Case studies
Case Study 1: FSH testing
Let’s explore a clinical setting that is high on the list of importance for any in fertility patient and one that evokes extreme emotions and anxiety: FSH testing. Let’s say that your FSH comes back at 15 (elevated by most standards). There are two directions the discussion could take using our patient rapport vs laboratory report paradigm. Let’s look at each.Lab report approach to planning:
The discussion is more biased toward strict medical interpretation and less toward the rapport side. The conversation might proceed as follows:
Your FSH is elevated and in our practice, we refer all patients with an elevated FSH of 15 for oocyte donation. Period. Regardless of age or background. IVF is not an option and I think it would be best for you to discuss this with our oocyte donor coordinator.
This approach offers rigid structure which many patients respond to. It is not unusual for some patients to present with a very black or white approach to decision making. Their stand is: I’ll do one more thing and I’ll take that step which offers me the highest likelihood of success and a live birth. All options on the table. When success rates are overwhelmingly in favor of one option, the decision in this setting is easy. However, n some settings and with some patients, a broader and more complex discussion is needed. The decision to move to an option higher likelihood of success at the expense of sacrificing any hope of using their own oocytes is simply not workable. And for any couple or individual with that perspective, the conversation and counsel must be more broadly based. In this setting a balanced discussion of rapport and report may offer the best chance at formulating a successful treatment plan.
Patient rapport approach to planning:
Let’s look at another exchange that is a bit broader and takes into account clinic specific experiences and the broader clinical and personal context of the patient (more rapport driven than report driven). The conversation may proceed as follows:
An FSH in this range in our clinic in some age categories does not mean zero success nor does it mean that oocyte donation is the only option. This value suggests that there is a reduction in success rates (clinical pregnancy and live birth rates) when compared to age matched patients with a normal FSH value. Your FSH is elevated at 15 and in our clinic’s database our success rates in your age category is 10%-15% (pick a number). It is important at this point for us to discuss what your expectations are and the likelihood of success given your unique clinical profile and your expectations across a spectrum of treatment options. It is ultimately your decision about what is an acceptable success rate. Again in this setting oocyte donation on a clinical and numbers basis is the most clinically successful but we realize that final decisions in this setting are complicated and that equal emphasis may be placed on finances, what is personally and emotionally acceptable and what is clinically appropriate.
When conducted in this manner, the conversation opens and engages a couple in a different way. For that couple or individual not numbers driven (as the couple described above who are focused solely on live birth rates), this approach is essential lest they feel limited and restricted on all fronts of the evaluation process. For the short term, a discussion that touches on all options will mean the most in formulating a plan that combines all aspects within the rapport versus report paradigm. For the long term, it is important for this couple to feel empowered and to work within a framework that will enable them in 5, 10 or 15 years to view it favorably regardless of outcome. In other words, whatever the outcome whether it is a live birth, an end to the infertility evaluation or a movement towards other alternatives, they should be able to look back and say that it is as OK as it can be. It is always distressful when I hear from patients that they have concerns about What Ifs: what If I did try treatment X or Y would the outcome have been different.
I am by no mean suggesting that anyone be foolish or waste time or money or even more importantly jeopardize well being and chase a fool’s dream. But I am suggesting that the evaluation and treatment of infertility follow very closely your needs on emotional, medical and financial levels.
