Fertility options

Some people would do anything to become pregnant: undergo painful procedures, borrow money, mortgage their homes –anything, it seems, to have a child. While this is certainly understandable –parenthood is perhaps the raison d’être of our genes- it seems a shame that fertility would be something denied to some while granted to others. Arbitrary at first  glance, it sometimes remains so even after extensive investigations. And yet there has been a lot of progress in understanding the mechanisms that both allow fertilization to occur and, maybe even more importantly, implantation of the egg and subsequent successful development of the pregnancy.

Obviously, there is a whole cascade of events each having to unroll in the proper order –such things as development of a viable and healthy egg in the ovary; its ovulation and successful encounter with a (hopefully) normal sperm; a clear and unimpeded route to an appropriately developed uterine lining… And these are just the early requirements for the long journey to l’accouchement. But, like a planning a trip, it is more likely to arrive at its destination if the car is sound and there is gas in the tank.

There are many roadblocks along the way, however, not the least of which are the body’s defence mechanisms which try to destroy foreign proteins that might pose a risk to the health of the organism. A fertilized and developing egg contains a mixture of just such foreign material from the male, and so in some cases might be construed as an attack. Although the uterine cavity is designed as an immunologically privileged site to thwart such a mistaken identity, for some reason it doesn’t always work. While this can be a subtle issue and difficult to detect, it can be an even more difficult thing to correct. There have been attempts to do this with medications to increase success during IVF (in vitro fertilization), but with few breakthroughs so far.

Sometimes my patients know more about this than I do, or perhaps pay more attention to disparate media reports that view every paper published, even in obscure journals, as fodder -landmark achievements. The job of journalists is to interest their readers, not to critically analyze the data and research whether or not the findings were merely a one-off that has not been validated by others in the field. A crash is news; a non-crash is not. Or am I being too cynical?

Last year, I remember seeing Janice, a woman who had been trying to become pregnant for several years. She told me that all of her tests that her GP had ordered had been normal as were those of her partner. Because she was already approaching 40, I immediately suggested that she would likely benefit from being assessed at an infertility clinic to see if they could expedite things. I wasn’t sure that I could help.

She shook her head. “I’ve already been to a clinic…” she said, with a sad expression on her face. “They wouldn’t listen to me.”

“Listen to you? What do you mean?”

She probed my face with her eyes for a moment to see if I was likely to listen to her. Then, apparently reassured, she sighed and sat back in her chair. “Well when they saw the normal test results they added their own versions of the same things but still couldn’t find anything wrong. So they suggested IVF. Time’s running out, they said.” She straightened in the chair and uncrossed her legs. “We can’t afford IVF,” she said, all the while staring at her lap where she was alternately wringing her hands and straightening the fabric of her dress. “They basically shrugged and told me to think about it and come back if I changed my mind.”

I waited for her to continue. There must have been some reason her doctor had referred her to me.

“Anyway,” she said after a long thoughtful pause and a quick gulp of air, “I went on the internet to do some research on other options…”

I managed to stop my eyes from rolling but I have to admit she caught me holding my breath. I never know how to react when a patient innocently offers a totally unorthodox and largely un-researched idea that they’ve found on some website lying in wait in a dark corner of the web.

But she noticed my expression and chuckled at my obvious discomfort. “You must get this all the time from desperate women, eh?” I smiled, embarrassed at being caught. “I’d been trolling through some weird stuff and then noticed a reference to a paper published in the journal Science –it was dated 2015, so not very old. It was only the abstract, though, and I wasn’t really all that sure that I understood it correctly…” she said, no doubt to head off any criticism before I could formulate it. “But there was also a reference to a BBC article talking about it so I looked at that as well.” She handed me a piece of paper with its address so I could look it up as well:  http://www.bbc.com/news/health-34857022  and then to show she meant business, the abstract from Science: http://www.sciencemag.org/content/350/6263/970

When I didn’t immediately punch it in on my computer, she decided to explain. “There’s a parasite that increases a woman’s fertility, doctor,” she said, now intently studying the panoply of expressions that flitted, untended, in quick succession across my face. “Not all of them do, of course,” she added quickly, to show me that she wasn’t that foolish. “I mean, I don’t want to try one, or anything. I just wanted to know what you thought of the idea.”

While I gathered my thoughts, she explained. “I went back to the fertility clinic and asked their opinion about the worm… Ascaris lumbricoides –I memorized the name,” she said and immediately blushed. “Anyway, when I mentioned it to the clinic doctor, he just laughed at me. I don’t think he meant to, but it just kind of escaped from his face before he could stop it…” Janice suddenly leaned across my desk with a serious look on her face. “Of course I thought the doctor was being rude and dismissive, so I walked out on him and headed over to my GP’s office. At least she was more patient with me, but I could still read the disgust in her eyes. We managed to talk about it for a few moments, and then she decided to refer me to you. You’d listen, she assured me and then walked me out of the room…escorted me, almost. I think she just didn’t know how to handle the idea so she passed the buck.”

There was a sudden twinkle in Janice’s eyes that I almost missed –a mischievous expression that flirted briefly with her mouth, then disappeared. “My GP obviously didn’t think I needed an urgent appointment –although I did remind her of my age- so it took me a while to get in to see you.” She smiled a more ordinary smile this time, although it was still nuanced. “Several months, in fact.” I could hear the italics around the word from across the desk. “You’re a busy man, doctor.” I think I blushed.

She waited for a moment to let the thought embed itself in the desk. “So, what do you think of the worm idea?”

I struggled for words initially. It was an unusual idea, but I remembered a brief flurry of rumours when I was in medical school about fashion models infecting themselves with intestinal parasites to help them to stay thin. Perhaps they were just that: rumours, but the idea at least was not without precedent. “Well, I suppose if we could be sure that it wouldn’t affect the developing baby in any way… or you!” I paused for effect. “And that we could reliably get rid of the parasite when it had done its job –again without harming you or the baby- then…” I had run out of words. I had no intention of endorsing the idea, but I didn’t want to dash her hopes entirely. Hope is what keeps us going. I leaned across the desk towards her and smiled. “Let me just say that if you were my daughter and you had honoured me by asking for my opinion, I would have to say that some things are just not worth the risk.”

“You mean you’d advise against it?” She seemed relieved.

I nodded carefully, sensing I was being led into a trap.

A smile almost split her face in two and her eyes lit up and sparkled like lights on a Christmas tree. “Well, I’m pregnant now,” she said, italicizing the important word again and leaning across the desk as well. “It took so long to get to see you, I thought I’d use the time constructively.” My eyes must have betrayed something, because she suddenly extended her hand and grasped my arm. “Don’t worry, doctor, my husband and I decided against the worms. He said he was really worried about them…”

I relaxed my expression and was about to say something about a caring partner, when I noticed another twinkle in her eyes. “Yes,” she added before I could open my mouth. “He was afraid of getting them from me.”

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You Got Me Pregnant!

Some things seem to go unappreciated don’t they? They’re background noise. Shadows in the moonlight. You might think that this doesn’t apply to medicine, but it does. Much of what we do is taken for granted –or at least taken for expected… appreciated, but for a variety of reasons, not publically acknowledged. And that’s fine with me; I’m certainly publically humble. Shy. I seek shadows not spotlight. I’m not certain I would know what to do on a pedestal.

Besides, I don’t do what I do for accolades –I embarrass easily. And I’m content with smiles, or even a face that signals thanks; I probably should have gone into Pathology, or some other solitary field where the propensity to blush is not a handicap. They didn’t teach us how to accept praise in Medical School; they didn’t even mention blushing –or maybe I just missed that class.

But, not to diminish the appreciation I do receive –I’m an obstetrician, and in the fullness of  l’accouchement  there are congratulations all round. Thanks in spades. It is enough -it is their moment after all, not mine.

And anyway, I forget things –forget people, for example. I may have seen them every month for a year, and yet on the street, they are sometimes just faces that smile at me when I pass, and like most faces, vaguely familiar… Maybe. Some eyes seem to ask for more than just a fleeting nod but these are requests to which I dare not accede lest I be required to remember something of their past… I don’t do pasts the justice they deserve sometimes. Pasts matter; they are what knit the fabric we wear and to ignore them is to ignore the coloured  patterns that make the present so vibrant. The future so hopeful.

Memory was a given in Medical School –it was what you had to have to get there in the first place. It was not so much educere –a Latin word suggesting drawing out or eliciting something already there- as inducere –putting something in that they wanted you to have… But I digress.

I have carried this neural handicap with me my whole career: my memory seems selective at times.  I am prone to remember things I don’t need –a hair style on an elderly lady, a lilting way of speaking, the eyes of a woman looking at her newborn baby… Interesting things that help to flavor the roiling stew of facts and numbers I’ve stored behind the eyes I try so hard to keep neutral in the office. Things that disguise the otherwise unadorned potpourri of diseases and anatomical discrepancies hidden beneath the words that stagger so reluctantly from my patient’s lips. Things –flowers- so precious in the world of suffering my job is wont to assess.

I need to escape sometimes: long walks along the beach, a movie, dinner with friends… or dinner alone. They’re all tricks to dampen down the past. Too much past, and you’re condemned to live there –or at least visit uncomfortably often. And for me, dinner in a nice, crowded little restaurant at table along the wall is the perfect anodyne. Like a bodhisattva, I am of the world, but comfortably without as I sit, hidden in the corner, sipping casually on a glass of wine, watching others do the same. I am peacefully alone in the crowd, digesting my thoughts in joyful anticipation of the ritual of food.

I was at one such place a few months ago. The room was crowded, and quietly boisterous  as I was shown to a table by a window overlooking… Well, it was so dark outside, it overlooked the reflection of the room –a double room, in effect -perfect for inspecting plates on other tables and who was sitting in front of them. Everybody was dressed as if they knew others would be watching them: the woman nearby in the designer jeans, so tight she looked unable to move, with only  a salad in front of her; and her partner, casually elegant, tucking into some sort of pastivorous mixture that steamed as he forked it. They were quietly avoiding something –communication, likely. Others nearby were toasting each other with sloppy, uncertain gestures, waving napkins at one another as each attempted to prevent the inevitable spills. Everyone seemed engaged in something; everyone was alive and enjoying it.

My eyes were drawn to the aisle where I’d entered. The room was full to overflowing –nobody was leaving- but I could see one of the servers staring at me. She was a tall young woman with her blond hair pinned back into an attractive bun, and as usual there was something familiar about her face. She was talking excitedly to a man behind the bar and nodding in my direction. At first I was flattered; I thought perhaps she had noticed that my wine glass was almost empty. Great place, this, I thought and smiled back at her. She returned the smile with an expression I’d seen before. Then a puzzled look attacked her face, as if my smile had confirmed something. She bowed her head for a moment, as if thinking it through, and suddenly her eyes opened wide and I could see her take a deep breath.

Then, as luck would have it, there was one of those stochastic diminutions of sound that seem to occur in restaurants from time to time as people decide to pursue their dinner for a moment rather than their conversations.

“You got me pregnant!” the server screamed in her excitement, pointing at me and walking towards my table with an intense but unreadable look on her face. I couldn’t tell if she was angry or bent on revenge. Me? I just hoped she was mistaken.

The restaurant was muted when she said it. Completely silent when she’d finished. Everyone turned to stare at me, the accused, as if I’d abandoned her after a night of debauchery. I could see the look of disapproval on the woman in the designer jeans. Perhaps she was regretting her choice of partner for the evening but I couldn’t tell because she was staring at me with a malevolence I’ve only seen in movies. People began to whisper to each other and I could sense, as much as hear, guffaws and sniggers. Caught, I could hear them think. Serves him right!

I could tell they were all waiting to see what the server would do once she reached my table. There was a palpable silence when she did. They were preparing themselves for a battle. Deciding what to do. How to react. What is the appropriate protocol to be followed in such a raw and unusual circumstance anyway? Grab me and pin me down? Call 911? Take a video of me with their cell phones and post it on YouTube? I thought about all this as she approached, but my social skills had never been stretched that far before.

In the eternity of those last few steps before she reached me, I could feel my face redden, and my mind racing like it is said to do in the moments before an impending and inevitable accident. I scoured mental relationship files and flipped through the disappointing ones in the blink of an eye, desperately searching for some mistake I’d made. An indiscretion, perhaps. A date I’d forgotten –or blocked from conscious memory. Anything. But, for some inexplicable reason, there was nothing to exculpate. In terms of the reaction I was provoking, my life was undeserving. Banal, if not entirely flawless.

Suddenly she was there, standing excitedly in front of me in the tomb-like silence of a room full of frowns. Their eyes, their expressions, their postures –all were balancing on a knife’s edge. Hoping for a resolution of the tension and yet dreading, what was to come.

She stared at me for a moment, teetering on the edge of a conflicting internal debate on what she should do now that she had an unanticipated and, no doubt, unwanted audience. Then her eyes twinkled and her face dissolved into a smile so large it hardly left room for ears; so genuine, I thought she might faint with ecstasy; and so intense I had to stand to acknowledge it. She grabbed my hand and squeezed it until it hurt. And then, putting her arm around me, turned to the crowd and said, “Sorry folks. I didn’t mean to disturb your dinners. It’s just that I never did thank my doctor for solving my infertility problem!” She pulled me close and kissed me on the cheek and then promptly blushed when the room erupted into applause. “I’m so impulsive sometimes,” she said and backed away, still holding my hand.

The room slowly settled back into its usual rhythm after that, and she walked quickly back to the bar to see if her next order was in. Later, when I was simply a mildly diverting memory in the drunken crowd, my own server –fortunately one with an unfamiliar face- presented me with a bill with a smiley-face drawn on it, and a big zero where the charges should have been. But the vaguely familiar-faced owner accosted me as I left.

“I’m sorry about that, doctor,” he said, looking embarrassed as he shook my hand. “My wife gets so excited about things now that she’s a mother… Never rests any more -even here. She’s always finding something to do.” He looked at me for a moment as if he wanted to tell me something else and then smiled and turned away. As I reached the door, however, he spoke again. “Can you get us a boy next time, though, doc..? The girl we got never seems to sleep.”

A Patient Named Cindy

I enjoyed Cindy (not her real name); how could I not? Short, plump, with uncertain hair of indescribable colour that was tossed on her head like a salad begging for dressing, she captured my interest the first time I saw her in the waiting room.

She was pretending to look at a magazine, all the while sneaking amused glances at the more staid and nervous patients waiting for their turns on the obstetrical pedestal. Her heavily made-up eyes whispered fashion but her dress screamed Walmart. I could see others in the room look away in embarrassment –confusion, more likely- but Cindy just smiled: a queen supremely aware of the distance between her and her court. Regally bemused at their furtive glances, she would sometimes confront the faces hiding behind their own pretended reading, inadequately camouflaged with turning pages, or pointing out a picture to a curious child.

Something about her made them uneasy. Maybe it was the hem of her sequined dress that she wore distressingly close to the edge of her more brightly coloured panties. Or the tattoos on her legs that stretched ever upwards even beyond the hem. But I suspect it was that she knew they were looking and didn’t care. Relished the attention, actually…

And yet the attention her clothes seemed to invite was as unimportant to her as the screen in a movie theater: you needed to stare at it, but it wasn’t really the center of your attention. It was the vehicle necessary for you to appreciate the show. And Cindy knew she was the show.

It was hard to be formal with her –she was so… out there. She did not invite –she would not permit– the usual power pyramid so rampant in a medical office: she was Cindy, and I was the doctor –with a small ‘d’. She needed advice, and I was its purveyor. Period. If she needed shoes, or a dress, she would have gone somewhere else. I was merely the seller of medical suggestions; she could pick and choose from the assortment offered.

When she sat in the chair by my desk that first time –provocatively again, over-revealingly again- she stared at me for a moment, probably wondering if I would react. But I only smiled, kept my eyes riveted on her eyes, and asked her why she had been referred.

A hint of a smile touched her face briefly and then immediately exploded into a delightful and disarming laugh. “Guys never know where to look when I sit like this,” she said, adjusting her posture to a more socially acceptable form and sliding her hem back down over her knees. “You can judge a man by where he puts his eyes, don’t you think?”

“And..?”

“And I suppose I can trust you,” she said with an expression that seemed older and wiser than her twenty-three years.

“Well,” I said, carefully avoiding the mine-fields she had already sprinkled around the conversation, “what can I do for you?” I thought it was the most direct way to elicit a usable response.

A smile so large it nearly split her face in two suddenly materialized. “You know, doc, your question almost makes me dizzy… It’s usually my question. The one I  have to start with as well.” I have to admit that I shifted uncomfortably in my seat. She noticed it, of course. Cindy would. She straightened politely in her chair and dropped her smile to a category B and shrugged. “Sorry. Everybody says I’m a bit direct. I think it goes with the job.”

“Which is?” I asked when I recovered a bit of my usual equanimity.

The smile turned wicked. Naughty. “I’m a hooker.” She thought about the word for the briefest of moments and then added: “Well, actually I usually use the word ‘escort’ but I figured you’d see through that right away. Most men don’t –or at least pretend they don’t. Guys are like that –they like to pretend that you’re not doing it just for the money.” She stared at me for a moment, as if waiting for me to respond. Then she shrugged dramatically. Theatrically.

I casually picked up my pen as if I were going to write it all down and, as with everything I did, she noticed. It was almost as if she felt she could control me with her words. She did, I suppose…

“You want me to stop wasting your time and tell you why I’m here,” she said with a loud sigh and leaned forward across my desk. Normally I feel a need to protect the space on my desk –over the years it has become an extension of my authority, my personal space- but she did it so naturally, it caught me off guard. Anyway, before I could react she said “I want to have a child,” and sat back, retreating into neutral territory.

I must have looked puzzled –You couldn’t hide anything from Cindy, because she answered my expression before I had even framed a question. “Even strumpets want babies, doc.” Then she smiled at my apparent amusement with her vocabulary. “We also read sometimes…”

“Anyway, I came more just to size you up today…” She tittered at her unintended trade-talk pun. She was silent for a moment –something I came to realize was an uncommon jewel with Cindy – and then her eyes twinkled and her whole body smiled. “I think you’ll do, doc. I think I like you.” Praise indeed.

I never succeeded in helping Cindy with her infertility issues, but all the same, she became a regular distraction in the waiting room. She modified her clothes and hair styles, of course, but I had the impression they were all for the same effect. She found ‘regular’ people banal, uninteresting, and so she teased them. Goaded them, really. She seemed to relish harsh looks, and her body language spoke novels about the seating arrangements she usually provoked. She was the only relaxed one in the room, and she knew it. Loved it. Craved it, maybe.

One day, when I peeked around the corner to see if a particularly obnoxious patient had arrived, I noticed Cindy sitting in the corner seat with a heavy looking briefcase. She had placed it between her lewdly open legs, almost daring anyone to try for it. And she had an oddly satisfied look on her face.

When her turn finally came to be invited into the office, she started talking –as usual- before I could open the chart. Not that I needed a chart for her. After preliminary investigations had suggested that the reason for her failure to conceive was that her Fallopian tubes were no longer open –blocked, perhaps, by one of the many episodes of infection she had encountered in her life on the street- I had tried to refer her to an infertility clinic. She hadn’t liked their attitude after one visit, so she kept coming back to see me.

“Got something for you, doc,” she said, positively beaming. “I wrote a novel,” she said, anticipating my question. “I thought you might like to read it before it’s published,” she continued. My eyebrows must have twitched, because she immediately continued. “Yeah, one of my…friends is a publisher; we did a trade.” I didn’t ask.

But I did read it when I got home that night. It was short –fifteen chapters and more of a novella- but amazingly well-written. It didn’t surprise me – Cindy was obviously bright and a shrewd observer of mankind (I use the word advisedly). What did surprise me, however, was the subject matter: the medical system in general and me –disguised, of course- in particular.

It was a story of the life she knew best: she and her friends in the business –the violence of the street, the drugs, the john-encounters, but more poignantly the unsuccessful attempts of the women to be taken seriously. To be treated as needful humans, not occasionally-moving receptacles. Her words were street-harsh, but no less effective. Certainly no less persuasive. It was a book written from the heart, not from the mind, and this made it all the more compelling to me.

The story was one of suspicion of life outside her world. How it disappointed and disparaged the protagonist and her friends; how they mistrusted outsiders by necessity –survival was knit by acquiescence and tribe. Even in illness and need, they felt themselves alone, bereft of help from a mistrustful and unkind society whose judgments were cruel and who forced impoverished expectations of treatment on them.

Then the woman decides her need for a child is so great, and her attempts to become pregnant so unsuccessful, she needs some outside help. So she visits various clinics where the doctors don’t take her seriously. Her friends just shrug and shake their heads. Of course there’s no help out there for people like her –people like them.

But she persists and manages to get a referral to a specialist –a male specialist is all she could get, but she decides to visit him anyway. The waiting room she finds herself in is middle class and she thinks the women sitting there are so intense she is amused. Not a good sign, she figures, but she has gone this far so she is determined to persist.

When the doctor finally leads her into his office she is struck by one thing: a tall carved wooden statue of a thin native woman holding a baby. It is sitting on his desk and there is a plant beside it through which it peeks with curious eyes. And it is smiling. The carving seems to talk to her about refuge. Safety. And it comforts her. This is the man who can help her, she decides. He’d put the carving on his desk beside a beautiful plant for a reason.

And the story ends with her feeling hopeful. No, he can’t help her, although he tries. But that is the point for her: he tries. And that’s what really matters. Not the result, not the abnormal tests, not even the fact that she probably can’t have a baby. Somebody heard her cry of desperation; somebody listened. And maybe that’s what she really wanted all these years: someone who cared.

I have to admit I cried. My god, is taking notice of someone that important? Is what some of us are searching for merely to be heard? Noticed? To be distinguishable from the background?

You know she never returned to the office after that. Maybe she was too embarrassed, or maybe she had no further need, but I really hope her novel was published. And I hope the man who had promised her a voice, became one and not just another moveable shadow in her life.

Should IVF be denied to Obese Women?

Obesity has a long and chequered history. Different cultures have both defined it and viewed it differently: in some it was a sign of wealth and was seen as desirable; in others, a sign of weakness, dysfunction, sloth. I use the past tense advisedly, given the rise of fast food outlets throughout the world and their putative role in the rise of obesity in all social strata. Adiposity wears different clothes today.

The classification of weight is now largely dependent on measurement of the Body Mass Index (BMI) -(calculated by dividing the person’s mass -weight- in kilograms, by the square of their height in meters. i.e. M/H x H). In North America, at least, ‘Normal’ weight is less than 25; Overweight is 25-30; Obese is greater than 30. The levels assigned for each category are somewhat arbitrary, however, and various countries -perhaps reflecting differences in diet, genetics, or their own studies- have defined them quite differently.

Obesity, then, is a chimera -a culturally enhanced improvisation; there is little argument about the extremes, but much debate in the middle ground, and therefore about the value at which to begin an intervention -and the resultant stigmatization- if it is solely on the basis of BMI. Not all large people are unhealthy, and neither hypertension nor diabetes, for example, are restricted to that population. So, to base important judgements -with their attendant far-reaching effects- on the measurement of BMI alone is more of a societal bias, a cultural bigotry, than a well-founded and scientifically validated decision.

I am not arguing that excess weight is healthy -or even desirable- but suggesting that to justify treatment decisions on BMI alone risks applying generalizations that are useful when dealing with large populations, but inadequate when considering individuals. No one of us is the herd. And the distinction is an important one.

For example, there seems to be a constantly-shifting move afoot to deny fertility treatments -especially in vitro fertilization (IVF)- to obese women.  Canadian MDs consider denying fertility treatments to obese women   It is based, apparently, on several factors: success rates tend to be lower in this group; the procedure is technically more challenging, and the woman is more likely to suffer complications in the pregnancy that may jeopardize both her and the foetus. The fact that in some jurisdictions, the first one or two treatments may be covered by a government subsidy, suggests that there might also be a feeling that the taxpayer’s money could be better spent on projects more likely to succeed. Or perhaps on issues that benefit more of the electorate.

I have to admit I am conflicted in this. One likes to hope that funds -be they private or public- will be well spent. That there is a reasonable likelihood of success. That the risk/benefit ratio is weighted in favor of the funder. And if this is not the case, then it should be made perfectly clear at the start; the outlook honestly explained, lest expectations trump reality.  http://www.creatingafamily.org/blog/obese-women-banned-vitro-fertilization/

But hope is often unquenchable no matter the argument, so what is an infertility clinic to do? Obviously there have to be some standards for IVF. BMI may well be one of them, but as I have suggested, this is likely only a rough guide to success and seems to have discriminatory overtones, no matter the data.

In medical ethics, decisions are often guided by a few simple principles: Autonomy -the right of an individual to make an informed decision; Beneficence -promoting the health and well-being of others and attempting to serve their best interests; and Non-Maleficence -not intentionally doing them harm (primum non nocere). It is the last of these that seems the most problematic for the IVF clinics. Should they knowingly embark upon a treatment -an elective treatment at that- which may have adverse consequences for their patient? The argument has been raised that doctors don’t apply the same values with respect to dealing with, say, smokers or alcoholics that they do with obese infertile women -all of whose problems are often considered to be self-inflicted, at least by society at large. The argument, of course is specious: the condition of infertility, however unfortunate, is not comparable with emphysema, lung cancer, or liver failure…

I think that a more reasonable approach would be to divide the risks both to the obese woman and her foetus into what I will term heedless risk and assimilable risk. It would be irresponsible, for example, to consider IVF in an older woman, obese or not, with severe, unstable and longstanding insulin-requiring diabetes with hypertension and end stage renal failure -the risks are far too great and the outcome unpredictable at best. Contrast that with a large woman -otherwise healthy- whose only risk is her weight. Yes, there may be technical challenges for the IVF, and each of these would need to be assessed on its own merit and risk; and yes, obese women do have a higher likelihood of pregnancy complications, but so do normal weight women who have, say, pre-existing hypertension, or SLE (lupus). And what about obese women who have become pregnant on their own? We struggle through pregnancies with them…

So I suppose the issue is not so much the risk as the guilt of complicity. The sin of acquiescence: collusion with the woman’s dreams of having a baby. Of actively fostering it. Stepping out of the role of omniscient parent and into the character of enabler. But to see it this way, is to be blind to the other equally important, and yet often forgotten ethical principle: Autonomy. If the risk is assimilable, does the patient not have the right to participate in the decision? Is this not also a requirement of that third principle, Beneficence: serving what she perceives to be in her best interest?

It’s a difficult issue, to be sure, and there’s likely no algorithmically valid approach to its resolution. But in the end, we’re humans, not flow charts -our minds simply do not function well that way. Decisions are not unidimensional, because we are not. Let judgements be based not on the letter of the textbooks, not on the litany of complications, nor on the statistical analyses of non-players, non-actors in the drama. As with the Law, let us consider the spirit in which it was written; details are important, but so are people. Even if they happen to be obese.