When talking about the different options in the field of assisted reproduction, it is almost impossible to enumerate all the available alternatives. There are lots of options that vary in their complexity, cost, and effectiveness. Not all are useful for everybody, and everyone doesn’t choose the same option — even 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 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 when making decisions could be dangerous. When we help patients to choose among the options, we should help them think 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 at blastocyst stage, MACS, preimplantation genetic screening (PGS), endometrial receptivity array (ERA), IMSI, time-lapse, elective single-embryo transfer (e-SET) or two at a time? It is just a short list of the decisions that every patient has to make in each fertility treatment. Making decisions when there are so many options is really difficult.
Having many options should be a good thing. The problem is that, many times, there isn’t enough time to fully assess which option truly fits each person. However, we, as doctors, have to take that time. It is very important to know about the clinical history of patients, to know if they have already undergone any infertility treatment, how those previous treatments went, and what they felt about them.
“We should know if their priority is to have a healthy baby, or if it is to make it happen soon, or in the simplest way, or in the most inexpensive way, or if their most important value is to use their own gametes.”
I know that everybody would like all of these things, but the priority is different for everyone. Everyone is different, and everyone has different preferences and values. Understanding those preferences and values will take us to obtain our shared 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 step into our patients’ shoes, to help them according to what truly matters to them.
At my office
One of the moments I enjoy most is when patients tell me what they want, what they would like to do — before I tell them what alternatives I can offer. I usually encourage 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 on the issues that are important for my patients. And sometimes I can also help them see some other things that were out of their focus, and bring them into the conversation. This way, it is easier to reach our shared objective — through a smoother process, paying attention to patients’ values, and helping them build new ones when needed.
