about their resources.
Too many alternatives in assisted reproduction! Which is the best?
Intrauterine insemination (IUI) or in vitro fertilization (IVF), own gametes or donor gametes, high doses of gonadotropins or minimal stimulation protocol, fresh embryo transfer or freeze-all strategy, day-3 embryo transfer or transfer in blastocyst stage, annexin V columns (MACS), preimplantation genetic screening (PGS), endometrial receptivity array (ERA), IMSI, time-lapse, elective single-embryo transfer (e-SET) o two at a time? It is just a short list that I made regarding the decisions that every patient has to make in each fertility treatment. Making decisions when there are so many options is really difficult.
Last week, at the radio, someone said: “When I go to the restaurant, I like to receive a menu with only two options; if I see more options, I don’t know what to choose”. Having many options should be a good thing. The problem is that, many times, the waiter doesn’t have the necessary time to ask and assess us about the type of food that we like, how long we’d like to stay at the restaurant, if we have already eaten previously in that restaurant or if we were allergic to any ingredient. However, we, doctors, have to take that time. It is very important to know about the clinical history of the patients, to know if they have already undergone any infertility treatment, how were the previous treatments and what they felt about the treatment that they already did. We should also know if their priority is to have a healthy baby, or if their priority is to make it happen soon, or in the simplest way, or just in the most inexpensive way, or if their most important value is to use own gametes. I know that everybody would like all of these, but the priority is different for everyone. Everyone is different, and everyone has different preferences ad values. Understanding their preferences and values will take us to obtain their objective sooner. Asking and listening is a huge part of our job…one of the best parts of our job. That is the way we can be, for a while, on our patients’ shoes, to help them according to what they like.
At my office
One of the moments that I enjoy more is the moment when patients tell me what they want, what they would like to do. That is even before I tell them what alternatives I can offer. I usually stimulate them to think about their values and preferences because, even when they have never taken the time to think about them, everybody acts according to their own preferences and values. I like to focus in those issues that are important for my patients. And, sometimes, I can also help them to see some other things that were out of their focus, and bring them to the scene. This way, it is easier to get to our objective, in a smooth process, paying attention to patients’ values, and helping them to build new ones, when needed.