Following an unfortunate heated debate on naprotechnology vs IVF on TVAM, it is pertinent to clarify some points. While it is understandable that those who perform one service as opposed to the other will defend their own field, as a bioethicist my interest is with patients’ rights – patients have a right to know unbiased information
I have no axe to grind against or in favour of one or another, even though sometimes debate may lead to think so. I am sorry if I came across as being sceptical of naprotechnology. I am not; in fact it should be promoted even in Malta to ensure that everyone gets this service before going on to IVF. However, I do insist that there are two reservations. Naprotechnology is nothing really new but a putting together of knowledge and techniques we already had. It is probably true therefore that many (abroad) who had been channelled to IVF may not have benefited from natural method information (to which they have a right to) beforehand. Therefore, statistics from abroad saying that naprotechnology worked for those who had been through IVF is not surprising at all.
What is flawed is trying to portray that image on Malta. It is an indirect accusation saying that those in Malta who had IVF did not have any counselling on natural procreation (NaPro). As a doctor, and as most GPs, I feel insulted to say the least. Naprotechnology takes it a step further; it is true – by using methods, such as drugs which stimulate the ovaries, and even counselling done by gynaecologists, who may be better than GPs in some instances. However, are we saying that once a patient is referred by a GP, the gynaecologist immediately channels a patient to IVF? This would be a serious accusation and I am sure that Maltese gynaecologists would have a lot to say about this.
It is the gynaecologists themselves who have always advocated that before IVF one should exhaust all other means. In fact, clomiphene (the drug used by both camps to stimulate the ovaries) and possible surgery are offered before. So what I said was that what is fodder for the goose should be fodder for the gander. If you include this group with the success rate of naprotechnology, you should also include it in the group which finally arrived to IVF.
Now the main argument here is whether we should have naprotechnology. There is no doubt that we should if it fosters a pathway by our health authorities to exhaust means if they feel they are not being exhausted already. But if we are to accept the argument that naprotechnology has over a 90% success rate, then in effect what we are saying is that we do not need IVF. And since investment in naprotechnology does not seem to be that much, then why the ado about IVF? It is not a matter of choice. If one has the success rate that it claims to have (whilst IVF has much less), then one should simply choose the former for the latter and I would be the first to ethically advocate for it.
The reason it is not so is however the flawed way we are interpreting statistics. A similar incident occurred in the US when they compared death rates in hospitals. One was given a bad name because they had a higher incidence of death rates. This of course makes news. But the truth was that this hospital was dealing with more difficult cases and therefore one would expect this difference. But to the public that did not seem to matter. Are we doing the same mistake here? I assert that we are, even though, I re-iterate, I am in favour of naprotechnology being done as first line treatment. No-one has ever denied, on the other hand, that IVF has limited success; it deals, or at least should deal, with the more difficult cases.
The fact is that not all those who arrive to IVF can have their problem managed simply by counselling or simple medical treatment. The fact is also that one has to see objective studies as we are seeing with IVF – which give a more fair picture of what goes on. When the statistics are being gathered by those who practise the technology, one has to look for sources which are credible to the medical world. On Cachrane, PubMed, etc, one sees a lot of studies on IVF but nothing showing that naprotechnology actually works better. Those that show that it worked where IVF had failed will also show that the same women were not given good advice before being channelled to IVF, as admitted on TVAM yesterday morning – something we have been deliberating for 20 years here to avoid. I hope we are not making this accusation.
If naprotechnology has the success rate it is claiming (and I hope it does – for patients’ sake), then within a few years (assuming all infertile women go through the mill) the Gozo initiative will have solved our national infertility problems as we would have no women who need IVF left to treat at all! We would have proved it is unnecessary. Now that would be an accomplishment!
Pierre Mallia is Associate Professor in Family Medicine, Patients’ Rights and Bioethics at the University of Malta; he is also Ethics Adviser to the Medical Council of Malta.
He is also former president of the Malta College of Family Doctors