Reproductive Ethical Issues

There are few ethical issues in medicine that are more challenging than those based around reproductive issues. Personal opinions can be very strong, especially when people have differing values based on strongly held personal religious and/or cultural beliefs. This page will attempt to review several important ethical issues surrounding reproduction and discuss the different ethical principles involved in these issues. The primary principles of medical ethics Medical Ethics Medical ethics are a set of moral values that guide the decision-making of health care professionals in their daily practice. A sense of ethical responsibility has accompanied the profession of medicine since antiquity, and the Hippocratic oath was the 1st document to codify its core ethical principles. Basics of Medical Ethics include nonmaleficence, beneficence, autonomy, and justice.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Introduction

Principles of medical ethics Medical Ethics Medical ethics are a set of moral values that guide the decision-making of health care professionals in their daily practice. A sense of ethical responsibility has accompanied the profession of medicine since antiquity, and the Hippocratic oath was the 1st document to codify its core ethical principles. Basics of Medical Ethics

Although others do exist, there are 4 major principles primarily referenced in medical ethics Medical Ethics Medical ethics are a set of moral values that guide the decision-making of health care professionals in their daily practice. A sense of ethical responsibility has accompanied the profession of medicine since antiquity, and the Hippocratic oath was the 1st document to codify its core ethical principles. Basics of Medical Ethics:

  1. Nonmaleficence: Do no harm.
  2. Beneficence: Do good.
  3. Autonomy: Patients have the right to self-determination.
  4. Justice: Is it fair?

Medical ethical dilemmas versus personal ethical dilemmas

In general, medical ethical dilemmas are situations in which opposing arguments can be made using the 4 main principles of medical ethics Medical Ethics Medical ethics are a set of moral values that guide the decision-making of health care professionals in their daily practice. A sense of ethical responsibility has accompanied the profession of medicine since antiquity, and the Hippocratic oath was the 1st document to codify its core ethical principles. Basics of Medical Ethics.

Example: Jehovah’s Witnesses will often refuse blood transfusions because they have a religious objection to them.

  • The medical ethical dilemma is that the patient has the right to refuse treatment (autonomy), but this decision may cause them harm (violates the principle of nonmaleficence). 
  • Generally speaking, autonomy wins—The patient should not get the blood transfusion.
  • For patients who have no personal objections to blood transfusions, there is no medical dilemma.

Autonomy is important for both clinicians and patients:

  • Clinicians do not have to violate their own personal ethics when treating a patient.
  • Patients have a right to be treated in accordance with their own beliefs, assuming it is otherwise medically appropriate.
  • In general, then, if a clinician is uncomfortable treating a patient according to the patient’s desires (assuming the patient’s desires are medically appropriate), the clinician is obligated to refer that patient to a provider who is comfortable managing the situation.

Contraception in Minors

Definition

Contraception refers to measures a person or couple takes to prevent pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care. There are multiple different types of contraception available, including:

  • Hormonal contraceptive agents: e.g., combined oral contraceptive pills, vaginal ring, patch
  • Intrauterine devices (with or without progestins)
  • Barrier methods: e.g., male and female condoms
  • Surgical methods: e.g., vasectomy, salpingectomy
  • Physical methods: e.g., withdrawal/coitus interruptus, or “pulling out” (not considered reliable contraception)

Arguments in favor

  • Patient autonomy: Patients have the right to control their reproductive health.
  • Prevention of unintended pregnancies and its consequences 
  • Balancing risks and benefits: 
    • There are many safe and effective options available.
    • Pregnancy is higher risk than contraception.
  • Additional noncontraceptive medical benefits of hormonal contraceptives Hormonal contraceptives Hormonal contraceptives (HCs) contain synthetic analogs of the reproductive hormones estrogen and progesterone, which may be used either in combination or in progestin-only formulations for contraception. Hormonal Contraceptives include:
    • Decreasing heavy menstrual bleeding
    • Treating dysmenorrhea
    • Reducing the risk of ovarian, fallopian tube, and endometrial cancers

Potential barriers

  • Inherent adverse effects of contraception, primarily:
    • Slightly increased risk of thrombosis
    • Hormone-related side effects (e.g., headaches, nausea, mood swings)
  • In adolescents: fear of disclosing sexual activity to guardians
  • Cultural/religious views of the individual and/or their guardians regarding sex and reproduction:
    • Cultural views on sex, virginity, and marriage
    • Some religions do not support the use of contraception (e.g., belief that preventing pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care is against God’s will).
  • Cultural/religious views of a clinician’s employer:
    • Some clinicians are prevented from prescribing contraception by their employer. 
    • Most commonly seen in Catholic and/or other religiously affiliated hospitals and health systems
  • Incorrectly associating contraception with abortion

Primary ethical issues

  • Patient autonomy (and privacy)
  • Nonmaleficence (do no harm) 
  • Ensuring adequate access

Clinician obligations

  • Respect patient autonomy:
    • Educate patients about all contraceptive methods, explaining their advantages and adverse events.
    • Empower the patient to make an informed decision regarding contraception.
  • Access to contraceptive methods must be free and without obstacles.
  • A pelvic examination is not required prior to initiating contraception.
  • Minors have a right to privacy with regard to contraception:
    • Parental consent or knowledge is generally not required prior to obtaining contraception (almost all states).
    • Discuss with a minor what will and won’t be visible to their guardians (e.g., medical records, insurance records, etc.).
  • Especially if institutional barriers or concerns about disclosing sexual activity to guardians are present → ask patient about symptoms of dysmenorrhea ( DM DM Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus) and/or heavy menstrual bleeding (HMB):
    • Hormonal contraception is 1st-line treatment for both conditions.
    • Both are very common disorders, with clinical diagnoses made based on subjective patient histories.
    • Some teens (and guardians) may be comfortable with contraception taken to treat DM DM Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus and/or HMB (instead of simply to prevent pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care).
    • Many employers who prevent prescriptions for contraceptives make exceptions when they are used to treat medical conditions.
  • If a clinician is personally uncomfortable prescribing contraception (in cases without medical contraindications), referral must be made to another clinician who is willing to provide contraception.
Hormonal contraception

Oral contraceptives

Image: “Pilule contraceptive” by Ceridwen. License: CC BY-SA 2.0

Case

A 16-year-old female comes to the clinic alone requesting contraception. She is sexually active with one current partner and has been using condoms, but would like something more reliable to prevent pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care. She has had one other partner, who she was last with 6 months ago. She has no medical problems and takes no medications. Her parents do not know that she is sexually active, and she does not want them to know that she is using contraception. How should you proceed?

Discussion

This patient has a right to make her own reproductive choices, which includes the decision to take hormonal contraception. She does not require a pelvic exam or (in most states) need parental consent. If you are not willing to prescribe her contraception or your employer does not allow it for religious or cultural reasons, you should refer her without judgment to a clinician who will. You should also discuss safe sex practices with her, including recommending the continued use of condoms to prevent STIs. Finally, she should be offered screening for gonorrhea Gonorrhea Gonorrhea is a sexually transmitted infection (STI) caused by the gram-negative bacteria Neisseria gonorrhoeae (N. gonorrhoeae). Gonorrhea may be asymptomatic but commonly manifests as cervicitis or urethritis with less common presentations such as proctitis, conjunctivitis, or pharyngitis. Gonorrhea and chlamydia Chlamydia Chlamydiae are obligate intracellular gram-negative bacteria. They lack a peptidoglycan layer and are best visualized using Giemsa stain. The family of Chlamydiaceae comprises 3 pathogens that can infect humans: Chlamydia trachomatis, Chlamydia psittaci, and Chlamydia pneumoniae. Chlamydia if this hasn’t been done yet, which is recommended as annual screening for sexually active people < 25.

Sterilization

Definition

A surgical procedure rendering the individual incapable of reproduction. In women, this is typically via occlusion or removal of the fallopian tube (or hysterectomy for other indications); in men, sterilization is via vasectomy (occlusion of the vas deferens).

Ethical issues

  • Autonomy is crucial: Sterilization should never be performed unless the patient themself gives full informed consent.
  • Truly informed consent → ensure patients understand the permanent nature of the procedure
  • Consent is required only from the patient (not the partner).
  • Sterilization may be performed over the objection of a partner.
  • Balancing risks and benefits:
    • Procedure risks are much lower than pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care risks.
    • Sterilization often allows female partners to stop taking hormonal contraceptives Hormonal contraceptives Hormonal contraceptives (HCs) contain synthetic analogs of the reproductive hormones estrogen and progesterone, which may be used either in combination or in progestin-only formulations for contraception. Hormonal Contraceptives, which may carry higher risks over the long term.
    • Biggest risk of sterilization: regret (especially in younger patients)
  • As with contraception, some clinicians and/or institutions have personal religious/cultural objections to sterilization.

Clinician obligations

  • Take a complete medical history and determine if the patient is an appropriate medical candidate for the procedure.
  • Thorough counseling:
    • Counsel patient on the permanent nature of the procedure. 
    • Ensure that patients, especially younger patients, are fully aware of the risk of regret.
    • Ensure that patients are aware of all alternative contraceptive options (e.g., intrauterine devices, patches, etc.).
    • Discuss risks of the procedure.
  • Balancing patient autonomy with risk of regret:
    • Assess risk of regret: Consider tactfully asking if they would regret the procedure if their current partner and/or all living children were to suddenly pass away (e.g., in a car accident).
    • In general, patient autonomy should be respected.
    • There is no absolute age or number of children at which sterilization is contraindicated.
    • Individuals < 25 years old have the highest rates of regret.
    • Having no children is frequently associated with lower risks of regret (the theory: individuals who have always known they never wanted children are more confident in their decisions).
  • Ensure that patients know when the procedure is effective (e.g., vasectomies require a follow-up semen analysis in 3 months to confirm sterilization).
  • In general, patients should be encouraged to discuss the procedure with current partner(s). 
  • If you or the institution you work for are unwilling to perform a sterilization procedure in an individual who is otherwise an acceptable candidate, you should refer the individual to a clinician who can perform the procedure.

Case

A 23-year-old G4P3013 presents to the clinic requesting a tubal ligation. She is married and has 3 children under the age of 4 with her husband. She has also had one elective abortion while in high school. She has no medical problems and is currently using oral contraceptive pills (OCPs) for contraception. She reports getting severe migraine Migraine Migraine headache is a primary headache disorder and is among the most prevalent disorders in the world. Migraine is characterized by episodic, moderate to severe headaches that may be associated with increased sensitivity to light and sound, as well as nausea and/or vomiting. Migraine Headache headaches (with aura) while taking the OCPs and wants to get off hormones Hormones Hormones are messenger molecules that are synthesized in one part of the body and move through the bloodstream to exert specific regulatory effects on another part of the body. Hormones play critical roles in coordinating cellular activities throughout the body in response to the constant changes in both the internal and external environments. Hormones: Overview. She states that she and her husband “are totally done” having children—she reports feeling overwhelmed caring for 3 young children, and desperately wants to avoid having more children. How do you approach the visit?

Discussion

This young mother is reporting emotional distress at the thought of another pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care. In this case, it is important to start by determining whether the patient is even aware of other contraceptive options. Because she gets migraines with aura, combined hormonal contraception is contraindicated for her, so regardless of your final decision regarding sterilization, she should be switched from her current OCPs. 

Regarding her request for sterilization, she should be thoroughly counseled on the permanent nature of the procedure and on the high risk of regret in young women. Even if she feels very sure now, it is important for her to recognize that as her children get older, her feelings may change. 

Many experts would likely recommend strongly encouraging her to try an intrauterine device (IUD) before jumping straight to sterilization. Generally speaking, an IUD would also have lower medical risks than sterilization, and it eliminates the risk of regret. 

If, however, the patient is adamant and persistent in her request for sterilization (whether or not she agrees to try an alternative option first), it would be reasonable to offer this patient a sterilization procedure based on the ethical principle of respecting patient autonomy. Still, some clinicians may feel uncomfortable with her young age, and, knowing the high risk of regret, decline her request based on the ethical principle of nonmaleficence (do no harm). If her request is denied, she should be offered alternative safe contraception and/or referred to another provider. Either way, excellent communication and demonstrating empathy are key in fostering a therapeutic physician–patient relationship.

Abortion

Definitions

Elective abortion is the intentional termination of pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care by medical (e.g., with misoprostol) or mechanical (e.g., with aspiration or curettage) means.

Therapeutic abortion is the termination of pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care as a therapeutic measure when the life of the mother is in danger.

Note:

  • Medically, the term abortion simply refers to termination of a pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care and includes spontaneous abortion Spontaneous abortion Spontaneous abortion, also known as miscarriage, is the loss of a pregnancy before 20 weeks' gestation. However, the layperson use of the term "abortion" is often intended to refer to induced termination of a pregnancy, whereas "miscarriage" is preferred for spontaneous loss. Spontaneous Abortion, which is referred to colloquially as a miscarriage.
  • When used alone, the term abortion often implies an elective procedure.
Demonstration against abortion laws

Protest in favor of the legalization of abortion in São Paulo, Brazil

Image: “Ato em São Paulo pede a legalização do aborto” by Rovena Rosa/Agência Brasil. License: CC BY 3.0

Indications

  • Patient desire to end a pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care.
  • Other reasons to consider abortion (assuming the pregnant person agrees):
    • The pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care poses a danger to the woman’s health (e.g., cases of maternal pulmonary hypertension Pulmonary Hypertension Pulmonary hypertension (PH) or pulmonary arterial hypertension (PAH) is characterized by elevated pulmonary arterial pressure, which can lead to chronic progressive right heart failure. Pulmonary hypertension is grouped into 5 categories based on etiology, which include primary PAH, and PH due to cardiac disease, lung or hypoxic disease, chronic thromboembolic disease, and multifactorial or unclear etiologies. Pulmonary Hypertension).
    • Severe fetal malformations, especially those incompatible with life
    • Conception is a product of rape or nonconsented artificial insemination.

Contraindications

  • Abortion is illegal in the given clinical circumstance and location. 
  • Consider whether or not the infant could survive outside the womb (e.g., a normal fetus at 34 weeks).

Ethical issues

  • Abortion is a unique example in medicine where there are 2 “patients,” whose medical health are tied to one another, yet who have potentially opposing interests.
    • The fundamental question lies in how the right to life of the fetus is balanced against the right of autonomy of the pregnant person.
    • There are valid ethical arguments for and against elective abortions.
  • Life and personhood of the fetus: When does a fetus become a person? 
    • At conception?
    • With formation of the inner cell mass?
    • With organogenesis/heartbeat?
    • At viability?
    • At birth?
    • This question is often at the heart of debates regarding abortion and is highly influenced by a person’s personal religious/spiritual beliefs.
  • Autonomy of the pregnant person: The right to control one’s own body is paramount in medical ethics Medical Ethics Medical ethics are a set of moral values that guide the decision-making of health care professionals in their daily practice. A sense of ethical responsibility has accompanied the profession of medicine since antiquity, and the Hippocratic oath was the 1st document to codify its core ethical principles. Basics of Medical Ethics.
    • What if the pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care is the product of rape or incest?
    • What if the pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care has a high risk of maternal mortality?
  • Does the health and/or viability of the fetus weigh into the decision-making process?
  • Autonomy of the clinician/staff:
    • Just as patients have autonomy over their own bodies, staff have autonomy over the care they participate in. They cannot be forced to participate in abortions against their will.
    • Some clinicians are comfortable participating in certain types of abortions but not others—for example:
      • Willing to prescribe medication that a patient will take herself, but not willing to perform surgical abortions
      • Willing to perform abortions in cases of rape/incest, but not in purely “elective” cases

Arguments in favor

Autonomy of the pregnant person:

  • A person cannot be forced to do something with their body they do not want to do, even if that results in the death of another.
  • Consider an alternative hypothetical scenario: A child contains a unique type of blood antigen and is slowly hemorrhaging to death; they will die unless they get a blood transfusion from a compatible donor. There is a single compatible donor found; however, this person refuses to donate blood. According to most medical ethicists, this (adult) person cannot be forced to donate blood, and blood cannot be taken against his will, even if it means the child will die. This can be compared to a woman who does not want to “donate” her uterus to support a fetus.

Nonmaleficence:

  • Pregnancy carries much higher risks of serious morbidity and mortality than abortion procedures.
  • In cases of known anomalies incompatible with life, an abortion is likely the safest option for a pregnant person.
  • Reducing trauma related to sexual violence: 
    • Forcing a pregnant person to carry a pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care that is the product of rape can be exceedingly traumatic (daily, often physically painful reminder of the assault).
    • It is important to remember that adoption is an alternative to parenting, not an alternative to pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care.

Note that depenalization is a public health measure seeking to stop unsafe clandestine practices.

Arguments in opposition

The major argument in opposition to abortion is that the embryo/fetus has a right to life, regardless of gestational age.

  • An abortion can be viewed as violating the principle of nonmaleficence for the fetus.
  • Is there a difference between abortions done before or after fetal viability? 
  • Does it matter if the fetus has an anomaly incompatible with life?
  • What is the difference between abortion of a potentially viable infant and homicide?

Clinician obligations

  • Refer patient to an obstetrician/gynecologist (OB/GYN).
  • Any advice given or plan of action in the clinical setting must be informed by local legislation (e.g., waiting periods are enforced in some states in the United States).
  • All counseling should be objective and free from personal bias Bias Epidemiological studies are designed to evaluate a hypothesized relationship between an exposure and an outcome; however, the existence and/or magnitude of these relationships may be erroneously affected by the design and execution of the study itself or by conscious or unconscious errors perpetrated by the investigators or the subjects. These systematic errors are called biases. Types of Biases.
  • After appropriate counseling, a patient’s wishes should be respected.
  • Physicians, nurses, and pharmacists have the right to not participate in abortion care.
    • If you are not willing or able to perform an abortion (or prescribe medications), you should make referrals to other clinicians who are willing.
    • You should not deceive the patient in any way that may prevent her from obtaining a legal abortion, for example:
      • Stalling until she is outside the legal gestational window
      • Referring her to a pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care crisis center while leading her to believe they can help her with abortion services

Case

A 40-year-old G1P0 at 19 weeks of gestational age presents for her routine anatomy ultrasound. This patient struggled with infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility for years, and desperately wants this child. At her anatomy scan, she learns that her child has anencephaly (no cerebral hemispheres), an anomaly incompatible with life the moment the umbilical cord is cut. She is devastated, and wants your advice on what she should do, because she still really wants a child.

Discussion

It is important to approach these situations with empathy, and recognize that your patient may have very strongly held beliefs regarding the topic of abortion. When discussing a diagnosis that is not compatible with life, it is important to let parents have time to grieve during the conversation. When discussing what to do next, you should review her primary options: carrying the pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care to term and delivering versus terminating the pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care

It is important to consider the woman’s desire for a child—at age 40, and after already struggling with fertility, every additional month reduces her chances of being able to conceive another child owing to natural age-related declines in fertility. It is important that she understand what her chances of conception look like (either naturally or via in vitro fertilization Fertilization To undergo fertilization, the sperm enters the uterus, travels towards the ampulla of the fallopian tube, and encounters the oocyte. The zona pellucida (the outer layer of the oocyte) deteriorates along with the zygote, which travels towards the uterus and eventually forms a blastocyst, allowing for implantation to occur. Fertilization and First Week (IVF)) if she were to abort now rather than wait until after delivery.

For some patients, the idea of carrying a child they know they are going to lose for an additional 20+ weeks is more than they can bear emotionally. Terminating a pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care is safer the earlier in gestation it is performed. From a purely physical, medical standpoint, terminating the pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care now is the safest option for the woman. The primary ethical principle of nonmaleficence with regard to the fetus may also hold less weight in this case, since this infant would not have a life outside the womb.

For other patients, the idea of aborting a child, even one without a chance of survival, is one that would cause more guilt and emotional distress than they can bear. In these cases, patient autonomy should be respected and the pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care care continued. Plans should be made for delivery in accordance with their wishes. For example, some may want to have a religious official there to perform a ceremony (e.g., baptism) prior to cutting the umbilical cord. Would the woman want to have a cesarean delivery Cesarean Delivery Cesarean delivery (CD) is the operative delivery of ≥ 1 infants through a surgical incision in the maternal abdomen and uterus. Cesarean deliveries may be indicated for a number of either maternal or fetal reasons, most commonly including fetal intolerance to labor, arrest of labor, a history of prior uterine surgery, fetal malpresentation, and placental abnormalities. Cesarean Delivery for the baby to be born alive if there was a complication during labor Labor Labor is the normal physiologic process defined as uterine contractions resulting in dilatation and effacement of the cervix, which culminates in expulsion of the fetus and the products of conception. Normal and Abnormal Labor?

In both cases, patients and families should be offered mental health support and grief counseling. If in a hospital setting, offering to call a chaplain may also be helpful.

Assisted Reproductive Technology (ART) and Preimplantation Genetic Diagnosis (PGD)

Definitions and procedure descriptions

Assisted reproductive technology is the use of medical techniques and technology to bring about fertilization Fertilization To undergo fertilization, the sperm enters the uterus, travels towards the ampulla of the fallopian tube, and encounters the oocyte. The zona pellucida (the outer layer of the oocyte) deteriorates along with the zygote, which travels towards the uterus and eventually forms a blastocyst, allowing for implantation to occur. Fertilization and First Week and birth of a child, including:

  • Ovulation induction with either:
    • Timed intercourse
    • Intrauterine insemination (IUI)
  • In vitro fertilization Fertilization To undergo fertilization, the sperm enters the uterus, travels towards the ampulla of the fallopian tube, and encounters the oocyte. The zona pellucida (the outer layer of the oocyte) deteriorates along with the zygote, which travels towards the uterus and eventually forms a blastocyst, allowing for implantation to occur. Fertilization and First Week (IVF):
    • Oocytes and sperm are obtained:
      • Sperm are isolated from semen samples provided via masturbation.
      • Oocytes are retrieved surgically after hormonal ovarian stimulation.
    • Eggs are placed in a specialized medium, and sperm are added → fertilization Fertilization To undergo fertilization, the sperm enters the uterus, travels towards the ampulla of the fallopian tube, and encounters the oocyte. The zona pellucida (the outer layer of the oocyte) deteriorates along with the zygote, which travels towards the uterus and eventually forms a blastocyst, allowing for implantation to occur. Fertilization and First Week can occur
    • Embryo(s) are placed back into the uterus (known as reimplantation).
  • Intracytoplasmic sperm injection (ICSI): 
    • An additional technique used during IVF cycles when the sperm are incapable of fertilizing an egg on their own
    • Individual sperm are directly injected into the egg, causing fertilization Fertilization To undergo fertilization, the sperm enters the uterus, travels towards the ampulla of the fallopian tube, and encounters the oocyte. The zona pellucida (the outer layer of the oocyte) deteriorates along with the zygote, which travels towards the uterus and eventually forms a blastocyst, allowing for implantation to occur. Fertilization and First Week.
  • Preimplantation genetic diagnosis (PGD):
    • Genetic testing done on embryos created during an IVF cycle, prior to reimplantation
    • Embryos without the mutations of concern can be selected for reimplantation.
    • Considered a technology for selective reproduction

Uses in clinical practice

  • Infertility
  • Genetic parenthood for same-sex couples
  • Ability to do PGD:
    • Avoid passing on genetic mutations known to cause disease (e.g., Tay-Sachs disease Tay-Sachs disease Tay-Sachs disease is an autosomal recessive lysosomal storage disorder caused by genetic mutations in the hexosaminidase A (HEXA) gene, leading to progressive neurodegeneration. Classic symptoms in infants include rapid degeneration of cognitive and neuromuscular abilities, progressive blindness, and a macular cherry-red spot on physical examination. Tay-Sachs Disease, cystic fibrosis Cystic fibrosis Cystic fibrosis is an autosomal recessive disorder caused by mutations in the gene CFTR. The mutations lead to dysfunction of chloride channels, which results in hyperviscous mucus and the accumulation of secretions. Common presentations include chronic respiratory infections, failure to thrive, and pancreatic insufficiency. Cystic Fibrosis, BRCA).
    • Avoid pregnancies with fetal aneuploidy (e.g., trisomy 21, Turner syndrome Turner syndrome Turner syndrome is a genetic condition affecting women, in which 1 X chromosome is partly or completely missing. The classic result is the karyotype 45,XO with a female phenotype. Turner syndrome is associated with decreased sex hormone levels and is the most common cause of primary amenorrhea. Turner Syndrome).
    • Sex selection of a fetus

Arguments in favor

  • Beneficence (do good): Allow couples who desire it to become biologic parents.
  • Alleviate psychological pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain and social/cultural/religious stigmas associated with childlessness.
  • PGD: 
    • Removes the component of random chance that a couple carrying known genetic mutations will have a child with a potentially serious, life-limiting diagnosis
    • Significantly reduces the likelihood of aneuploidy

Ethical issues

  • Ownership of gametes or embryos used in ART ART Antiretroviral therapy (ART) targets the replication cycle of the human immunodeficiency virus (HIV) and is classified based on the viral enzyme or mechanism that is inhibited. The goal of therapy is to suppress viral replication to reach the outcome of undetected viral load. Anti-HIV Drugs can be complicated.
  • Not all created embryos are implanted:
    • A couple may create many more embryos than can safely be put back at one time (e.g., a couple may create 10 embryos, but only puts back 1 per cycle).
    • The rest can be saved and used later (i.e., for 2nd and 3rd children).
    • Once a couple’s family is complete, there are often embryos remaining.
  • Remaining embryos can be:
    • Discarded/cremated
    • Put up for adoption (to be carried by couples unable to create their own embryos)
    • Donated to science  
  • ↑↑↑ High cost raises ethical concerns regarding access and fairness
  • PGD: 
    • Considerable controversy in the reproductive endocrinology and infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility community regarding the ethics of using PGD solely for sex selection
    • Theoretically allows couples to select embryos based on certain desirable genetic characteristics
    • PGD on a population scale could be considered eugenics.

Clinician obligations

  • For patients who desire fertility treatments and/or PGD → refer the patient to a fertility specialist (i.e., reproductive endocrinologist) if you are not one.
  • Patient counseling regarding:
    • All their reproductive options
    • The cost, risks, and chances of success associated with each option
    • Ensuring that both partners are in agreement with the plan
    • Having a plan for what to do with any embryos that are not implanted. 
  • Have general policies regarding the use of PGD for sex selection, etc. in place to ensure that treatment between patients is fair and consistent.
  • Be sure to follow local laws regarding reproduction.

Cases

Case 1: IVF with PGD for aneuploidy testing

A 34-year-old woman (G1P0010) and her husband come to the office saying they want to have children but are concerned about the risk of Down syndrome Down syndrome Down syndrome, or trisomy 21, is the most common chromosomal aberration and the most frequent genetic cause of developmental delay. Both boys and girls are affected and have characteristic craniofacial and musculoskeletal features, as well as multiple medical anomalies involving the cardiac, gastrointestinal, ocular, and auditory systems. Down Syndrome, given her age. She reports she would almost certainly terminate a pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care complicated by aneuploidy. The patient was doing some research online and was reading up on PGD. The couple is interested in pursuing IVF with PGD. She has a history of one prior pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care with a different partner 10 years ago that she miscarried at 8 weeks. She and her current partner are both healthy and have not yet attempted to conceive. How do you proceed?

Discussion

This patient has a history of a prior pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care and no medical reason to suspect infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility. A major ethical question surrounding the use of IVF is what to do with the embryos that are created but not used, since the majority will be discarded. Similar to the topic of abortion, there is a question of how the rights and autonomy of the couple is weighed against the rights of any embryos created. Some people (often for religious reasons) have strongly held beliefs about rights afforded to an embryo, and personal opinions on this matter can vary widely. All 4 ethical principles come into play here.

In general, medical ethics Medical Ethics Medical ethics are a set of moral values that guide the decision-making of health care professionals in their daily practice. A sense of ethical responsibility has accompanied the profession of medicine since antiquity, and the Hippocratic oath was the 1st document to codify its core ethical principles. Basics of Medical Ethics principles primarily favor the living couple rather than the embryos. IVF is widely accepted as an ethically sound medical treatment option for couples with infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility seeking a biologic family based on the principles of beneficence and autonomy. Although the case may be weaker for patients without infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility who request IVF, it is still widely accepted and done based on principles of autonomy.

The other major ethical question here is surrounding the use of PGD to avoid aneuploidy. Currently, PGD for aneuploidy testing is almost always recommended to couples using IVF starting after age 37, given the increasing risk of aneuploidy with age. 

The use of PGD raises ethical questions because it requires a judgment call on the part of clinicians (and patients) to determine “how bad is bad enough” when considering what types of conditions to avoid. When multiple embryos are created but only a few will become children, is it reasonable to choose the “healthiest” embryos, which have the highest chance of successful pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care and a healthy life? 

There is general agreement that life-limiting conditions (such as Tay-Sachs disease Tay-Sachs disease Tay-Sachs disease is an autosomal recessive lysosomal storage disorder caused by genetic mutations in the hexosaminidase A (HEXA) gene, leading to progressive neurodegeneration. Classic symptoms in infants include rapid degeneration of cognitive and neuromuscular abilities, progressive blindness, and a macular cherry-red spot on physical examination. Tay-Sachs Disease or trisomy 13 Trisomy 13 Trisomy 13, or Patau syndrome, is a genetic syndrome caused by the presence of 3 copies of chromosome 13. As the 3rd most common trisomy, Patau syndrome has an incidence of 1 in 10,000 live births. Most cases of Patau syndrome are diagnosed prenatally by maternal screening and ultrasound. More than half of the pregnancies result in spontaneous abortions. Patau Syndrome (Trisomy 13)) are reasonably excluded for reimplantation because these children (and their parents) would have significantly increased physical (and emotional) pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain and suffering; avoiding this outcome is a reasonable choice based on the principle of nonmaleficence. Trisomy 21 is also a common reason for pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care termination, and if pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care termination would be planned, using PGD to avoid that outcome also is reasonable. 

As with other issues in reproductive medicine, a physician needs to be mindful of their own personal beliefs and biases and recognize that a patient may have different beliefs. Physicians must respect a patient’s autonomy, even if their beliefs differ, and refer the patient to appropriate care providers according to the laws in their area.

In this case, the patient should be referred to a fertility specialist. Based on scientific evidence and current practice guidelines, IVF with PGD for aneuploidy testing is an ethically reasonable option for this couple.

Case 2: PGD for sex selection

A 29-year-old woman (G2P2) presents to the clinic with her husband. They already have 2 girls and really want a boy but know that they do not want more than 3 children. They are interested in IVF with PGD because they want to select a male embryo. How do you proceed?

Discussion

The use of PGD solely for the purpose of sex selection is controversial. Is preimplantation sex selection considered gender bias Bias Epidemiological studies are designed to evaluate a hypothesized relationship between an exposure and an outcome; however, the existence and/or magnitude of these relationships may be erroneously affected by the design and execution of the study itself or by conscious or unconscious errors perpetrated by the investigators or the subjects. These systematic errors are called biases. Types of Biases? Many would consider having a baby of the nondesired gender not “bad enough” to justify IVF and PGD, while others feel that it is reasonable and will offer the procedure based on the principle of patient autonomy. There is no clearly right or wrong answer here, other than that infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility practices should have policies regarding this subject and apply the policy fairly to all patients.

Note that in some cases, sex selection may be beneficial to prevent transmission of recessive X-linked genetic diseases (e.g., hemophilia Hemophilia The hemophilias are a group of inherited, or sometimes acquired, disorders of secondary hemostasis due to deficiency of specific clotting factors. Hemophilia A is a deficiency of factor VIII, hemophilia B a deficiency of factor IX, and hemophilia C a deficiency of factor XI. Patients present with bleeding events that may be spontaneous or associated with minor or major trauma. Hemophilia A and Duchenne muscular dystrophy Duchenne muscular dystrophy Duchenne muscular dystrophy (DMD) is an X-linked recessive genetic disorder that is caused by a mutation in the DMD gene. The mutation leads to the production of abnormal dystrophin, resulting in muscle-fiber destruction and replacement with fatty or fibrous tissue. Duchenne Muscular Dystrophy).

Embryo, Oocyte, and Sperm Donation

Definitions and descriptions

  • Oocyte and sperm donation: 
    • The act of donating haploid cells (e.g., oocyte or sperm cell) to a sperm or oocyte bank so that it can be later made available to another individual, unrelated to the donor, for fertilization Fertilization To undergo fertilization, the sperm enters the uterus, travels towards the ampulla of the fallopian tube, and encounters the oocyte. The zona pellucida (the outer layer of the oocyte) deteriorates along with the zygote, which travels towards the uterus and eventually forms a blastocyst, allowing for implantation to occur. Fertilization and First Week and conception of a child 
    • Sperm donations are provided via male masturbation.
    • Oocytes are retrieved surgically after hormonal ovarian stimulation (identical to the procedure used in IVF cycles).
  • Embryo donation: 
    • The act of giving up or donating an embryo to be later implanted into a different, unrelated woman’s uterus for gestation
    • The mother carrying the embryo is considered the parent (terminology: she “adopted the embryo”).

Rights of oocyte, sperm, and embryo donors

  • Anonymity (this is becoming more difficult with the widespread use of commercial DNA DNA The molecule DNA is the repository of heritable genetic information. In humans, DNA is contained in 23 chromosome pairs within the nucleus. The molecule provides the basic template for replication of genetic information, RNA transcription, and protein biosynthesis to promote cellular function and survival. DNA Types and Structure testing, such as 23andMe)
  • Freedom of responsibility from biologic offspring

Rights of recipients

To be informed about:

  • Any known genetic diseases carried by the donor
  • Limitations of current testing capabilities 
  • Potential complications of the procedures

Arguments in favor

  • Reproductive autonomy
  • Satisfy the desire for parenthood and potentially the experience of being pregnant.
    • An option for couples where one partner’s infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility is related to problems with their gametes
    • Same-sex couples
    • Individuals without a partner who desire parenthood
    • Allow opposite-sex couples privacy regarding infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility.
  • A way to avoid passing on a known genetic mutation Mutation Genetic mutations are errors in DNA that can cause protein misfolding and dysfunction. There are various types of mutations, including chromosomal, point, frameshift, and expansion mutations. Types of Mutations without doing PGD
  • Embryo adoption:
    • Opportunity for embryo rescue: implant embryos that otherwise would have been discarded 
    • Respects the life and personhood of the embryo

Ethical issues to consider

  • Donor compensation and commodification of reproductive material 
  • Ability for parents to select certain traits
  • May raise questions regarding who is the real parent if not clearly established ahead of time
  • Gamete and/or embryo donation may conflict with personal religious/cultural beliefs of the clinician regarding:
    • Sharing of reproductive material or conception of a child outside marriage
    • Oppositions to same-sex marriage

Clinician obligations

  • Refer patients to a fertility expert (e.g., reproductive endocrinologist).
  • Provide accurate information about all available fertility options, regardless of personal beliefs.
  • Follow local laws.

Surrogacy

Definition and description

  • A contract in which a woman carries a pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care for another couple
  • The embryo is typically created from gametes of at least one of the intended parents via IVF.
  • Reasons couples may use surrogates:
    • Uterus of a female partner is unable to carry a pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care owing to abnormalities.
    • Individual or partners without a uterus
  • Motivations of the surrogate:
    • Altruism
    • Monetary compensation

Arguments in favor

  • Surrogate autonomy: Surrogates are making informed decisions to participate.
  • Allows couples to have biologically related children even if they do not have a healthy uterus
  • Surrogates are frequently known to the intended parents.

Arguments in opposition

  • Concern for true surrogate autonomy:
    • How is her decision influenced by the potential for (possibly significant) financial compensation?
    • Does she truly appreciate the risks associated with pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care and how they might impact her body long term?
  • Complex legal relationship of the surrogate mother with the child

Clinician obligations

  • The general practitioner should redirect care to a fertility expert (e.g., reproductive endocrinologist).
  • Counsel patients on all appropriate fertility options available to them.
  • Provide appropriate legal advice: 
    • Laws on this subject regarding who the real parents are can vary widely.
    • Having a lawyer draft a legal contract prior to the pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care may be beneficial in some cases.
    • If asked unexpectedly in the office, at least inform patients that laws on this topic can be very complex and to make sure they are well educated.

Cases

Case 1

A 23-year-old woman (G1P1) underwent an emergency hysterectomy after delivery of her 1st child as a lifesaving measure to stop a severe postpartum hemorrhage Postpartum hemorrhage Postpartum hemorrhage is one of the most common and deadly obstetric complications. Since 2017, postpartum hemorrhage has been defined as blood loss greater than 1,000 mL for both cesarean and vaginal deliveries, or excessive blood loss with signs of hemodynamic instability. Postpartum Hemorrhage. She and her husband want another child and decided to ask a friend to be a surrogate for them. The couple created an embryo using IVF and the embryo was implanted in their surrogate.  

Situation A: During the surrogate’s pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care, she decided she no longer wanted to be pregnant and terminated the pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care.

Situation B: During the surrogate’s pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care, she decided she wanted to keep the child as her own.

Discussion

Individual autonomy is paramount when considering medical ethics Medical Ethics Medical ethics are a set of moral values that guide the decision-making of health care professionals in their daily practice. A sense of ethical responsibility has accompanied the profession of medicine since antiquity, and the Hippocratic oath was the 1st document to codify its core ethical principles. Basics of Medical Ethics. In Situation A, although this may be viewed as a significant betrayal on the part of the surrogate, the surrogate has autonomy over her own body and cannot be forced to carry the pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care against her wishes, even if she originally agreed to it.

In Situation B, often these cases wind up in courts, with variable Variable Variables represent information about something that can change. The design of the measurement scales, or of the methods for obtaining information, will determine the data gathered and the characteristics of that data. As a result, a variable can be qualitative or quantitative, and may be further classified into subgroups. Types of Variables outcomes as to who ends up with parental authority. These cases are always challenging, and the laws can vary.

Case 2

A gay couple wants to have a child, and a close female friend volunteers to be a surrogate for them. The couple is unable to afford IVF, so instead, one of the men has intercourse with the friend, and she conceives. Who are the legal parents?

Discussion

In this case, since the pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care was conceived “naturally,” the woman and man whose gametes created the embryo will usually have parental authority at birth. It will be up to the female friend to voluntarily forfeit her parental rights and for the man’s male partner to formally adopt the child. Cases can become complicated and end up in court when disagreements arise.

References

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