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Sutton's law is named for the bank robber
Willy Sutton . When asked why he robbed banks rather than offices, given
the fact that banks were much better guarded and harder to rob, he
replied "Because that is where the money is". In medicine, this is the
name given to the principle of going straight to the most likely
diagnosis. In simple terms, this could be paraphrased as “ Go for where
the gold is “ – and for infertile patients, this often means – “Choose
the treatment option which maximizes your chances of conceiving
quickly.”
Traditional treatment for infertility used a logical
step wise approach. First, make a diagnosis – find out what the problem
is. Then, try to fix it, using a progressively escalating approach. Try
medications first. If this fails, try surgery. If this fails, then do
IUI. If this does not work, then try HMG superovulation plus IUI; and
if this fails, and the patient is still not fed up, go in for IVF.
While this is logical, and looks great on paper, the
fact remains that it often does not work out well in real life. This
approach is time consuming, and patients get fed up and drop out of
treatment rather than move on to the next step. This can be a real
tragedy, because these are often patients who could have got pregnant
with IVF. This approach might be reasonable for some couples, but you
cannot use a “one size fits all” approach.
The fact is that there is a price you pay for
everything , and the price you pay for this sort of methodical logical
approach is an opportunity cost.
I recently saw a very successful and very busy
couple who was responsible for a dramatic change in my way of thinking.
The wife was 29 years old and said, “ I want a baby quickly. Money is
no object and I want you to do IVF for me. I want to have my first baby
by the time I am 30, and don’t want to waste time. What can you do to
help me achieve my goal ? I know I may get pregnant in my own bedroom,
but I prefer IVF as I don’t want to waste time.”
This was a very unusual request, and I was
surprised, but in retrospect this approach makes sense. She argued, “ We
all want more control over our life, including our reproductive
decisions. Why should we have to depend upon Nature’s vagaries when we
don’t need to ? After all, Nature is not very efficient at producing
babies, and if we can give Nature a helping hand , then why not do so
?”
“There is no risk in performing IVF – either to me
or to the baby. It is safe and effective treatment, and has no downside,
other than the financial risk . I am willing to spend the money in order
to buy time. For me, this is the perfect time in my life to have a baby
– this is my window of opportunity ! With my busy schedule and
carefully planned out life, the opportunity cost of NOT doing IVF will
be considerable !”
Traditionally, we have used IVF for treating
infertile couples. However, it would be equally valid to use IVF to help
couples to achieve their personal reproductive goals, as long as they
make a well-informed decision, and are aware of the pros and cons. An
analogy would be cosmetic surgery, where surgical techniques are used to
help patients to enhance their self-esteem. Why should I refuse her ?
Actually, if I had a choice, the only treatment I
would offer would be IVF – after all , I want all my patients to get
pregnant as soon as possible. If they can do so with IVF, then why not
use this as Plan A rather than as a fallback option when all else fails
? It’s well known that pregnancy rates with IVF are much better for
younger women than for older women, so it’s much more cost effective to
do it when you are younger. It is true that doing IVF means spending
considerable money. On the other hand, not getting pregnant has a
considerable cost attached to it too – the drainage of emotional energy
and the time spent waiting and hoping. IVF may be more cost effective
and time effective for many patients.
Equally importantly, IVF gives infertile couples
peace of mind that they tried their best - that they gave infertility
treatment their best shot. This peace of mind can be priceless !
In the past, IVF was considered to be the treatment
of "last resort" - and was reserved for patients who had failed all
other treatment methods. Today, it is often the treatment of first
choice, because it maximises the couple's chance of conceiving quickly,
no matter what their medical problem.
I feel the best option would be to allow couples to
choose for themselves. I can assure that I will never let them make a
wrong choice, but when there are options, the responsibility for
deciding depends upon then – they cannot abdicate it to anyone else.
Everything in life comes back , but time does not –
and kicking yourself afterwards does not help !
“ For of all sad words of tongue or pen,
The saddest are these: "It might have been!"”
Why not do IVF when you are young and can enjoy your
kids, rather than regret not doing it when you are old ?
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