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Couple with violence issues now want IVF

Different approaches to a tricky consultation dilemma

Case history

Hazel Smith has only been to the surgery once ­ to check her ribs weren't broken.

She admitted her husband had pushed her over, as he was angry that she was not keeping the house tidy. The notes say Hazel does not want stockbroker husband John to know she came in. She has no intention of leaving him as he is only ever bad tempered after drinking, and was very remorseful.

The Smiths have been offered IVF 18 months after referral for infertility. You are sent a form asking you to confirm they are suitable for treatment and that any children would not be at risk of harm.

Dr David Morris

'I would check they still want IVF; situations change'

My first step would be to invite Mrs Smith to the surgery to verify that she and her husband are keen to pursue IVF treatment. The situation may have changed in the 18 months since referral. If they want to proceed, pulling the plug would need to be strongly justified. I would raise the issue with Mrs Smith of her husband's drinking and violent behaviour that she had earlier reported to me, and explain that I have been asked to complete a form regarding suitability for infertility treatment. Her response would decide what I do next.

In the face of escalating domestic violence I would suggest that starting a family would be fraught with danger and that I could not complete the infertility form. I would advise Mrs Smith to seek help from a support group or, if necessary, contact the police. This may aggravate the situation but there is no escaping the fragility of their relationship and the danger to any future children.

But if Mrs Smith could reassure me about her husband's behaviour and the stability of their marriage I would ask her husband to see me, perhaps under the auspices of a well-man check. I would also mention that I need to meet him to fill in the form. If he does not attend I would send a letter.

At Mr Smith's appointment I would ask about alcohol consumption and if appropriate suggest help. I would point out that to complete the form

I need to have his assurance that his alcohol consumption would not be allowed to interfere with his parenting ability.

Maintaining a good doctor-patient relationship will be a real challenge and good record-keeping will be very important.

Dr Mark Wallace

'I'd want to monitor them before filling in the form'

When dealing with a victim of domestic violence, one often can only offer support and sources of advice. But if vulnerable minors are at risk one's role must be much more proactive. I would invite Hazel to discuss the form. At the appointment I would tactfully refer to her husband's violent conduct and talk about the potential impact on both her own and a future child's health. I would need an accurate account of John's behaviour, including the frequency and force of his outbursts.

Assuming that when John is sober he doesn't pose a threat, I would urge her to discuss our consultation with him and for them both to return, when I'd give John the opportunity to be seen alone to tell his side of the story. I'd want to take an alcohol and drug history and explore his attitude to starting a family. It may transpire that work stress underlies all this and he needs to consider a less onerous job.

Other doctors and nurses, including the health visitor, need to be made aware of this couple. Before completing the from I would certainly contact my defence organisation ­ I could be deemed culpable if anything happened to Hazel and John's children. If I could, I would defer completing the form.

Regardless of the IVF issue, it's important that John addresses his behaviour. He may need referring to the local drug and alcohol team, counselling or anger management. I'd want to see John and Hazel over a period of time to monitor progress and then I would be better placed to complete the form. Of course I'm only too aware how many other couples with no history of violence are queuing up for IVF, but as the Smiths' GP I am doing my best for them.

Dr Tina Ambury

'Why are only infertile couples under such scrutiny?'

I intensely dislike 'lifestyle' forms. Rarely do they ask pertinent questions leading to useful answers. More often they are intrusive and downright unethical. If I can put 'this is a lifestyle question which I am not in a position to answer' I do. But this is not the case here.

If the form is not accompanied by signed consent, I would write to the couple asking them to see me. I don't intend to gain informed consent for the clinic, but I do need to cover the matter of domestic violence. As Hazel's notes state she does not want John to know she has attended with injuries from domestic violence, I would contact her first stating I can't proceed without discussing the issue.

There is a possible danger to Hazel. If I refuse to sign the form without giving John a reason, he may blame Hazel and become more violent. If he finds out about the disclosure of his past behaviour, again he could blame Hazel. There is also the possible danger to any unborn child. I could not sign a form if I felt John's behaviour was anything other than a remote memory.

John needs the opportunity to tell his story. Why does he drink? Can we resolve this behaviour and prevent further abuse of Hazel?

All this doesn't escape the irony that had Hazel and John conceived naturally, his behaviour may never have come to our attention. Why are infertile couples subjected to such intense scrutiny and not every other feckless and uncaring parent?

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