When is it time to stop IVF?November 15, 2010Carole 16 Comments »
A new study by Professor Barbara Luke of Michigan State looked at 300,000 IVF cycles in the US. Professor Luke’s study showed that 36% of women became pregnant after one cycle of IVF. Of women who went on to a second IVF cycle after the first cycle failed, only 12% more conceived (48%) in the second cycle. Continuing on for a third cycle produced a pregnancy in only 5% more of the women who had two failed cycles behind them (53%).
Percentages are confusing so let’s look at 100 women starting IVF using their own eggs. So if 100 women have a first IVF cycle, 36 become pregnant. If the 64 that did not get pregnant go on to a second cycle, 48% of the 64 will become pregnant, or another 30 will become pregnant on the second try. If the 34 that are still not pregnant go on to a third try, then another 19 will be pregnant. If the remaining 15 women go on to a fourth try, only about half again will get pregnant. More tries do not significantly increase the chances of pregnancy beyond the 50% rate. Dr. Luke concludes that there are diminishing returns after three IVF cycles and it may be time to look at other technical interventions such as donor egg or surrogacy. Adoption of either an embryo or a already-born person are other options to consider.
What factors might change your chance of pregnancy? The jump in pregnancy rate between first and second cycles could be attributed to “tweaking” the stimulation cycle the second time or making other adjustments (like recognizing that ICSI is necessary). These data suggest that there is not much learning or improvement after the third cycle, meaning your clinic may have exhausted most of the bag of tricks they have after the third cycle.
Dr. Luke’s study did not look at the effect of maternal age or obesity on pregnancy rates which are two huge factors in outcome. None-the-less, the conclusions dovetail with my experiences in IVF clinics. We didn’t begin to lose our hope for a patient’s chance of conceiving until they had two failed cycles behind them. When we started seeing repeat cycles that had no adjustments in the stimulation and no adjustments in the technical approach, we began to expect that the odds of success would be slim.
So what do patient advocates recommend about when it is time to stop IVF? Resolve has a thoughtful article called “When is enough enough?” written by Eileen Ivey, LCSW-C, and Joan Rabinor, LCSW-C. When patients reach the point of asking these questions will be different for every person struggling with infertility. Ivey and Rabinor’s article focuses on four areas that patients should consider at some point, namely
- “Evaluating and setting limits on our resources”
When they discuss resources, they mean not only financial resources, but also emotional and physical resources. IVF treatments are no cake walk. At what point are IVF treatments hurting instead of helping patients in their lives?
- “Listening very carefully to our inner voices”
Here they recognize that IVF treatments may become all consuming and deafen patients to other options in their lives – paths untrod- that beckon to them and may be more possible if they get off the IVF merry-go-round.
- “Teasing out the components of our wish for parenthood”
In teasing out the components of our wish for parenthood, they ask patients to consider what elements of parenthood are essential to them and which can be set aside. For instance, is it genetics or the experience of pregnancy or child rearing that are most important to you? Through intercourse, these desires were all wrapped up in one package. Assisted Reproductive Technology can let patients to chose among these competing needs. Egg donor or embryo adoption may be the answer if pregnancy and child rearing, and not genetics are most important. Everyone answers these questions differently, Hopefully a couple can get to the same page on this.
- “Communicating in a plain and conscious way with our spouses”.
Which gets us to their final area of consideration, our partner or spouse. At some point, IVF is a clear and present danger to our deepest emotional relationships. Patients may find themselves in the position of choosing between their partners and their relentless pursuit of parenthood. A failure to communicate about our deepest fears and hopes may doom a relationship. We have seen couples scream at one another in treatment rooms which underscores the emotional cost of infertility treatments. As outsiders observing this marital distress, we wonder whether this couple really should raise a child together since the together part seems to have fallen by the wayside.
ASRM has published their ethical opinion on stopping treatment in this article “Fertility treatment when the prognosis is very poor or fertile” which is also worth reading. You may be surprised to learn that ASRM thinks it is ethical to pursue treatment even in futile cases if the physician feels there may be a “psychological benefit” from pursuing treatment. The idea here is that -assuming yet another try won’t bankrupt you- you can go on and accept that continuing treatment is futile after “one last try”- the psychological benefit is closure, apparently.
ASRM also recognizes that the issue of when to stop can “reveal conflicting interests among clinicians and their patients”. Doctors may be reluctant to stop treatment because they don’t want to accept “failure” on their part as a provider or they may feel that part of their job is to remain eternally hopeful and optimistic for you. On the other hand, doctors do have the right to refuse treatment if they think that it is unethical to pursue treatment when the odds of success are too low.
ASRM also comments on other non patient-centered motives for continuing or discontinuing treatment: “Decisions about treating or refusing to treat couples and/or individuals always should be patient-centered. Protecting fertility center success rates is not an ethical basis for refusing to treat couples and/or individuals with futile or very poor prognoses. Conversely, care should not be provided solely for the financial benefit of the provider or center.”
Because the decision to stop is a difficult one for physicians as well, perhaps patients shouldn’t rely on their physician to tell them when it is right for them to stop. When you go to on-line chat rooms that invite physician involvement, you will often find several physicians weighing in with different opinions about how to help a particular couple- which may or may not involve a transfer of care to their own clinic. This is human nature. Good physicians are driven to help their patients, perhaps more than is really beneficial for the patient. Not so good physicians may be driven by the business of IVF and their own success and this may inform their recommendation for you. In either case, the bottom line is that this is your and your partner’s decision.
Frances W. Ginsburg, MD has written a very thoughtful piece about the physician’s role in discussions about ending treatment, entitled “When Should Infertility Patients Consider Stopping Treatment?/Fact Sheet“. She comments on her own burden of having to recommend between a “sure thing and a long shot” without the benefit of a crystal ball.
This same fact sheet (keep scrolling down) also contains advice from Linda Hammer Burns, in “A Therapist’s View”, in which she considers the components of a “good” decision, namely that they are based on “sufficient and accurate” information and both partners (if applicable) participate and neither feels bullied by the other. Good decisions may mean a review of all options, even those that were previously rejected because priorities or perspectives may have changed since starting down the infertility treatment path.
She also suggests an interesting mental exercise. Project yourself into the future 20- 30 years from now and look back on this period of infertility treatment. If you stopped treatment today, do you think you will look back with regret or peace of mind? She notes that peace of mind may be due not to success of treatment but rather from being satisfied that good decisions were made based on the information/options available at the time.
Having to deal with infertility is unfair and difficult. Knowing when to stop is very difficult for most patients. External factors like running out of money to pursue treatments may eventually make the decision for patients- which is another emotional hardship. Infertility treatments often leave patients feeling that their lives are out of their control. When IVF treatments fail repeatedly, saying enough is enough may be the first step to feeling that your life is under your control again, allowing you to pursue other paths to parenthood or possibly considering other paths in your life that are now possible.
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