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.

 

Advertisements

It’s never easy to be a doctor -especially an obstetrician. Accouchement is just too unpredictable; babies are just too vulnerable, too fragile. Too many things can go wrong. Quickly. Unexpectedly. Too many people are affected -the doctor included.

Most of us travel through our days in the naïve hope that we will somehow escape unscathed; that bad things only happen to others; that there are probably no slings and arrows of outrageous fortune -not really. We will be, by and large, protected either by good fortune or statistics -we and our children. We rightly assume that with due diligence, and a good doctor, complications can be predicted and bad outcomes prevented. Otherwise why attend clinics? Why arm ourselves with knowledge, gird ourselves with expectations? Hope does indeed spring eternal.

But circumstances sometimes conspire to frustrate even the best intentions; the most thorough preparations are occasionally inadequate. In Life, nothing is certain; the unforeseen is just that, and only after the event is it predictable. Only after the tragedy is there a possibility of some elucidation, and even then, only a possibility of instruction. Of a lesson learned. Even after endless review -and it is always reviewed- it so often remains random and unfair.

Surely at this stage of our progress in Medicine, these things should not happen -not today, not in hospital.  Anticipation. Prevention. Avoidance. Isn’t that what we always preach? That if we think hard enough, monitor long enough, and analyse well enough, most things are either preventable or at the very least, avoidable? The key word, though, is ‘most’. Some things can and do slip through the fine net of surveillance no matter how hard we watch. Some situations arrive at the door unannounced and we have to do our best to deal with them before they enter -or at least minimize the damage if they manage to knock us down as they elbow past…

But while it’s never easy for anybody involved, it is the parents for whom I grieve. They have waited so long in joyous anticipation of a life with their child. That its arrival should be traumatic after all those months and all that excitement, that all that promise need be put on hold, or stored on some high shelf as Hope, is almost unbearable.

And yet, endure it we must, until the path emerges once more from the forest and we can see again. Thank god its a route I have seldom travelled, and yet each time, as if it were the first, I am lost. We are all connected; when one suffers we all suffer. And this is how it should be: the link is strong. It’s what makes us human, binds us together as a society: we care. God forbid that it could ever be different.

And even in the darkest place, there is still hope. I remember Helena trying to explain to the King how she can help in All’s Well That Ends Well:

“Oft expectation fails, and most oft there
Where most it promises; and oft it hits
Where hope is coldest, and despair most fits.”

We all need a hint of light, no matter how dim it seems when it first approaches.

Intimations of Mortality

Early Morning Musings

There are times -often early in the morning after just getting to bed and then being awakened again to go to the Operating Room for some emergency, or more commonly, the Case Room for a delivery- when I wonder why I chose the field I did. After all, I could have gone into Pathology where microscopes never phone, or maybe Dermatology where a rash can usually wait until daylight to be evaluated. Things seem so much worse in the middle of the night.

But then dawn rolls around and things don’t seem so bad. I reconsider and re-evaluate the malevolence of the night and in the new light, I find I have new thoughts. Fresh thoughts. Happy thoughts, though seen through the aching of fatigue and the haze of bleary, reddened eyes. I am, I realize again and again, a Morning person. I relish the colours that spill over the sky from the newly born sun; I look forward to the world self-lit. I am an unabashed pantheist with respect to the freshly washed day. And I realize anew what a privileged life I live and what I have still to learn.

There are daily happenings I struggle to express -little things perhaps, but deeply meaningful in their context. Profound, even. Like the delivery of a child in the wee small hours to a woman with a major cardiac anomaly -one that may have ended in death in a setting less prepared than ours. My role as an accoucheur was admittedly minor -a technician really- but still, I was caught up in the moment. The woman smiled so loudly when I handed her the healthy infant that I just had to say to the beaming husband that he really had a special wife. There was a language barrier to be sure, but he shook my hand, looked me in the eye and said “Of course she’s special!” as if it was so obvious it didn’t even need to be said. I had to turn away so he wouldn’t see the little tear forming in my eye.

Or the time, a world away in Newfoundland, when I tried to bring some Western Canadian Wisdom to a staunchly self-reliant culture. I was working in the small little village of St.Anthony at the Grenfell Mission -a mission dedicated to ‘improving the health, education, and social welfare of people in coastal Labrador and northern Newfoundland’. I was a freshly minted specialist and too full of training to be mindful of the situation. I’d just seen a middle-aged woman with extremely heavy and frequent menses. She’d come to see me along with her obviously concerned husband, a local fisherman. I did what I had been taught in the big city schools and proceeded to discuss the differential diagnosis with them and the various treatment options available. After what must have been a lengthy monologue I asked them what option they preferred. I remember they both looked at each other for the longest time, and then at me. “Well, the way I figures it,” the husband said glancing at his wife, “When my family’s hungry, I don’t ask them fish in my boat what they wants. I jes do what I needs to do, boy. So do what you needs to do; fix my wife!”

Sometimes a difficult decision has to be made, and although the situation mandates explaining the reasons to the patient and their loved ones, and their opinions canvassed, in the final analysis they expect me to make a decision in their best interest. They have no way of knowing all the background that goes into making the best decision; ultimately and for better or worse, the buck, the expert opinion, really does stop with me -and the treatment if they agree. It’s a weighty thing to have to be a final arbiter; after all, they may disagree and seek a second opinion. But ultimately, a decision must be made by somebody. And that’s what they want: however onerous the responsibility, most are seeking someone to take charge of the situation. To do something.

But you know, it’s not all death and taxes. There are some truly delightful moments, even in the dead of night. I had been following a friendly couple through their labour and in the course of my visits as the night wore on, I discovered that he was a violist in the Symphony Orchestra. Although they were playing that evening, he didn’t want to take the chance of missing the delivery of his first and anxiously awaited child. But in case she delivered early, he’d brought his viola and it sat in its little black shell in the corner. He never so much as glanced at it as far as I could tell. Unfortunately, labour did not progress as we had hoped and so somewhere around three A.M. I decided she needed a Caesarian Section. They were both disappointed, of course -so was I, in fact- but were both reassured by the ability of being together in the OR. And yet as I checked to make sure her epidural was working and then made the skin incision, I wondered aloud where he was. It had seemed so important to him to be there with her. I asked her about it. “Oh, don’t worry about him,” she said from behind the drapes. “He’s got it all planned.”

I could see the anaesthesiologist grinning behind his mask: he was obviously in on a surprise. For me, the only surprises so far were the father’s absence, and the fact that the doors to the OR were wide open -something that would never be allowed during the busy daytime hours. So I continued with the operation and in a few minutes extracted a big, healthy and screaming baby. Suddenly, echoing along the empty corridor outside I could hear a viola playing Happy Birthday. You can’t wipe your eyes when you are scrubbed -a nurse had to do it. But only after she’d wiped her own. I still can’t listen to the tune without a sigh and a deep breath.

My field is hard and at times difficult, but there are moments… Many of them, in fact.

Words and Names

Words are important, let’s face it; they help us address those most existential of all entities: concepts. They describe things, modify things, name things. Without them, we’d no doubt be reduced to gestures -limited descriptors at best. The richness that is reality would still be there, but unexpressed, identified perhaps, but somehow unrepresented. To an extent then, we, the world -everything- is partly  how it is described. Words are powerful.

By now I’m sure you’re wondering what all this has to do with women’s health. Why is an obstetrician pretending he’s a philosopher? Words again, you’ll notice… Well, when we name something -a process, a condition- it engenders a certain expectation. If you name an experience, the name comes to represent what was experienced. Pain comes to mind. Or laughter. We know how it felt to experience these and if someone were to suggest that they were going to occur again, we’d probably have a pretty good idea what to expect. It’s what names are for, after all. Of course, what we call pain might be different from what someone else experienced, but we know what that experience meant for us. We would be able differentiate it from, say, tingling, or maybe fatigue. And if someone were to say you were going to experience pain, the very word would likely engender an expectation of something fairly identifiable and even relatively specific.

Okay, how about ‘labour’? You are a woman in your second pregnancy; your first labour was terrible. Maybe the contractions were deemed inefficient despite their pain, and augmentation with oxytocin was necessary. It seemed slow and interminable, punctuated with frustrations you could never have anticipated, delays that seemed unnecessary, maybe even resulted in something you wanted to avoid: forceps perhaps, or a Caesarian section. You have all that to look forward to (backward to?) again.

But do you? Well, we use the same word for second labours, sixth labours, whatever. So with minor variations on the theme, you expect the same thing. You know what to expect; you know what mindless suffering awaits, and if there was some trouble with the actual birth process, you know it will repeat: you haven’t changed. Your pelvic measurements are the same and this baby measured even bigger than your last baby on the ultrasound you had a month ago. So if anything, it’s going to be worse. Your midwife or obstetrician has tried to reassure you that second labours are quicker, more efficient creatures than first labours. Different creatures, in fact. But despite the rhetoric, something tells you they’re wrong. After all it’s still called ‘labour’ isn’t it? And you know what that means; you’ve experienced ‘labour’…

So why don’t we call subsequent labours by a different word if they really are different? Like the apocryphal description of different kinds of snow by the Inuit using different words: not all snow is the same, obviously, so if you were to hear a different description, a different word, you would expect that what you were going to see and experience was going to be different as well. Words are powerful.

I tell this to my patients and they usually laugh, politely to be sure, but secure in their knowledge that it’s all going to turn out the same no matter what I say. For one thing, I’m a man, so how would I know? And for another, and an even more convincing certainty, if it were truly different, there would be a different word for it.

I have struggled for years to come up with another word, but alas, with no success -no Nobel Prize for advancement of women’s psychological health, no media attention whatsoever.  I suspect I’ve not even been particularly convincing, coming at it as I do from the ‘other side’… But Hope springs eternal, eh?

Any suggestions?