A thoughtful New York Times piece affirms CHR's belief in patient autonomy
When first confronted with the article under this heading by Nick Bhasin in The New York Times, we initially thought that here is, once again, one of those very difficult to read stories of somebody over and over trying to conceive for a very long time and, then, usually one of two things would happen: The woman either miraculously conceived (the “happy ending”) or the couple, out of either financial and/or spiritual exhaustion, found themselves forced to stop trying and give up on having a child (the “unhappy ending”).
What a surprise it then was to find the unexpected, starting with the author of the piece, which was not as usual the wife but, interestingly, the husband. The story was also not, as we expected, an endless sequence of failed in vitro fertilization (IVF) cycles but, often no less devastating for couples and no less challenging for physicians, five consecutive spontaneous miscarriages in a couple’s attempt to give their first child a sibling.
Do men write differently about the agony of failing to have a child than women? After reading this piece by Bhasin, it appears they do, and to a degree he also explained why: As miscarriages accumulated, he succeeded with every consecutive miscarriage to distance himself psychologically further from the idea of having a second child, a luxury, he felt, his wife did not have as a woman. In other words, not surprisingly, the impact of failing to successfully reproduce affects women and men apparently very differently.
Fortunately, the story had a happy ending in that a trip to Bali resulted in a sixth pregnancy that did not miscarry. It was, as Bhasin noted, “their final attempt,” and resulted in a five years younger brother for their older son after three years of failed attempts.
We are left with the question why did Bhasin, after ultimately succeeding in having a second child, headline his family’s story as he did with, “when to stop trying to have a child?” He and his wife really never stopped trying. Indeed, he also never answered the question he posed. Just because he and his wife declared to themselves that the Bali trip would be their “last attempt,” does not mean that, had it failed, they might not have changed their mind. We, here at CHR, see patients changing their minds following such “last attempts” literary every day.
It was this incongruity that attracted us to this article and especially to its heading because when to stop trying to have a child (through fertility treatments) is, indeed, a crucially important question for patients and treating physicians alike; yet it is almost never discussed in medical literature or lay press.
Though we, here at CHR, do not, and never will, pretend to be able to tell our patients how to live their lives, it appears timely to address this issue! There, likely, is indeed a (right) time for everybody when to stop having a child through fertility treatments. The problem, however, lies in the fact that this right time will for almost everybody be different.
If even husband and wife, as Bhasin so deftly described in his article, emotionally perceive fertility treatments so differently, how then can any third-party physician presume to know when this time has come for a woman or for a couple? We here at CHR, therefore, have come to strongly believe that it is not the physician’s responsibility to advise patients when to throw in the towel, whether it comes to giving up on using one’s own eggs or semen for donor eggs or donor semen, one’s own uterus for recruitment of a gestational carrier or whether one reaches the point of giving up on parenthood as a whole.
It, however, is the physician’s responsibility to provide patients in truly “merciless” fashion with the most accurate supporting information, so that they, with their own timing and in consideration of their own medical, social, psychological and economic circumstances, reach a decision that suits them best.
It all starts with quality of care. Coming back to Bhasin and his wife, it is not difficult to imagine the agony this couple must have experienced in five consecutive pregnancy losses after a quick and uneventful first pregnancy. But medically, this is not an unusual case. In medical lingo their circumstance is called a secondary habitual (or repeat) aborter.
And here are a few simple facts: Secondary aborters (i.e., women who start miscarrying after a first successful pregnancy) are very frequently immunological aborters. This does not mean that other causes cannot also contribute, but based on the clinical presentation of Bhasin’s wife, abnormal maternal immune function was in our opinion by far the most likely underlying cause for the miscarriages; and it can be treated.
We in this case know much too little about the female’s history, test results and treatments before the miscarriages occurred to further speculate whether anything else could have been done to help this couple earlier and better. But if there is one area that, as we repeatedly have pointed out in these pages, usually gets the short shaft even in excellent fertility centers, then it is reproductive immunology. It, therefore, really all starts with quality of care!
But should patients be “forced” into any infertility treatments?
Of course not! Every decent provider of fertility services will strongly oppose any form of psychological coercion on patients to undergo treatments they actually would prefer not to have. Yet, even though we have never met a woman who did not prefer conception with use of her own eggs, in daily practice women are constantly “forced” into egg donation cycles because either physicians, insurance companies and even at times governments, consider it appropriate to unilaterally declare use of the patients’ own eggs impermissible. The reasons are usually economical but can also be ethical in nature, as physicians often perceive themselves as the “protectors” of patients who must be saved from their own irrationality.
We here at CHR have a problem with such paternalistic views of physician responsibilities. As we said before, we do not feel qualified to tell people how to live their lives, nor do we believe that other physicians have those qualifications either, even if they, themselves, may believe so.
Unfortunately, “forcing” patients into selected treatments in association with IVF has gained in popularity in recent years: There is, likely, no more obvious example for that than centers that refuse patients access to IVF, unless they concomitantly agree that their embryos undergo preimplantation genetic testing for aneuploidy (PGT-A), previously called preimplantation genetic screening (PGS). CHR, of course, has been opposing the utilization of PGT-A/PGS for many years, but even proponents of this in our opinion expensive, useless and sometimes even harmful test, will have to agree that “forcing” patients to expose their embryos to PGT-A/PGS is ethically inappropriate.
In conclusion, when and how patients pursue fertility treatments, ultimately, should always be their own choice. Our contribution as physicians and other health care providers lies in giving them, unvarnished, all the information they need to make the best possible decision for themselves. When to stop fertility treatments, therefore, ultimately is always the patient’s decision!
This is a part of the May 2018 CHR VOICE.
Norbert Gleicher, MD, leads CHR’s clinical and research efforts as Medical Director and Chief Scientist. A world-renowned specialist in reproductive endocrinology, Dr. Gleicher has published hundreds of peer-reviewed papers and lectured globally while keeping an active clinical career focused on ovarian aging, immunological issues and other difficult cases of infertility.
DISCOVER YOUR TREATMENT OPTIONS
