Infertility and a question of ethics, rights, choice and professional duty

**Updated - now with a poll at the end of the post - pls participate in the poll**

I have a friend; a wonderful, wacky, clever, in-touch, out there, together, crazy friend who has been trying to conceive for several years.  At this stage in her life, at her age, the odds of her conceiving with her own eggs are very, very low.  As in less than 1%*. 

She had been trying for several years when she went to a fertility specialist who told her, in no uncertain terms, that she would need a donor egg in order to conceive.  

Being the type of person she is, she told him, in no uncertain terms, that she knows and accepts that she has very little chance of conceiving with her own eggs, but it a chance she is prepared to take, and she would like to go ahead with an IVF with her own eggs anyway.

He refused, she stormed out.

She carried on trying for a few attempts (with another doctor), which did not succeed and is now ready to move on.

So here is my question.  Does the doctor have a duty to refuse treatment that is highly unlikely to succeed – as in less than 1%, or is up to the individual woman concerned to decide whether she is prepared to take that chance?

In the doctor’s defense – the odds of it working are extremely low, surely he has a professional obligation NOT to waste the patient’s time, his time and her (lots and lots) of money.  Would he not be regarded as irresponsible on many levels for going ahead with IVF treatment?

In the patient’s defense – surely it is HER decision as to whether she wants to take her chances with the treatment.  This is elective treatment, and she elects to do it.  She is educated, she is fully aware of the facts involved, but she still wants to go ahead.

I am torn. I see this often in my line of work in the egg donor program.  Women who are over 45, who are otherwise extremely healthy and fit, and would make great mothers, but whose chances are, statistically, extremely poor of an own egg IVF ever working.  And yet they want to carry on trying, they NEED to carry on trying until THEY get to the point where they are ready to accept either moving on to donor eggs, or giving up trying all together. 

On the one hand, I understand.  It is a process; and you need to do it on your own time.  If it takes 1, 2, or 10 attempts with your own eggs before you are ready to move on, then that is what it takes.  That process of being emotionally and mentally ready to move on has nothing to do with statistics and everything to do with the individual’s own internal processing.

On the other hand, I see doctors treating 47 year olds with their own eggs, and I think – what a rip off!  How can any doctor in their right mind take the patient’s money and raise their hopes when the chances are so very very slim. Surely that is immoral?  How can you take that chance, offer that hope and take their money on a 1% chance?

And yet, is it the doctor’s decision to make?

I know lots of doctors, especially in America where stats are so important, refuse treatment on patients over 42.  They are too scared to have the failures as it messes with their success rates. 

But success rates aside, my question is this:  Is the doctor right to refuse to treat a woman who chooses to have elective treatment like IVF, where the success rates are proven to be extremely poor, or is it the patients right to elect to go ahead with the treatment, knowing full well what the facts are. 

Her money & her body vs his professional duty?

What do you think?

PS any nasty comments that get personal, will get deleted.

Edited to add (based on your comments to date):

1. This is not an insurance issue, I don't think

2. There is no greater risk to the patient (other than the risk of miscarriage) than there would be with a donor egg IVF.

* For instance at 45, there is a one percent chance of getting pregnant at all and then at least a fifty percent chance of miscarrying.

For more information on Egg Donation / Egg Donors in South Africa, please view Nurture Egg Donor program www.nurture.co.za

Comments

[Peach]

I can only speak for America, but another thing to consider is the doctor's insurance.

For instance, I want to have my tubes tied, but my insurance won't pay for the surgery unless I meet certain "requirements" (must be 35 or older or have at least 2 kids, etc. - the reqs. change depending on the insurance). Now, I can choose to have the surgery as "elective" surgery, but then, the problem is finding a doctor whose insurance will cover him to do the actual procedure. Because the doctor's insurance also has requirements that must be met before they will cover him to perform the surgery. And, as a side note, I've yet to find a plastic surgeon in this area who is skilled in a tual ligation, so on I must wait to have the surgery *sigh*.

So, it's possible that some doctor's insurance will not allow them to perform certain things unless certain requirements are met. I would hope if that were the case the doctors would inform the patients thusly (as my doctor explained to me).

[Marna Gatlin]

So here is my question. Does the doctor have a duty to refuse treatment that is highly unlikely to succeed – as in less than 1%, or is up to the individual woman concerned to decide whether she is prepared to take that chance?

My answer: No, if the patient knows her odds clearly and the doctor has been clear to her then the patient has the right to undergo treatment as long as it's not harmful to her. (i.e. transferring back eight embryos etc...)

Many women in the United States that can afford it try over and over and over with their own eggs when it's clear they need to be headed down the donor egg route in the event they want to ever get pregnant, and carry a pregnancy to term.

If this doctor who this woman clearly trusts won't treat her, she will go find another doctor who might not have her best interest in mind. Patients find the doctors who will treat them even if its to their own detriment.

It's all about being upfront and clear with the patient.

[Tertia]

As far as I am aware, it is not an insurance issue.

[Kim]

I don't know what the risks are for and IVF or IUI cycle are at that age but I think if there are significant risks involved it would be irresponsible for a doctor to allow a patient to take that risk when there is virtually no chance at success. Also, I can appreciate that a doctor would have ethical concerns about making money off a procedure he knows will not produce the desired results for the patient. I really can appreciate how your friend is feeling but I think I am definately going to have to side with the doctor on this one.

[Anna]

Wow, Tertia. This will stir things up.
I am not a doctor, and I think the issue should be looked at from the point of medical ethics, i.e., doctors, please step in here and leave comments.
Anyway, if I were being treated for a disease, I would expect a doctor to treat me in the most effective way, i.e., if medicine -A- had a 1% chance of helping me, and medicine -B- had a two-digit chance of helping me, he would not be doing his job if he gave me -A-. And if I went to see my doctor and asked him to do an unnecessary procedure on my body I would expect his ethics from preventing him to accept the job. One thing is an elective treatment (still a treatment), one thing is, say, removing one's healthy leg.
I believe it is a doctor's duty to recommend the most effective treatment, and alternatives too if there are any. However, a 1% chance statistically is not an alternative, unless you are dying and there is NO alternative. If the chances are really 1%, then your friend's doctor is being honest and ethical and doesn't want to play with your friend's body for nothing. I think she is not being rational here, for obvious reasons, and the doctor who refused treatment is a good professional.

[Kristin]

I think as long as the doctor is brutally honest about the chances of conceiving, there is nothing wrong in proceeding if the patient wishes to.

[Pia]

I think that the doctor has a duty to fully explain the risks and the percentages of success. But if a woman can pay and wants to proceed. Then, that's her call.

Unless the doctor feels that some psychological intervention is appropriate, he cannot interfere with the rights and wishes of the patient??

[princessoftides]

In this case, which is elective and not life-threatening, I think it is absolutely the woman's choice - if she can pay for it, the doctor should not refuse treatment. HOWEVER, it is the doctor's responsibility to make ABSOLUTELY sure the woman truly understands how low her odds are, and how much higher the odds would be with alternative treatments.

That said, much as I think it's an inalienable right to spend one's own money on low-odds elective procedures, I don't think it's an inalienable right to spend someone else's. And since insurance costs are spread over an entire insured population, I do think insurers - whether public or private - have a right to (and probably should) limit coverage to a certain number of tries.

[apieceofwood]

Difficult one.. going through this myself, i can see both sides, I know we and probably most people have to get to the point of acceptance, but the Doc has a responsibility to point out the facts.. Still think as long as it doesn't cause harm to the individual and they are funding the treatment, it's their right to choose.

[Femi Olarogun]

There are different levels of "success" for a patient. For some patients trying even though with negative results is an end point and they need to reach this end point to be satisfied.. Personally I give the patient the odds and the options as well as time to think about it and if they still want to then would try one cycle the response to which would be another way to prove to her the fact that it is unlikely to work

[Tertia]

PS Dr Olarogun above is a Fertility Specialist. Thanks Dr Olarogun for popping by and adding your thoughts

[millie]

Actually in America they split out the stats by age group so someone who's a lot older won't adversely affect clinic stats. I think the SART groupings include under 35, 35-37, 38-40, 41-42 and 43-44 are not shown unless you specifically look for it. So if clinics are saying they are refusing because a patient is messing with their stats, they just don't want to offer treatment to that patient.

Having been on the very low odds side of the table (even when I was a much more respectable 37), I think that it's the ethical responsibility of the doctor to discuss the numbers and percentages, including cancellation rates and guidelines, and let the patient decide. I think it's detestable when clinics refuse treatment and not allow the patient to decide.

Even in cases where insurance is a factor, I think there should be some treatment covered (at least up until 423 or 44) and then patients should be allowed to self-pay if they desire.

[Haitian-American Famiy of Three]

Hmmm, I think its her body, her choice. She is well aware of the chances and why can't she try if that's what she desires?

[Kathy B.]

In my opinion, any doctor has the right to refuse elective treatment for anything for any reason.

[Amy in AL]

My 41 yo friend was refused treatment from our only local RE. She went to another city 90 miles away and went through a couple of test cycles, i.e. they stimulated her to see what her ovaries would do. They did nothing. After a couple of test cycles, she accepted donor eggs and is now in line to try IVF w DE this spring.

I think women have to be given the opportunity to try, just to see, but if their ovaries do very poorly, the doctor should call off the cycle. My friend would have never accepted donor eggs without making sure she couldn't have her own genetic child first.

[bad penguin]

I think as long as the doctor has been honest and upfront about how awful the chances of success are, if the woman wants to proceed, she should be able to do so. As long as it isn't going to harm her physically to try, why should he turn her down?

I don't think donor eggs are right for me, although who knows, I haven't actually gotten to try or fail at IVF yet. We'll see how I feel later this year if I'm not successful. I do know I'd be FURIOUS at any doctor who told me I couldn't even try with my own eggs, as long as there was a chance at success, even a miniscule one.

[Rachel]

I think it is the Dr's professional choice. I can see why she would want to try, but I think with such a dismal chance at success, I can see why the Dr. would refuse to try.
I think he could let her have a go at it, just to prove his point, but I think he is just trying to be kind and save her time/money/and heartache.

[amber]

the onus is on the patient as long as a few conditions are met by the doctor:

1) doctor has educated patient on the reality and does not raise false hope.
2) doctor gives his/her professional opinion.

if the doctor does those things and the patient wants to go ahead it is up to her.

doctors do take an oath to do no harm, so, i think there would be some grey area if the treatment would have a negative impact on the health ot the patient to the point where the doctor felt that performing the treatment, even with informed consent, would be negligent on their part. but, as you said, that is not the case here.

it's an elective procedure, that won't hurt her physically, it's her choice. similarly, i think that doctos should also not try to stop young and/or childless people from getting surgical sterilization. as long as they know what they're doing, it's their body, it's their choice.

[Jill]

I had a less than 1% chance of conceiving on my own. After 2 failed IVFs - I did just that - TWICE.

I think the patient has some say in the kind of care they want.

[HappyGrl]

If she's aware of the reality and prepared to pay for it, no one has the right to tell her what she can do with her life, her body and her money. People try to climb Everest all the time - and some die doing it - they know the risks and guides accept money to help them do it. Why should it be any different with medical treatment?

[k.]

I have been in this position personallY, which explains my very strong feelings. The issue of doctor's stats( success rates) cannot be excluded from any discussion around this point because that is what infertiles study when looking for a doctor and how most doctors market themselves. No it's not the doctor's choice to decide for the woman in my opinion. It's her choice and she is now at the point where she is ready to look at other option. The 'what if' in her mind is now resolved, she had to go through the process in order to be comfortable using docor eggs or giiving up. I think it's her money and it's her dreams and it's body = HER CHOICE.
She has the right to herself, her partner and her unborn future children(hopefully) to get to teh point where she is satisfied that she did everything in her power to make the best decision for herself and her family.

I think that the arrogance of doctor's always presuming/knowing what is best for a patient is sometimes overrated, especially in this area.....sorry, I do feel that this is an elective procedure and so much is also in your head and your heart!

[L.]

Am not IF myself. First of all, I assume that she is paying for the attempt; if other people are (i.e. insurance) then I feel more caution is justified. Second, I do believe there is an age at which it would be a complete waste of resources (time, money, energy) and at which the patient really needs to be told no regardless of emotional investment--say, just as a random number, 60. Actually for me that number would be lower, but I don't know enough about the statistics (likelihood of conceiving) to draw a line. Probably it would be situation-dependent.

When the chances of conception are age-related that also brings up questions for me about the potential baby--your ability to be a good parent, and also I believe there is a moral obligation to consider the risks to which the baby might be exposed, if there's a possibility they could be significantly increased in the late term or postpartum.

Taking money and outcomes for the child out of the equation, I feel it's up to the doctor. Either outcome (doctor saying no or yes) does not strike me as a huge ethical issue or infringement.

I find the amputated-healthy-leg analogy above very interesting. I think most of us would say that would be a wrong surgery to allow, but the question is how that differs from your scenario. I suppose because it is a permanent change that would cause disability? IVF can be hard but there are no permanent risks attached from what you are saying. Not to mention that there is a possibility of a positive outcome, no matter how slim. I suppose the trouble is that a very slim probability of a positive outcome will always exist for most IVF patients. It must be very hard to turn an emotional corner when you always have that number, no matter how small, beckoning at you and telling you there is a chance.

[k.]

sorry my passion precluded checking for spelling mistakes....

('docor eggs' should read donor eggs, the rest you'll probably figure out!)
SORRY!

[The Cape House]

I think the doctor is obligated to fully disclose all of the risks and chances of success given the patient's circumstances. S/he should also then give his or her personal opinion on what the patient should do. The whole, "If you were my sister..."

After that, insurance issues aside, I think it's up to the patient to decide what to do, and the doctor should do it since, as you said, it is part of an emotional process. The patient may need to go through with it for her own emotional healing which is a part of mental and therefore overall health.

Now, regarding the woman from California who just had octuplets via IVF, I think it gets really iffy when you start talking about doctors being allowed to refuse to perform an elective procedure based on their own beliefs or moral grounds. Obviously, all doctors must perform procedures that are critical to the health of the patient. When you're talking elective procedures, however, I suppose a doc could refuse to do it and willingly lose that patient and money. There doesn't seem to be much the patient can do about it.

If they're so concerned about success rates, there are tons of ways for a clinic to arrange its stats. They could break it down into age categories so, for the younger couples, they could still have good success rates to boast about. If we're speaking strictly in terms of supply and demand economics, then the doctor, working in a private organization dealing with non-critical elective procedures, is completely within his rights to deny his services just in the same way that patients are allowed to shop for the best providers. I wonder though, if a mental health practitioner could order an ART doc to provide services in the interest of helping the patient move on emotionally. What a scenario.

I think it's also an iffy issue when you talk about elective procedures which may then put a patient's health at risk. For example, a woman has known conditions that would cause serious health problems were she to become pregnant. Should her doctor help her achieve a pregnancy knowing it may be severely detrimental to her health? If he gives her all of the info and she wants to go ahead, should he respect her decision? Or is that grossly irresponsible on the part of the doctor and he should put his foot down in certain circumstances? (See octuplets, single mom of 14)

But then, a woman who can achieve a pregnancy without assisted technologies can become pregnant on her own even if her doctor advises her against it. Why should an infertile be "held hostage" to the decisions of a doctor when a fertile wouldn't be?

I don't know. I'm very pro adoption so I have a hard time understanding why people go to such extraordinary lengths to have children.

Regardless, there are so many doctors around who will perform elective procedures if you're willing to provide enough money that, if you REALLY want it, you could probably find it (See surgery, plastic).

thanks for the soapbox!

[The Cape House]

Sorry, one more thing. Should the doctor make it policy to refuse treatment for patients with less than a 1% chance? 5%? 10? Where does he draw the line?

[The Cape House]

I think the doctor is obligated to fully disclose all of the risks and chances of success given the patient's circumstances. S/he should also then give his or her personal opinion on what the patient should do. The whole, "If you were my sister..."

After that, insurance issues aside, I think it's up to the patient to decide what to do, and the doctor should do it since, as you said, it is part of an emotional process. The patient may need to go through with it for her own emotional healing which is a part of mental and therefore overall health.

Now, regarding the woman from California who just had octuplets via IVF, I think it gets really iffy when you start talking about doctors being allowed to refuse to perform an elective procedure based on their own beliefs or moral grounds. Obviously, all doctors must perform procedures that are critical to the health of the patient. When you're talking elective procedures, however, I suppose a doc could refuse to do it and willingly lose that patient and money. There doesn't seem to be much the patient can do about it.

If they're so concerned about success rates, there are tons of ways for a clinic to arrange its stats. They could break it down into age categories so, for the younger couples, they could still have good success rates to boast about. If we're speaking strictly in terms of supply and demand economics, then the doctor, working in a private organization dealing with non-critical elective procedures, is completely within his rights to deny his services just in the same way that patients are allowed to shop for the best providers. I wonder though, if a mental health practitioner could order an ART doc to provide services in the interest of helping the patient move on emotionally. What a scenario.

I think it's also an iffy issue when you talk about elective procedures which may then put a patient's health at risk. For example, a woman has known conditions that would cause serious health problems were she to become pregnant. Should her doctor help her achieve a pregnancy knowing it may be severely detrimental to her health? If he gives her all of the info and she wants to go ahead, should he respect her decision? Or is that grossly irresponsible on the part of the doctor and he should put his foot down in certain circumstances? (See octuplets, single mom of 14)

But then, a woman who can achieve a pregnancy without assisted technologies can become pregnant on her own even if her doctor advises her against it. Why should an infertile be "held hostage" to the decisions of a doctor when a fertile wouldn't be?

I don't know. I'm very pro adoption so I have a hard time understanding why people go to such extraordinary lengths to have children.

Regardless, there are so many doctors around who will perform elective procedures if you're willing to provide enough money that, if you REALLY want it, you could probably find it (See surgery, plastic).

[Shandra]

I think there's a difference between a risky procedure in terms of the health of the mother &/or child/ren, and a procedure not likely to be successful.

So, I guess I think doctors should go for it if it's not going to harm the patient (within the usual parameters of risk). In this case I do wonder if there are concerns about the potential child, but I don't know enough to really say.

[Sarah]

I think it is the woman's right, and the doctor can set a limit (i.e. I'll do 3, we'll shift the protocol etc) and then after that, you need to consider DE or moving on. But I don't think it's unethical, but think that doctors can act unethically by not informing them of their chances. I also think there should be much more work done,with therapists, about how to face the sense of annihilation that accompanies ending an IVF with your own eggs, journey.

[Jen]

A mechanic can refuse your car. A stylist can refuse your hair. A doctor can refuse a patient. Period.

In the same sense, she absolutely has a right to try it her way no matter how remote the chances of success, but she'll have to find a doctor that agrees.

[Andrea]

You raise an excellent question. The one flaw I see in your argument -- and this is coming from soneone who is very skeptical of doctors -- is that statistics, almost by definition are usually wrong. Statistics reflect averages and most people are not average. You can have a 20 year old and a 40 year old and their average age is 30, yet no one is close to 30.
Now, I do understand that fertility declines with age, and yes, I do think doctors should counsel their patients about that. However, in my experience, they based everything on age and did not consider other factors. A good friend of mine who was age appropriate but would not respond to even five times the usual amont of stims, was given repeated treatment. Other "older" patients with much better profiles were told to give up.
I certainly think doctors are irresponsible to provide false hope. On the other hand, I wonder just how many people out there who were given a 1% chance ended up conceiving. Likely more than 1%.

[threeminutepalaver]

I think Drs always have a right to refuse to do an elective procedure if they don't agree with it for whatever reason and patients always have a right to find a new Dr and leave their old one for whatever reason. we don't have to stick with one clinic/dr and they don't have to do what we ask of them if they don't want to.

[Jo]

Infertility is NOT A CHOICE, it is a disease. So in my view this isn't elective surgery, it is the only CHOICE this woman has to hopefully become a mother. The doctor shouldn't make that decision for her.

[Diana]

I just find the timing of this question interesting with the single mom in California giving birth to her IVF octuplets in addition to her other 6 kids through IVF. That's 14 kids, all through donor sperm, for one, single mom. I've really been wondering about the responsibility of the doctor in that case. I'm trying not to be too judgmental, but it's hard.

My husband and I had one failed attempt at IVF and the doctor told us our chances were very low of it ever working after that. We really struggled with the ethics of trying again when we knew the chances were so low- all that money spent when it could be going somewhere else (only in cases where the chances are slim to none. Obviously a child is priceless). I would love to say it's the woman's/couple's choice and if people have the money to do it, who's to say they can't, but it is hard to think of all that money potentially being wasted when it could be used for other purposes (a wonderful experience with adoption in our case and now adopting a second).

But I know how strong that drive is to have children and people do beat the odds. . . Great questions to ponder.

[Amber]

I was a patient at a very good, large, well respected clinic on the east coast of the US. I got pg on my first cycle there (3rd over all) and had a little boy. I did 5 more fresh, and 3 frozen, in an attempt to get a sibling. Ironically, i finally got insurance coverage for what would be my last cycle.

When that last cycle failed, my wonderful RE told me the only way he would cycle me again was if I used donor eggs. I still have enough insurance for 2 more cycles. it does not cover donor eggs. This did not matter to the clinic.

It's a business. And I am bad for their stats.

I have no hard feelings. I understand. I just wish...it would have worked one more time.

[Dora]

I cycled with my own eggs at 45. It took FIVE cancelled cycles before I was finally able to get to retrieval and transfer. I was cancelled 4 times due to cysts, and once after 7 days of A LOT of stims and no response at all. Still, my RE (at one of the top 3 NYC clinics) understood my desire to get through a complete cycle before moving on. My chances were less than 5%.

After the cycle cancelled after 7 days of stim, I had phone consults with REs at 2 other clinics. They both told me they didn't think I'd make it to retrieval, but understood that I needed to try. I wound up having 2 eggs retrieved from 4 follicles. 1 fertilized and I had a lovely 11 cell, grade b/c embryo to transfer on day 3. But a 45 year old egg is a 45 year old egg. I did not get pregnant, but I was much more at peace with moving on.

In 2 weeks I will be having a donor embryo transfer. This is a directed embryo donation, and my donor and I couldn't be more thrilled about our connection and what we are making happen. I couldn't get to this place overnight. Now that I'm here, I'm imagining my scrumptious redheaded baby, like my donor's beautiful children.

Sorry to go on so long, but as a 45 year old hoping to get pregnant in 2 weeks, I really related to this post.

[a]

I think fertility doctors have the right to refuse treatment, if the patient is clearly ignoring their advice. I don't necessarily think it's about stats either. Insisting on a particular course of treatment may be a red flag of a mental state that the doctor does not wish to deal with. For some, it may indicate craziness. For others, it may just be a determination to get to an end point. But it's probably hard for a doctor to tell which, and so he (ethically) refuses to treat the crazy person, but by collateral damage also refuses to treat the determined person.

[queermommy]

hey t.
have you heard about the 60yr old woman in Canada that just gave birth to twins?

http://www.cbc.ca/canada/calgary/story/2009/02/04/cgy-twins-60yearold-mother.html?ref=rss

lots of questions regarding care, esp. since she conceived in India after doctors here wouldn't treat her. and now the health care system here must cover the expenses of their nicu stay. haven't read all the details but wanted to send it along.

[Paz]

I was 43 when I conceived naturally after a handful of miscarriages. At 44, I had a healthy boy. I shared the odds of your friend. The odds, the statistics do not represent the individual. My 32 year old friend was given the donor egg speech. She now has twin boys via IVF donor. Neither of us fit our age profiles.

The doctor has the obligation to help a patient, but if a doctor refuses, then I think your friend should count herself lucky to move on.

But she has the right to try to have a child in the way she wants.

One last thing. I believe in my heart that no matter how you become a mom, once you are there...you are a mom.

Best of luck to your friend.

[amy]

I actually sort of respect the doctor. He laid out what he saw to be true and stuck with his beliefs. He could have followed her wishes and made more $$ off of her but he chose not to. She had the choice to seek out another doctor who would do the procedures and did.

[Flicka]

I think it's a balance of both, which is how it worked out for your friend. A doctor must behave as ethically as he possibly can; i.e., he must live up to his own ethical standards. One doctor may truly believe that it is wrong to do IVF for a patient with your friend's stats. In that case, I do believe it's the doctor's choice to refuse to do the procedure. Another doctor may feel that it's worth a shot and be willing to cooperate. It's that way with any medical procedure (in the USA). If the doctor feels it's too risky to perform, he doesn't do it. If you feel differently, you get a second opinion, or a third, or a fourth until you find someone who agrees with you.

IVF gives the illusion of control over an uncontrollable situation. It becomes addictive to think "Just one more try." Sometimes it takes a person outside the situation to make a decision that you just can't make when you're in it. And a doctor is probably in the best position to do that. And I do think in some cases it will take a doctors "no" to help a woman realize that she's far transgressed reality and is only hurting herself.

I say what I say with a humble heart, having been there, having traveled a road where IVF (the only thing I really wanted for a long, long time) was completely out of my reach because my husband wisely determined it would ruin us financially. I resented him for so long but I can see now that I needed him to make that decision for me. I was incapable of making it myself.

xx
Flicka

[MLO]

As long as the woman (or couple) has been apprised of the realities around their chances and there are no risks that would be outside the normal standard of care, the doctor should not be allowed to choose. He or she, if uncomfortable, should be prepared to refer a patient to someone who is more willing to treat that particular issue.

Too many physicians are way to blithe with donor eggs. For some, donor egg will never be an acceptable alternative due to religious, ethical, or complex emotional concerns. For some others, cultural and religious mores make adoption a non-option. (There are religions that do not allow adoption.) There are also growing ethical and legal concerns surrounding the adoption industry. The Hague Convention has unmasked fraudulent activity running rampant in some countries' programs.

In the USA, and most of the western world, there has been an unfortunate tendency to allow physicians to be treated with deference when it wasn't warranted. I'm lucky in that my great grandmother and other relatives counterbalanced that by considering all MDs as no better than quacks. I don't think that, but I have a hefty dose of skepticism about what physicians tell me and know how to use Medline.

The octuplet mom should not be used in these discussions as her history contraindicated transferring more than 1 embryo by the current standard of care - and any US clinic should be prosecuted to the fullest extent of the malpractice laws by the state of California. What was done there - if reports are true - was outside the standard of care. Honestly, even the newest reports make me more convinced that she is more a poster child for the failure of Mental Health Care in the US than anything surrounding fertility treatments.

These are complicated issues. There are doctors who seem to have a knack for making the "impossible patient" pregnant - Dr. Jerome Check in New Jersey - but even he has probably told patients there is nothing more he can do for them. (Do a Medline search on some of his case studies - its rather amazing.)

An individual doctor should be able to say to a patient that they cannot help them - but they should be prepared to give them a referral to someone who may be able to. Just as we have specialists in areas of medicine, there are subspecialties within specialties. Some doctors do better for PCOS patients, others for High FSH patients, while others are expert at dealing with uterine issues. Sometimes it takes a woman or couple going to a multitude of physicians to create an environment where a pregnancy is even possible.

Ok, I'll stop... I should probably just write a blog post about this.

[victoria]

to the poster above. Adoption is not simple. I too am pro adoption but find that it is a very difficult process (partner and I live in different cities for job reasoins). One question no one has discussed, some women go into debt to do these treatments, should the doctor treat her and let her go into debt and possibly not have the money to do DE when she finally wants to? The money here makes a huge difference, unfortunately, witness the different attitudes between women who have insurance coverage and those who don't.

[Heather]

A woman in Canada just gave birth to twins at age 60 yesterday... but I'm not sure if fertility treatments were involved or whose eggs might have been used. Excellent question for debate!

[bj]

My understanding was that for older women the chance of conceiving with IVF (with their own eggs) is no better than with just having sex. If so, doing IVF would be like selling snake oil, when they could just let them drink the free water (assuming the woman has sperm available to her). So, the 1% (or whatever) chance isn't the right question, it's how much IVF increases your chances of pregnancy.

[lolismum]

The doctor can draw the line anywhere he sees fit. So does the patient. As you said, this is elective medical care, not life-saving medical care. He is no different from some other professional providing a service. If he thinks providing that service messes up his stats, or puts him in a ethically difficult bind, or simply becomes a service not worth the cost, he has every right to refuse it. If your friend went to a doctor, let's say, for some elective plastic surgery, removing some scars lets say and the doctor refused to do it because the procedure is very unlikely to remove the said scars, we would not even be discussing it. You mention infertility and a lot of people simply judge it by a different standard and it should not be so.

[Adi]

I think a doctor has a right to refuse treatment, whether others consider it reasonable or not. I don't think all doctors would refuse treatment for the same scenario thought, and I hope she finds a doctor that is willing to assist her, without just wanting to cash in on a cheap IVF that has high probability of not resulting in a transfer (which I think this doctor is probably trying to avoid, in good ethics).

I wonder if she would at all be open to considering starting the IVF together with a donor, perhaps someone that is donating for another lady, but all three of them are in the same cycle (or is she really not interested in a donor at all?). So if her eggs fail by d3, she may have the option to complete the IVF with donor eggs on d5. Sorry, this is a long shot and sounds like a massively complex organisation, but it is just a way of meeting both parties' concerns halfway. And if anyone can make it happen, it is you. I doubt if a fertility clinic would go through this type of complexity and its possible failures and heartaches.

I'm so sorry for your friend though. I have sometimes felt like throwing the heaviest book ever published over a FS's desk in anger. I have seen 3 FS's - and (perhaps not physically, but virtually) stormed out of all of their rooms in frustration. She must be going through quite a rough time. :(

[Gabrielle]

Kim,

I think I agree with you with the time and percentage thing. However, I think it must also be horribly painful to have that one chance taken away again.

I think if I were the doctor, I would have done the same thing. And if I were the patient, I would have done the same thing.

And when you're not dealing with a life-or-death situation for the patient (as opposed to say, a heart patient who only has a 1% chance of surviving a surgery but it means 5 more years on his life or dying in 2 months) I think the doctor's professional judgment needs to be taken into consideration.

Not a very helpful argument, but my .02.

[Nicola]

I think it is ultimately her decision to make. But that goes against my strong opinion regarding doctors who allow eight (eight!!!) embryos to survive in a womb. I feel that, in that case, the doctor has an ethical responsibility to ensure that this does not happen. But who am I to say? How many embryos are "OK" the? 2? 3? 4? Why not? If a 46 year old women should be allowed to have fertility treatment, shouldn't a young, healthy women (unemployed with 6 other kids, sure) be allowed to have 8 babies? Why do I support choice of women in one situation, and obligation of doctor in the other?

[Gabrielle]

Forgot to say: a professional's judgment needs to be taken into consideration in an ELECTIVE procedure.

[jacki janse van rensburg]

oh my! as usual, the comments section of your blog is the most interesting part. :-) sorry tertia, but you do seem to be able to bring out a lot of interesting opinions here...

one thing that has only been touched apon here, is the psycological issues for the woman. what would be worse for her: trying everything, and failing? or not trying everything, and forever wondering? i think each case would be different there. regardless if the doctor refuses or helps, and regardless what the outcome is, i think she, and her husband, should go for some psycological counselling. it should be a pre-requisite.

i also think any doctor is well within his rights to refuse any patient any treatment, except if the patient's life is in immediate danger and he is the only one who can save the her. otherwise, i think he doesn't have to treat anybody he doesn't want to, for whatever reason.

so here i side for the doctor, not because i think your friend is wrong at all, but because i think the doctor may refuse if he choses to. but i feel for your friend, and i wish her many blessings!

[Paula Eyal]

I am a doctor (pathologist not fertility specialist, as well as recovering infertile post IVF) and in my opinion, the patient has the right to choose her treatment, after having been thoroughly advised on her chances for success, as well as all the aspects of the procedure. We are encouraged in med school to move away from the paternalistic you-will-do-as-i-say model towards a more patient-driven model, and especially in the case of infertility treatment where the emotional aspects cannot be ignored, the patient's choice should be respected. Having said that, in this type of senario I think the doctor should go out of his/her way to councel the patient properly. If he refuses she will in aby case just move on to another doctor. One should also not compare IVF treatment to other elective procedures which should definitely be refused by the doctor if not specifically indicated but requested by the patient.

[Jenny]

It would be a sad day if doctors only decided to do things that worked. If I only had a 1% chance of curing a cancer, the doc would take that chance surely? I think there must be other reasons they refused...

[Kerry]

This post comes at the perfect time in my life, and will be very long winded. I am 41 to be 42 in April of this year. I have 2 children son- will be 16 next month and a daughter - 11. They are my children from my first marriage. After my divorce I was a single Mom for 9 yrs. I have been remarried for a little over 2yrs. New husband has no children. We had an ectopic pregnancy 3yrs ago. Tube was saved. Spent the last 2 yrs seeing an RE for fertility treatments. Started out with injectibles with timed intercourse because my insurance covered this 100%. After 4 cycles we moved onto IVF last Jan 2008, a BFN. Using donor eggs was mentioned last Feb 2008, but I was not ready. Had Lap. surg. in April 2008 as I was having pain in right side that ectopic was in. Diagnosed with SIN (salpingitis isthmica nodosa) basically my rt. tube was shot even though HSG showed it was clear. June 2008 I had right tube removed as it caused constant pain and increased my chances of another ectopic preg. Recovered, started injectibles with timed intercourse in Sept 2008. So far nothing. I am a good responder with a low FSH, etc. All 7 eggs fertilized and divided during IVF last year, but did not implant. RE seems to think my eggs make the embryo just run out of gas and stop dividing. I am in the middle of our last time doing injectibles and timed intercourse. RE said he was willing to do IVF again if we really wanted, but he said he felt the outcome would be the same - BFN...he said my age is catching up with my eggs and he would prefer to help us be successful and would I please consider donor eggs after this cycle. He said he just felt like he would be taking advantage of us by taking our money with such slim chances. I cannot explain how different I feel this year compared to last year at this time. I am sick of needles in my belly, I am tired of looking at ultrasounds of my ovaries and empty uterus. I am tired of being sad, disappointed etc. every month. I want this cycle to work, but realistically I know it probably wont. Last week I had a moment of clarity...I just want to be a Mom again. We will be pursuing donor eggs if this cycle doesn't work. I will tell you I was hurt and insulted when RE mentioned donor eggs again, I didn't want my body to fail me. I went home with the promise to mull it over, I took a nap and woke up knowing donor eggs are right for us our next go around. Personally I feel that my RE has an obligation to look out for my best interest and not take advantage of us in any way. I believe he is doing just that, he knows how hard this has been for us and he really wants us to have a baby and believes that he is doing the right thing by trying to increase our chances of success. Ok, this was really longwinded, and not sure if it even answered the question. Ultimately I believe the Dr. has a right to refuse elective treatment of a patient if he feels uncomfortable with the treatment for any reason. It is our right as a patient to search out another Dr. if we do not agree.

[Maija]

What are the risks involved in IVF, to the patient? I had a friend who went seriously hyper during the treatments and nearly died. Something to do with growing the eggs... (sorry, I really know nothing of IVF). I suppose, if it's about balancing the risks (complications) and potential benefits (baby), then if I was a doctor and thought there was more risk of complication (even the normal day-to-day risk involved in any kind of treatment) than probabability of success, I would have to refuse treatment or at least have the patient sign a paper saying they're doing it against medical advice... tough one. I'm thinking, though, that doctors come up with judgement calls all the time. I'm refusing to answer the poll, though!

[caragh]

In all honesty, If I was her doctor, or another doctor I would not treat a women who was over 45 if she only had a one percent chance of getting pregnant.

Its not only the slim chance, but its the emotional toll it would take on on the paitent as well.

With the event of miscarriage, birth defects I just personally wouldn't feel comfortable.

A doctor is a person too, that person who has to live with the choices he makes.
If he does 5 IVF's with her own eggs at 1 % chance, it would probably take a toll on him as well if they continuously failed, or a miscarriage or birth defect occured...

I'm just saying and seriously no judgement to anyone.

[goodsandwich]

Individual doc has the right to refuse to treat in a manner s/he feels will almost certainly be no treatment at all. One is not a doctor but a charlatan if one just does a treatment that a patient really really HOPES will work.
Still and all, I would always hope that any RE would be very sensitive to the real emotional needs of a couple in your friend's position. And I would hope the doc could refer her to someone who WOULD be OK with doing her treatment of choice.

[Heike]

Hi there

I have just read this article, and I feel that these doctors that performed this IVF procedure, and all proceding ones totally unethical. Just for 5 minutes of fame? 13 kids all under the age of 7, mother is single and has no money WTF????? I applaud your friends doctor, and think at least he had the "balls" to be honest!

http://www.dailymail.co.uk/news/worldnews/article-1137273/I-wanted-huge-family-Mother-octuplets-speaks-time.html

[Leigh from 123 blog]

Tertia, I said yes because it is the ethical thing for the doctor to do.

I only wish we had more doctors that were prepared to be unpopular and do the right thing.

[Kirsty]

I am a physio, just moved back from the UK, so studied UK medical ethics, and this is what I perceive to be the correct ethical answer:
A medical professional can only ever advise a patient on what the best current research and practice guidelines shows. They have to remain impartial, cannot offer their own opinion - just give them the facts and let the patient make their own INFORMED CHOICE!
So, ethically, he should have just given her the facts and figures and gone with what she wanted. ESPECIALLY as it is PRIVATE healthcare. Had it been in the public sector, with less than a 1% chance of success, he would have been obliged to say no to treatment, as it is clearly a waste of taxpayers money. However - this was private, and he should not have rfused treatment. I guess he was worried about his clinics success stats and that is why he said no. Which is also morally incorrect! Unless the treatment is life threatening,it should always be done!

[LL]

Personally, I am grateful that my RE explained my statistical odds, gently offered DE in case I wanted to improve those odds, and let me make the final decision.

Between ages 43-45, I was able to transfer 1-2 high quality embryo each cycle I tried. After a year and a half of ttc with IVF (and one ectopic pregnancy), I became pregnant for the first time at age 45.0 on a cycle with one egg retrieved/transferred. I am now 31w with a little girl.

Are the "odds" truly as grim as most doctors say? I'm not sure. My family is very thankful for Cooper IVF in NJ, however!

[Tenacious]

Hi T, wink wink! I'm thrilled to see that the woman's decision is trailing only slighly in your poll and by the end of the day, I'm sure it will have overtaken the doc's decision. I would assume that the majority of votes pro the doc are women who have already been blessed with their own children and never reached the TTC over 45 bracket. I am nearing 48, extremely fit and healthy, look far younger than I am and know that I will soon be pregnant! I have had 4 miscarriages (41, 42, 44 and 45 -all within the first 12 weeks). Three were natural conceptions and the final was after an AI at a fertility clinic. In my opinion the doc should have done an IVF cycle. Falling pregnant, miscarrying and waiting for a period, cost me 6 months. My chances of conceiving with my own egg then dropped to 0.0000000(more of those).65%, so to me that meant, there was still a chance! The doc then strongly suggested that I "Get a donor egg!!" It was not that I didn't understand that my chances were slim, but rather that emotionally I was not ready to go the donor route. Besides, I did not like his insistent manner. My husband and I fled. At another clinic, we were received with open arms. I was again reminded that my eggs were old. All I received was warm and loving support. 8 IVF cycles later,(I didn't have many eggs, but they always fertilised and divided. Once inserted, they swam right past the uterus and then asked "Where are we going?", the answer came back "Little darlings, you were going to the uterus, but you swam past that port two days ago and now you will just be washed out to see!) This occured each and every time. On the last cycle, I felt emotionally broken and knew then and only then that the donor egg route was my next option. The doc that was treating me at the time said that I had to get there myself, otherwise I would have always wondered "What if I had tried just one more time!" So for me having perfectly healthy mechanics, I was willing to take my chances and not be pushed into a decision that I did not make! So here we are waiting to welcome a couple of fresh young donor eggs who I am sure will know that they should dock at the uterus. My chances are a grand 65%! Adoption at this stage is not an option. I want to and will be pregnant and wish to thank all the kind and sensitive women out there who are donating their eggs! Hey Tertia, can I cast another vote? LOL XXX

[Egg Donor (ret)]

I don't even really understand why there is a question here. Actually I do - you are conflating two completely different questions. (1) Do patients have a right to make decision X and (2) Do doctors have a right to refuse patients who make decision X. There are places where these overlap, but I think it's actually a small space, and generally the two are completely independent, separate, and should be considered as such.

Doctors have a right to decide to treat or not to treat a patient (certainly for something elective like this). Like any business they can refuse a customer. A doctor refusing to treat a patient is not telling her to change her mind; it's telling her to find another doctor.

Your friend also has a right to make a decision and to find another doctor who will do what she wants.

Doctors cannot expect their patients to adapt to doing what they think is right. Patients cannot expect their doctors to just do what they want without question. Both have a choice that is independent.

The end. No one is even remotely "wrong" in your example nor, frankly, does your friend have any right to be upset at the doctor. They were a bad match. She found someone else. Big deal.

Merging the questions is illogical and leads to all kinds of illogical outcomes. This is aside from any ethics. The conflation really irritates me actually.

There isn't even any room for reasonable discussion on this question except when you get into the sticky overlapping area of ethics on a particular case. I think that may be interesting, but that's not the question you posed.

[Lena]

I think every Dr has the right to choose when he/she does not want to continue treating a patient. A lot of Drs suggest to patients when to "abandon" a specific cycle due to poor response. Most, if you insist, will continue after providing you with the facts and likely outcome.

I do not know how many Drs would actually tell a patient that "traditional" IVF is not working for them and they should seek alternative treatment. Mine, however, did just that.At my last IVF he said that based on all my treatments, cycles and poor responses he believes that eithr (A) I need to find a new FS (maybe a pair of fresh eyes will work) or (B) use donor eggs. There was no point for him to let me continue on the same path.

I felt hurt and rejected by a person who was trying to help me for a long time. It made my likelihood to conceive seem even more hopeless. I trusted him though and I understood that the only realistic option for me would be the donor egg route.

Giving me the right advice was more important to him that milking me for more money.

[Patricia Batton]

A doctor like any other professional should be allowed to do whatever he wants. He should not be allowed to IGNORE a patient who walks into his office dying but since when does a doctor HAVE to agree to do IVF for anyone? Let's say a woman has some strange disease and wants to have a baby before she dies. Does he HAVE to help her. Why should he? Let's say I am a real estate agent is there no client I can NOT service for any reason do I have to accept ALL clients? Let's say I'm a defense lawyer and I don't feel like I can successfully defend someone (maybe I believe he's guilty) do I HAVE to defend him? NO WAY!

[Barbara]

I think a doctor should be allowed to refuse to do a procedure he believes is not in the best interest of the patient. His risk is that if something goes wrong the patient will be harmed, and in the USA she would surely sue him, because he "knew there wasn't any chance of success and did it anyway". Obviously you can "doctor shop" like your friend did until you find someone who will do it. If you can find a doctor willing to do an IVF with 8 embryos risking the conception of octuplets, you can probably find a doctor willing to do something he knows won't work anysway. In my opinion, a doctor should not be forced to do something against his best medical judgment because he is going to be held responsible for the results. That only seems fair to me.

[Jessica]

I agree with Egg Donor above - these are two separate questions. I'm a doctor, and the only time I ever "have" to treat a patient is in the event of a life-threatening emergency. In all other scenarios, there is choice on both sides. I can refuse treatment I believe is inefficient and /or harmful, and the patient can search for a colleague who disagrees with me.

That said, I personally would have treated your friend, if only to give her closure (as someone mentioned, that, too, is a measure of success). But I don't blame her doctor for feeling differently, nor do I blame her for trying anyways. I wish her all the best of luck for the future.

[Tenacious]

To clear things up - In older women, (not sure from which age,) a maximum of 3 fertilised eggs are inserted and with donor eggs (donor normally under the age of 32), a maximum of 2 eggs ONLY. This is how it is down in SA anyway! So dear USA, your record breaking octuplets mother could not have possibly done this procedure in an ethical way.

To Kirsty the Physio, your comments completely resonate with me! Thanks for your professional opinion.

[Hannah]

I don't think this is a case of a woman's rights. Just because something is possible doesn't mean it is ethical. If you flip this around, there is about a 99% chance of it not working which means 100% in doctor-speak. That whole idea of being "addicted to hope" sees applicable here. At what point is the doctor feeding the addiction rather then helping her come to terms with her reality?

[kristylynne]

I'm about to use donor egg, and I voted no. I think that you hit the nail on the head when you said that a woman has to come to this place in her own mind and in her own time. No doctor can make that call on her behalf.

Besides, if I hit the lotto, you bet your ass I'd do own-egg IVFs until I hit menopause. The only reason I'm not doing that now is because I can't afford to risk that much money for so little a chance of succss. Choosing donor egg is a last resort, and last resorts suck.

That said, I guess technically a doc can refuse service to anyone, for any reason, although I think that it's a crappy thing to do. Especially if he's doing it to protect his success rates.

[Andrea]

I think it is unethical for any doctor to force his/her decision on the patient. If the treatment does no harm, the doctor's first ethical obligation is to respect the patient's autonomy, and her ability to choose.

[Dianne]

I think the doctor is within his rights not to do it. A dr. shouldn't have to do any procedure that he doesn't want to, especially if he believes that it is pointless and a waste of time and money for the patient.

[Alex]

As a high-FSher who conceived at 37 on my 4th own-egg IVF after being told (before my first) that I never would, I've thought a lot about this issue. I think it's a difficult one.

I think the doctors who refused me treatment were wrong, for reasons I'll set out below.

I think it is OK for doctors to refuse treatment under the following circumstances: if the treatment does not offer the patient any benefit. That sounds like it could be a no-brainer, but really it's not. Let's think about what it would involve in my case (~35 year old woman with high FSH). First, what is the per-cycle probability that a woman with my medical characteristics trying to conceive using the sperm of a man with my husband's medical characteristics will conceive (or, better, have a baby that survives birth) via ... pick a treatment: Clomid, IUI, IVF, etc. Next, what is the probability that a couple "like us" would conceive without assistance? Now, does treatment offer anything (better probabilities) over non-treatment (and which treatments)? My personal opinion is that the doctor ought to provide this assessment and that is within his or her rights to deny to offer treatments that don't improve over the odds of spontaneous conception.

The difficulty there is that statistics apply to populations, and outcomes are experienced by individuals. I don't, actually, think it would be unethical to, e.g., allow a 45-year old with unexplained infertility to try IVF once, maybe twice. But more than that ... it might be, even if she is paying out-of-pocket. Really, does a 45-year old who does own-egg IVF twice and fails have a better chance of conceiving via IVF or spontaneously? I have to guess it would be the latter, hands-down. That said, if she's never tried IVF and has tried spontaneously for awhile, I don't think it's "wrong" to let her do IVF a couple of times to find out if she's that "one in one hundred," even though probably she isn't.

As for me, my husband had had a vasectomy (and failed reversal), so our odds of conceiving without treatment were zero. For me, that shifts everything, and I think it was reasonable for me to say that I understood the odds with IVF+ICSI were poor, but that they were better than our odds of spontaneous conception and that we were willing to accept them.

As for comparative risks, I'd guess that DE is marginally safer for the egg recipient than own-egg IVF, as the intended mother doesn't have to undergo the anesthesia associated with egg retrieval. However, the donor does; and she's accepting risks from which she won't benefit directly, and she's presumably at phenomenally higher (albeit still low) risk of OHSS than the intended mother would be if using her own eggs (for the average DE cycle), so it seems to me that the overall risks of DE are larger than those of own-egg IVF, though perhaps not once you factor in the risks associated with m/c (however, you'd want to balance those out with the risks of twin and higher-order PGs that are more likely with DE ...).

[Dana]

So many things to say about this… so little time…
First, I will assume that we are talking about a serious medical professional and a stable adult who knows the chances and risks.
The poll is difficult to answer. Both alternatives, in my point of view, are correct. Even thought I am completely convinced of “her body, her mind, her heart = her choice”, nobody should feel the obligation to do anything when it is not a life threatening situation. The doctor provides a service and he should be able to refuse providing it for his own reasons (which may or may not be right for others). Going to an extreme, some doctors may have a problem with selective reduction or abortion, and even though some of us think it should be her choice, the doctor is within his rights to refuse treatment.
Having said that, it is not fair that she is denied her chances to go the infertility route at her own pace. Some women say “enough” after 2 rounds of IVF; others need a lifetime. A slim chance is still a chance and some people are just not ready to let go. The doctor telling her what to do is not helping her; he is not “being kind” at all. He is, maybe, being practical but that is not what she needs. She needs to find peace within herself in order to move on. She needs pregnancy or closure. And that, does not come from a doctor or a friend or a mother; it only comes from within at some point.
On a personal side note, I HATE with a passion when people, including REs, talk about donor eggs as “the next step” when your ovaries are not cooperating. It is not the next step of one same process. Donor eggs or adoption or any other direction are whole different games. They are totally unrelated; they maybe choices but are not consolation prices. Donor eggs is not for everyone (some people prefer to live childless before going the donor route) and it is not a substitute for slim chances at IVF…
Having gone through 9 IVFs, my heart goes to your friend. I hope she finds peace one way or the other.

[Tracy]

I personally know quite a few success stories that fell into that 1% success category, so I feel that if a woman is still making follicles and has a reasonable chance, she should be allowed to try. I personally achieved a pregnancy on my 44th birthday in October that ended up being ectopic (so not a loss due to age)....and that was an IUI.....I have now recovered and plan to try a few more cycles of IUI. I can't try IVF because I just found out my new insurance cuts off coverage at age 44......very unfortunate for me because now I'm down a tube because of the ectopic and could really use IVF!

[Alex]

I have to add that at least in the US doctors are lousy about communicating the difference between "You will never get pregnant [with your own eggs]" (the stats I've seen are that over time, among people who experience sufficient trouble conceiving to "qualify" as infertile -- i.e. one year unprotected intercourse, no conception -- roughly 15-20% will, actually, conceive spontaneously one or more times -- and many of those will have live births) and, "There is nothing I can do that will improve your prospects of achieving a healthy pregnancy." Those are two very different things (Tertia -- witness all you've been through and where you are now!).

[heleen]

People also buy lottery tickets with less than 1% chance of winning. In my opinion it should be the woman's decision but in return she should agree with having some counseling.

[Elise]

Although it may not be a specific insurance issue, there is a resource issue regarding cost and access to care that affects all of society. The reality is that there is a limit to the amount of medical treatment available, and a limited number of dollars in the world to pay for it. While this particular woman may have the funds (her own or via insurance), she is using the time and talents of a doctor, nurses, lab technicians and clinic on an elective procedure with effectively no chance of success. That doctor was educated at a university that was at least in part funded by tax payer dollars, and trained in hospitals funded by taxpayer dollars. He has an obligation not only to provide care to his patients, but also to ensure that he is providing it where it is needed most. I think that the doctor is demonstrating a level of professional integrity that is rarely seen.

The doctor/patient relationship is just that, a relationship in which a doctor has an obligation to give his patient the best possible care taking into account her particular needs. And she has every right to disagree and terminate the relationship and find another doctor, which it seems she did, sadly to her detriment in this case.

So yes, I think every doctor has not only the right, but the obligation to refuse to offer treatment in cases where there is no benefit to the patient. To not do so would be to subject a patient to needless medical procedures that could potentially harm her.

[Dana]

Now that I read a few other's responses, I would like to add something. I do not think we should dismiss the 1% chance as if it was no chance. One women every 100 gets to have a baby. Look at Tertia, for example; if you had asked his RE, after years of infertility, miscarriages, age, number of IVF treatments, PCOS, what were her chances of naturally conceiving a healthy boy, what do you think he would have said?

[Emily]

My thought is, we are talking about a medical procedure. A medical procedure that is not 100% risk-free (I think you need to compare the risk of her eggs + IVF to the risk of no IVF, not just her eggs vs. donor eggs). The doctor has an ethical obligation to NOT perform a medically-inappropriate medical procedure. Where to draw the line between medically-appropriate and medically-inappropriate may be fuzzy and grey. Which is why your friend is completely entitled to seek a second opinion, which it sounds like she did. In my opinion, that's an indication of the system working properly.

[4katnap]

I say yes to teh pole but here's my reasoning... A DR should be able to refuse treating anyone if they feel it's nto in their best interests. HOWEVER your friend is also welcome to find a second opinion and or DR that will treat her if she strongly believes that it is what is right for her. Dr's *SHOULD* have ethics. Patients *SHOULD* have the right to look for a different DR.

[Scout]

I think the doctor should have the right to refuse treatment if in his/her professional opinion it would not be effective or in the best interest of the patient.

I understand the argument that perhaps a woman has to try on her own until she's ready to accept the idea of donor eggs, but the clock is still ticking on her body's ability to carry a child. Sometimes maybe that slap in the face is needed. I don't know. That sounds pretty mean, but if the RE really doesn't believe there's chance of success is it ethical for them to treat the patient?

[lucy999]

It is a patient's right. I too had one ovary with high FSH and less than 1% chance on conceiving with my eggs or naturally. I got turned down by top clinics and they clinic i went to did not know what the heck they were doing.(failure on 2 expensive attempts..

Finally, I joined a forum (network54) and learned the name of an amazing doctor from New Jersey and after 2 more attempts got pg with my daughter whom I had last year. That doctor did not give up on me and that is why I have a daughter today.
One has to extensive research and figure what works for your body. I tranfered 3 embryos at 32 years and only got a singleton even though I wanted twins or triplets. go figure. You have to be proactive and don't let it all up to doctors as some are really quite ignorant.

I have seen many woman over 45 go on to have babies naturally and some with IVf using own eggs..

Low stimms IVF seems to work better for older people than pumping your body up with too many meds.
my 2 cents

[k.]

I've participated in your poll....

Something I should add though is that if the doctor does not want to use the patient's eggs if she's over 45, then BEFORE the appointment is taken this should be explained so she doesn't waste her time and emotional energy with this doctor.
This can be done on their web site, the doctor's rooms or by the receptionist or whomever makes the appointments.
Usually we IF's have a file or two that is sent over and aren't shy about finding out about doctor's success rates etc before we embark on another IVF or whatever with somebody new, so the age/egg explaination should not be a tricky one in my opinion.

[Jamie]

There are so many of these slippery slope questions going around today and I think it is impossible to answer them. I feel like it is absolutely her choice in this situation, but to the mother of 14, seen on the news recently for having eight babies at once, I feel like she should have been advised against her choice. I have nothing to justify this, it is just a personal feeling. And that is the problem with rules, cut-offs, regulations, it takes out the personal factor and that is really why we are all here, fertility issues or not, to make personal connections!

[chickenpig]

I think doctors in the US have to be able to deny treatment to patients to protect themselves. People here are so sue happy, that they will sue to get their money back if they feel the doctor "lead them on" in any way. Even when they make patients sign a waiver. If they have to defend themselves in front of a review board or ethics committee, taking money from someone with only a 1% chance of success will look highly unethical and he/she may lose their license to practice. Saying to a board "But she really really wanted to do it" isn't going to fly.

For example, I want to wear contact lenses but I am blind in one eye, and the sight in the other isn't great. I have only seen one doctor who was willing to prescribe contact lenses to me because of the risk of losing the sight in my one good eye, and that doctor was a mall quack. (I only wanted lenses for special occasions, I value what eyesight I've got, but who wants to get married in glasses?) I think your friend should ask herself "If a doctor is going to deny me treatment, how good or reliable is the doctor who WILL treat me?" I myself came to the conclusion that my eyesight wasn't worth the risk, and just take my glasses off for the photos.

[Christine]

I'm a veterinarian in the states. The bylaws governing vets in my state say clearly that I have the right to refuse service to anyone for any reason. In an emergency, obviously, I wouldn't, but my boss and I have agreed that we do not perform ear crops, cat declaws, or tail docking unless there is a medical indication for it. That's our choice. It's the pet owner's choice to find another vet. If we have such a fundamental disagreement, it's unlikely we're going to have a good working relationship anyway, so everyone is better off.

My boss once fired a client for being a pain in the ass, although she worded it a little nicer than that. I refused to perform a dental, with multiple extractions, on a dog when the owner refused to allow the dog to have any pain medication. While I am required to obtain informed consent for everything (and veterinary medicine is already client/patient-driven because the client is the one paying the bills), I'm not under any obligation to do exactly what an owner says. I get a choice, too.

[Louise M]

Interesting debate, on the heels of a 60 year old women in Calgary, Alberta, Canada, who gave birth to twin boys a couple days ago. She had been refused IVF in Canada and went to India for the treatment. Hmmm....

[akeeyu]

I see it from both sides.

He, as a doctor, can certainly decline to provide treatment or services if he honestly believes that they are unlikely to be successful or are in any other way ill advised.

She, as a patient, has a right to pursue treatment elsewhere if she disagrees with the doctor's position.

They're both right.

[Shylah]

As you said, this is an elective procedure. The doctor's responsibility is to give his patient all the information he can about the procedure, and then step back and allow her to make a decision about it. When she decided that she wanted to have the procedure, and hold on to her hope that she'd be in that 1%, him agreeing to proceed does not rob her of her time or money. It's a decision SHE made, for reasons that no one but her will ever fully understand. She did what she felt she needed to do, and avoided the chance that she'd always wonder "what if..?" or, worse, regret not trying. That's not the doctor's call to make.

I think that sometimes we put a little too much on our doctors. Granted, we can have incredible relationships with our doctors (I certainly do - I'm still with her even though I moved an hour and a half away) but the fact is that doctors are hired to provide a service. There are ethical and legal boundaries inside which they must operate, but those boundaries generally extend only to the patient's health and well-being (which is almost too subjective to even consider here.)

If having the IVF procedures with her own eggs would run the risk of physically damaging her, making it impossible for her to carry children at all, much less those from her own eggs, then I could agree with his refusal. As it is, though, that decision should absolutely be hers to make.

[Jenn]

I don't think any doctor should be obligated to perform a non lifesaving procedure. Especially a procedure where the benefit/chance of a pregnancy is so low and the risks associated with IVF, hormones et al become amplified in the light of the low benefits.

In Australia it would be unethical to do this as well on a financial basis because IVF is covered by Medicare.

[angel]

I reckon that the doctor can give the woman all the information she needs to make an informed decision, but since its elective- and if there's no risk to the woman of physical injury or death, he should go ahead with it.
Then again... these doctors are usually in private practice, so i guess they can refuse to treat a patient.

[Gary]

Ask the same doctor if he would refuse treatment to a person that only had a 5% chance of living - a life is a life at the beginning and the end...

[Helene]

I went through this same experience. After trying to 2 IVF's with my own eggs, my RE urged me to give donor eggs a try. I was only 34 years old but I had high FSH, with apparently only a 1-3% chance of conceiving a take-home baby with my own eggs. I remember having a phone conversation with my RE prior to making our decision on what we wanted to do. He agreed to do whatever I wanted (including cycling again with my own eggs) but he said he would feel badly about it and hated to see me waste my money when my chances of conceiving a take-home baby was so much better with donor eggs. I appreciated his honesty and I appreciated that he was willing to do what I felt was best, in the long run.

Ultimately, we did decide to use donor eggs and it was the best decision we ever made. We were blessed with twins. Two years later, we spontaneously conceived another set of twins. I feel very blessed but I don't regret following my RE's advice re: the donor eggs at all. I felt, at the time, he knew what was best for me.

[lorrie]

I tell you what is weird. My husband grew up Catholic back in the days when having a huge family wasn't fu-reaky. There were many with 9, or 12, and one family had 17 (19 pregnancies). It was very common for women with large families to have their last child at 44, 45, even 48. Nobody thought anything about it. Of course those were the days when women with those large families had husbands who paid their own freight (how quaint!) But what was it? If you use it, you don't lose it?

[Ev]

Although I don't personally like to treat infertility in my gyn practice, I have done some work ups and ovulation inductions, as well as been treated for an infertility myself. It seems that there are two questions posed: 1) should the doctor have refused to treat the patient despite her accepting informed consent? And 2) was it ethically correct for him to do so.

I approach patient care as a two way relationship. My job is the educate and advise. The patient always has the free will to comply, refuse treatment, or fire me. Likewise I also have the choice to treat or not treat a patient. Freedom to choose goes both ways. What is right for one patient may be a horrible decision for another. This area of medicine is fraught with controversies and uncharted waters. IVF is mostly "safe" but it does care some devasting risks. I have taken care of hospitalized patients with hyperstimulation syndrome, which can potentially lead even to death. (but driving in a car can result in death too). There are hundreds of other possible complications that cannot all be discussed or even thought of. So if this doctor felt that more harm could come from this procedure that has a very low chance of suceeding (risks outweigh benefits) then certainly he has the right to refuse treatment and I believe that it would be ethical. But if the motive is to pad his numbers, then the answer to the second question would be, no, that is not ethical. But it is still the doctor's right to have choice and we will never know his true motive.

[Julia]

I think that they are both right.
Dr has the right to refuse to do something that he is not comfortable with.
Patient has the right to go to a different doctor for a 2nd, 3rd, 4th opinion until she feels ready to move on.

[midlife mommy]

My only comment is that no one in private practice should be required to treat anyone for anything if it is something that is against their conscience. That said, simply refusing to treat someone because the chances of success are small is asinine.

[charity]

I voted Yes BUT want to also state that it still is her choice ultimately. If one Dr is not willing to help her, she understands the minimal chances of conceiving with her own eggs, then she should move on to a Dr who is willing to help her. Plus, do you really want a Dr performing a procedure on you who believes it won't work? Who needs that negativity? If she wants to see if she's lucky enough to be in the 1%, then go for it!