Up-to-date technologies: An Infertility Specialist needs to be able to provide state-of-the-art therapies. What was adequate therapy 5 years ago is probably not acceptabletoday. This field is changing so quickly that it is important that you receive the latest and most advanced treatments available because they will make a difference in outcome. The physician should be able to review with you all the "breakthroughs" which are reported. Some are real and others are hype, but we should always be able to thoughtfully evaluate what's important and what's not. If something is important, we need to be incorporating it into our practice.

Access to the physician: It is absolutely reasonable for you to expect to be seen by your physician. After all, that's what you're paying for! While it is sometimes appropriate to be seen by ancillary personnel, e.g. a phlebotomist on a day when you just need a blood test or occasionally by an ultrasound technician, it is not reasonable to be seen only rarely by the physician. It is too easy to fall through the cracks and get lost in a system where the patient is seen primarily by ancillary personnel. These situations are the ones where the patient may be randomly treated, and the therapeutic interventions seem haphazard and directionless. Phone calls should be answered the same day, or at the latest the next day in non-emergent situations. It is not requesting too much to expect to have contact with your doctor. At ACRM our physicians strive to provide the daily care and be directly involved in all phases.

Label experimental procedures as such: Without research, there would be no progress in medicine. It is imperative that we try new approaches in medicine. However, if a patient is being treated in an experimental fashion, that should be made quite clear to the couple. Furthermore it is inappropriate to hold out success rates from limited experimental series as "routine." Sometimes experimental protocols look great in the initial tests but as more patients in the "real world" are treated in the same fashion, the new protocols turn out to be no better than the old ones. If a physician is carrying out some truly new approach, billing and reimbursement become an issue. It is unethical to make a patient and/or their insurance company pay for research. Research funding exists for this very reason.

Efficiency

It's easier to keep going than to change courses: Although it's tempting to keep doing the same old things, that doesn't mean it's right to do so. It's hard to say to someone that what we're doing is not working. The medical literature clearly shows that our therapies are successful quickly if they are going to work at all. Typically pregnancies are established within 3-6 cycles of therapy. If a couple has not been successful within this time frame, it is important to reassess and probably change approaches. Prolonged treatment with the same approaches may mean that no one is critically reviewing the data or even scarier, the motivations for treatment may be ethically questionable. As a general statement, there is not a reason for carrying out more than 6 cycles of the same therapy when there hasn't been any success

Clear, thought out treatment plans are critical: Along the same lines as the above, it is obvious that the physician must project out a reasonable appropriate treatment plan. We find that patients are most comfortable when they know what we will be doing over the next 3-6 months. It is not at all unreasonable to expect the physician to make the working diagnosis completely clear, and the suggested treatment should make sense. Although a couple does not need to understand the subtleties of the medical literature, it should be a bare minimum to expect that a couple can walk away from the consultation with their physician knowing what the problem is, what the treatment approach will be and why. If you can't answer these questions at all times, there is a problem with your treatment.

Improvements which "increase" efficiency: Sometimes there are technological improvements which make an organization run more smoothly and efficiently and these ultimately help the consumer/customer. An example of this is ATM machines, which have facilitated banking for many people. Some innovations such as voice mail can make life miserable, however. They may make sense for the company, but they certainly don't help the consumer or customer. Too many "improvements" in a medical office may be cost effective for the practice but may make the physician inaccessible to the patient. There is of course a happy medium. It is not too much to ask to be able to have your questions answered quickly, easily and efficiently.

Honesty

Don't ever lie: Patients have repeatedly told us that they want to hear the truth. If a procedure is painful, say so. If it is unbearably so, do it under anesthesia. If something is expensive, don't hide it. It is unfair to say that a cycle of gonadotropin ovulation induction costs $1500-2000. The medications may cost that, but in order to carry out the cycle the patient will need ultrasounds, blood tests and so on. The cycle as a whole may end up costing $4000. It is in everyone's best interest to avoid surprises.

Don't misrepresent success: In order for a couple to make a decision regarding a given treatment, they must know the likelihood of success. A given amount of time, effort and money may be worthwhile for a 60% likelihood of success but not for a 20% likelihood. In order for a couple to make these decisions, then, correct data must be available. Once again, it is in everyone's best interest that we provide a true assessment of the chances for success. Furthermore, we should always provide an estimate of the desired end-point, which is a healthy baby. To focus on fertilization rates, pregnancies per transfer and other assessments, which ultimately are not important to the couple, is misleading. To make an educated decision, a couple needs to know what is the chance that a given therapy will lead to a baby.

Say it when it's time to stop: Unfortunately, there will be some couples who will not be able to get pregnant. As physicians, we are trained to always think of what we will do next. For example, in surgery we're trained to know what to do if we encounter unexpected bleeding. In reproduction, however, there are scenarios for which there isn't a next step. If a woman no longer has good quality eggs as a consequence of age, none of our therapies with her eggs will be successful at changing that reality. Although it is always easier to just repeat another cycle of treatment, we as physicians have to have the courage to tell a couple to stop that treatment. Our patients have told us that they would rather know up front if they aren't going to be successful. This way, they won't invest their time money and emotional energy into a futile process. It is never pleasant or easy to deliver bad news, but it is our obligation sometimes and it is the only ethical way to practice medicine. Other options to achieve becoming parents with donor eggs, or through adoption can then be realistically considered.