For patients suffering with infertility, honesty may be a doctor’s best treatment
When a woman is told that her chances of becoming pregnant are “futile,” her world may be shattered. One in eight women struggle with infertility, which is defined as an inability to become pregnant after 12 months of regular sexual intercourse, without any form of birth control. While the causes of infertility are far and wide and can often be treated, a number of women are told that their chances of becoming pregnant are “futile.”
Futility is defined as having an “exceedingly low chance” of becoming pregnant, with “a success rate of less than 1%,” Dr. Sigal Klipstein, Ethics Committee member for the American Society of Reproductive Medicine (ASRM), InVia Fertility specialist and senior educator at University of Chicago Pritzker School of Medicine, told ABC News. The caveat, Klipstein noted, is that it is nearly impossible to determine futility with 100% certainty.
In a recent press release and ethics committee update by ASRM, fertility doctors were instructed to be transparent about their patients’ chances of a successful pregnancy and refrain from offering treatment when fertility is futile. The concept of futility has raised questions about whether it is ethical to pursue fertility treatment against all odds.
“In reproductive medicine, there are few things as weighty and severe as [having to say] that a woman’s chances of a successful pregnancy are zero,” Dr. Zev Williams, chief of Columbia University Medical Center’s Division of Reproductive Endocrinology and Infertility, told ABC News. As such, there is “a grave need for caution before giving that kind of prognosis ... to make sure that every possibility has been carefully examined and explored.”
While delivering a percentage may seem straightforward, “the emotional component,” Dr. John Petrozza -- director of Massachusetts General Hospital's General Fertility Center and chief of the Division of Reproductive Medicine and IVF -- “is intense,” and entails “difficult conversations, for all parties involved.” Many patients are unprepared for the news.
The ASRM provides a caveat to their code of ethics, adding that special exceptions can be made for women experiencing “psychological distress” relating to infertility. According to Klipstein, it is reasonable to provide treatment to patients with a “very low to futile prognosis,” after a “detailed discussion with the [patient] regarding realistic expectations and expected outcomes.”
For Petrozza, this is a relatively common scenario, as he has treated many aspiring mothers with extenuating circumstances like unexpected military deployments, cancer diagnoses, and sudden break-ups -- sometimes related to the stress of fertility treatment, itself.
The financial ramifications can also be stressful, because while "clinicians define futility as a <1% chance of success, insurance companies often use <5% as their cut-off," Petrozza added. Although insurance policies can vary from state to state, in a number of cases, “patients have to pay out-of-pocket, and it’s a big expense: $12-15,000 for a 2-3% chance of success, [which] is very, very difficult.” As a result, patients may grapple with the emotions and finances of a treatment that may not be successful.
In these situations, ASRM tells physicians to balance the risks and benefits of treatment. According to Klipstein, it is important to leverage the “low odds of success with the risk of rare complications,” such as infection, bleeding, allergic reactions to medications, and a condition called “ovarian hyperstimulation syndrome (OHSS),” where the ovaries over-respond to fertility treatment.
Like Klipstein and Petrozza, Williams has worked with a number of women who were told their chances of success were futile, but still went on to have successful pregnancies. Other times, the outcomes have not been quite as successful. In these cases, treatment served as a “closure cycle.”
Closure cycles, Klipstein explains, provide “patients [with] a trial of therapy with the understanding” that if it is not successful, the patient and physician can more confidently say that a woman's chances of a successful pregnancy are very poor, to futile. This may be an important next step in helping patients to accept their infertility, and explore other options for having a family such as gamete donors or adoption.
While futility “is a very tough thing to call,” Williams concludes, “we certainly don't want to put a patient through fertility treatment if there is no chance for success.” Every woman has her own journey to parenthood, calling forth what Williams describes as "a certain need for both humility in declaring futility, and a desire to do everything possible to think outside the box and individualize treatment to give every patient [their] best chance of success.”
Navjot Kaur Sobti is an internal medicine resident physician at Dartmouth-Hitchcock-Medical Center/Dartmouth School of Medicine and a member of the ABC News Medical Unit.
