Reproductive Ethical Issues

Introduction

Principles of medical ethics 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. Medical Ethics: Basic Principles

Although others do exist, there are 4 major principles primarily referenced in medical ethics 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. Medical Ethics: Basic Principles:

1. Nonmaleficence Nonmaleficence Not acting with the intention to do harm. Medical Ethics: Basic Principles: Do no harm.
2. Beneficence Beneficence The state or quality of being kind, charitable, or beneficial. The ethical principle of beneficence requires producing net benefit over harm. Medical Ethics: Basic Principles: Do good.
3. Autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles: Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship have the right to self-determination.
4. Justice Justice An interactive process whereby members of a community are concerned for the equality and rights of all. Research Ethics: Is it fair?

Medical ethical dilemmas Dilemmas A clinical situation in which 2 ethical principles are at odds, and a course of action must be taken in transgression of 1 of the 2. Medical Ethics: Basic Principles versus personal ethical dilemmas Dilemmas A clinical situation in which 2 ethical principles are at odds, and a course of action must be taken in transgression of 1 of the 2. Medical Ethics: Basic Principles

In general, medical ethical dilemmas Dilemmas A clinical situation in which 2 ethical principles are at odds, and a course of action must be taken in transgression of 1 of the 2. Medical Ethics: Basic Principles are situations in which opposing arguments can be made using the 4 main principles of medical ethics 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. Medical Ethics: Basic Principles.

Example: Jehovah’s Witnesses will often refuse blood transfusions Blood transfusions The introduction of whole blood or blood component directly into the bloodstream. Transfusion Products because they have a religious objection to them.

• The medical ethical dilemma is that the patient has the right to refuse treatment ( autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles), but this decision may cause them harm (violates the principle of nonmaleficence Nonmaleficence Not acting with the intention to do harm. Medical Ethics: Basic Principles). 
• Generally speaking, autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles wins—The patient should not get the blood transfusion.
• For patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship who have no personal objections to blood transfusions Blood transfusions The introduction of whole blood or blood component directly into the bloodstream. Transfusion Products, there is no medical dilemma.

Autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles is important for both clinicians and patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship:

• Clinicians do not have to violate their own personal ethics 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. Medical Ethics: Basic Principles when treating a patient.
• Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship have a right to be treated in accordance with their own beliefs, assuming it is otherwise medically appropriate.
• In general, then, if a clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship is uncomfortable treating a patient according to the patient’s desires (assuming the patient’s desires are medically appropriate), the clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship 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 The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care. There are multiple different types of contraception available, including:

• Hormonal contraceptive agents: e.g., combined oral contraceptive pills Combined oral contraceptive pills Fixed drug combinations administered orally for contraceptive purposes. Hormonal Contraceptives, vaginal ring Vaginal Ring Hormonal Contraceptives, patch Patch Nonpalpable lesion > 1 cm in diameter Generalized and Localized Rashes
• Intrauterine devices Intrauterine devices Contraceptive devices placed high in the uterine fundus. Hormonal Contraceptives (with or without progestins Progestins Compounds that interact with progesterone receptors in target tissues to bring about the effects similar to those of progesterone. Primary actions of progestins, including natural and synthetic steroids, are on the uterus and the mammary gland in preparation for and in maintenance of pregnancy. Hormonal Contraceptives)
• Barrier methods Barrier Methods Methods of contraception in which physical, chemical, or biological means are used to prevent the sperm from reaching the fertilizable ovum. Nonhormonal Contraception: e.g., male and female condoms Condoms A sheath that is worn over the penis during sexual behavior in order to prevent pregnancy or spread of sexually transmitted disease. Nonhormonal Contraception
• Surgical methods: e.g., vasectomy Vasectomy Surgical removal of the ductus deferens, or a portion of it. It is done in association with prostatectomy, or to induce infertility. Nonhormonal Contraception, salpingectomy
• Physical methods: e.g., withdrawal/ coitus interruptus Coitus interruptus A contraceptive method whereby coitus is purposely interrupted in order to prevent ejaculation of semen into the vagina. Nonhormonal Contraception, or “pulling out” (not considered reliable contraception)

Arguments in favor

• Patient autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles: Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship 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 Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care 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 Heavy menstrual bleeding Excessive menstrual blood loss (objectively defined as > 80 mL blood loss/cycle). Can be based on heavy flow, as determined by the patient Abnormal Uterine Bleeding
  • Treating dysmenorrhea
  • Reducing the risk of ovarian, fallopian tube Fallopian Tube A pair of highly specialized canals extending from the uterus to its corresponding ovary. They provide the means for ovum transport from the ovaries and they are the site of the ovum’s final maturation and fertilization. The fallopian tube consists of an interstitium, an isthmus, an ampulla, an infundibulum, and fimbriae. Its wall consists of three layers: serous, muscular, and an internal mucosal layer lined with both ciliated and secretory cells. Uterus, Cervix, and Fallopian Tubes: Anatomy, and endometrial cancers

Potential barriers

• Inherent adverse effects of contraception, primarily:
  • Slightly increased risk of thrombosis Thrombosis Formation and development of a thrombus or blood clot in the blood vessel. Epidemic Typhus
  • Hormone-related side effects (e.g., headaches, nausea Nausea An unpleasant sensation in the stomach usually accompanied by the urge to vomit. Common causes are early pregnancy, sea and motion sickness, emotional stress, intense pain, food poisoning, and various enteroviruses. Antiemetics, mood swings)
• In adolescents: fear of disclosing sexual activity to guardians
• Cultural/religious views of the individual and/or their guardians regarding sex Sex The totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism. Gender Dysphoria and reproduction:
  • Cultural views on sex Sex The totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism. Gender Dysphoria, virginity, and marriage
  • Some religions do not support the use of contraception (e.g., belief that preventing pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care is against God’s will).
• Cultural/religious views of a clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship’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 Health systems The complexity of health systems and the delivery of healthcare has resulted in the growing field of health systems science, which has now joined basic and clinical sciences as the 3rd pillar of medical education. Health systems science allows for an understanding of the framework in which care providers practice, and in comprehension of the interconnected components of care delivery. Healthcare System
• Incorrectly associating contraception with abortion Abortion Expulsion of the product of fertilization before completing the term of gestation and without deliberate interference. Spontaneous Abortion

Primary ethical issues Ethical issues Clusters of topics that fall within the domain of bioethics, the field of study concerned with value questions that arise in biomedicine and health care delivery. Healthcare System

• Patient autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles (and privacy)
• Nonmaleficence Nonmaleficence Not acting with the intention to do harm. Medical Ethics: Basic Principles (do no harm) 
• Ensuring adequate access

Clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship obligations

• Respect patient autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles:
  • Educate patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship 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 ETC The electron transport chain (ETC) sends electrons through a series of proteins, which generate an electrochemical proton gradient that produces energy in the form of adenosine triphosphate (ATP). Electron Transport Chain (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 Heavy menstrual bleeding Excessive menstrual blood loss (objectively defined as > 80 mL blood loss/cycle). Can be based on heavy flow, as determined by the patient Abnormal Uterine Bleeding ( HMB HMB Excessive menstrual blood loss (objectively defined as > 80 mL blood loss/cycle). Can be based on heavy flow, as determined by the patient Abnormal Uterine Bleeding):
  • 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 HMB Excessive menstrual blood loss (objectively defined as > 80 mL blood loss/cycle). Can be based on heavy flow, as determined by the patient Abnormal Uterine Bleeding (instead of simply to prevent pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care).
  • Many employers who prevent prescriptions for contraceptives make exceptions when they are used to treat medical conditions.
• If a clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship is personally uncomfortable prescribing contraception (in cases without medical contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation), referral must be made to another clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship who is willing to provide contraception.

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 Condoms A sheath that is worn over the penis during sexual behavior in order to prevent pregnancy or spread of sexually transmitted disease. Nonhormonal Contraception, but would like something more reliable to prevent pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and 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 Judgment The process of discovering or asserting an objective or intrinsic relation between two objects or concepts; a faculty or power that enables a person to make judgments; the process of bringing to light and asserting the implicit meaning of a concept; a critical evaluation of a person or situation. Psychiatric Assessment) to a clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship who will. You should also discuss safe sex Sex The totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism. Gender Dysphoria practices with her, including recommending the continued use of condoms Condoms A sheath that is worn over the penis during sexual behavior in order to prevent pregnancy or spread of sexually transmitted disease. Nonhormonal Contraception to prevent STIs STIs Sexually transmitted infections (STIs) or sexually transmitted diseases (STDs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease. Sexually Transmitted Infections (STIs). Finally, she should be offered screening Screening Preoperative Care 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 Screening Preoperative Care 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 Fallopian Tube A pair of highly specialized canals extending from the uterus to its corresponding ovary. They provide the means for ovum transport from the ovaries and they are the site of the ovum’s final maturation and fertilization. The fallopian tube consists of an interstitium, an isthmus, an ampulla, an infundibulum, and fimbriae. Its wall consists of three layers: serous, muscular, and an internal mucosal layer lined with both ciliated and secretory cells. Uterus, Cervix, and Fallopian Tubes: Anatomy (or hysterectomy for other indications); in men, sterilization is via vasectomy Vasectomy Surgical removal of the ductus deferens, or a portion of it. It is done in association with prostatectomy, or to induce infertility. Nonhormonal Contraception (occlusion of the vas deferens Vas Deferens The excretory duct of the testes that carries spermatozoa. It rises from the scrotum and joins the seminal vesicles to form the ejaculatory duct. Testicles: Anatomy).

Ethical issues Ethical issues Clusters of topics that fall within the domain of bioethics, the field of study concerned with value questions that arise in biomedicine and health care delivery. Healthcare System

• Autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles is crucial: Sterilization should never be performed unless the patient themself gives full informed consent Informed consent Informed consent is a medicolegal term describing the documented conversation between a patient and their physician wherein the physician discloses all relevant and necessary information to a patient who is competent to make an informed and voluntary decision regarding their care. Competency, disclosure, and voluntariness are the key elements upon which IC is based. Informed Consent.
• Truly informed consent Informed consent Informed consent is a medicolegal term describing the documented conversation between a patient and their physician wherein the physician discloses all relevant and necessary information to a patient who is competent to make an informed and voluntary decision regarding their care. Competency, disclosure, and voluntariness are the key elements upon which IC is based. Informed Consent → ensure patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship 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 The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and 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 Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship)
• As with contraception, some clinicians and/or institutions have personal religious/cultural objections to sterilization.

Clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship 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 Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship, especially younger patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship, are fully aware of the risk of regret.
  • Ensure that patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship are aware of all alternative contraceptive options (e.g., intrauterine devices Intrauterine devices Contraceptive devices placed high in the uterine fundus. Hormonal Contraceptives, patches Patches Vitiligo, etc ETC The electron transport chain (ETC) sends electrons through a series of proteins, which generate an electrochemical proton gradient that produces energy in the form of adenosine triphosphate (ATP). Electron Transport Chain (ETC).).
  • Discuss risks of the procedure.
• Balancing patient autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles 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 Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles 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 Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship know when the procedure is effective (e.g., vasectomies require a follow-up semen analysis Semen analysis The quality of semen, an indicator of male fertility, can be determined by semen volume, ph, sperm concentration (sperm count), total sperm number, sperm viability, sperm vigor (sperm motility), normal sperm morphology, acrosome integrity, and the concentration of white blood cells. Infertility in 3 months to confirm sterilization).
• In general, patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship 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 Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship who can perform the procedure.

Case

A 23-year-old G4P3013 presents to the clinic requesting a tubal ligation Tubal Ligation Nonhormonal Contraception. She is married and has 3 children under the age of 4 with her husband. She has also had one elective abortion Abortion Expulsion of the product of fertilization before completing the term of gestation and without deliberate interference. Spontaneous Abortion while in high school. She has no medical problems and is currently using oral contraceptive Oral contraceptive Compounds, usually hormonal, taken orally in order to block ovulation and prevent the occurrence of pregnancy. The hormones are generally estrogen or progesterone or both. Benign Liver Tumors 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 Aura Reversible neurological phenomena that often precede or coincide with headache onset. Migraine Headache) 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 and Types. 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 The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and 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 Aura Reversible neurological phenomena that often precede or coincide with headache onset. Migraine Headache, 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 Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles. 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 Nonmaleficence Not acting with the intention to do harm. Medical Ethics: Basic Principles (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 Communication The exchange or transmission of ideas, attitudes, or beliefs between individuals or groups. Decision-making Capacity and Legal Competence and demonstrating empathy Empathy An individual’s objective and insightful awareness of the feelings and behavior of another person. It should be distinguished from sympathy, which is usually nonobjective and noncritical. It includes caring, which is the demonstration of an awareness of and a concern for the good of others. Psychotherapy are key in fostering a therapeutic physician–patient relationship.

Abortion

Definitions

Elective abortion Abortion Expulsion of the product of fertilization before completing the term of gestation and without deliberate interference. Spontaneous Abortion is the intentional termination of pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care by medical (e.g., with misoprostol Misoprostol A synthetic analog of natural prostaglandin e1. It produces a dose-related inhibition of gastric acid and pepsin secretion, and enhances mucosal resistance to injury. It is an effective anti-ulcer agent and also has oxytocic properties. Eicosanoids) or mechanical (e.g., with aspiration or curettage Curettage A scraping, usually of the interior of a cavity or tract, for removal of new growth or other abnormal tissue, or to obtain material for tissue diagnosis. It is performed with a curet (curette), a spoon-shaped instrument designed for that purpose. Benign Bone Tumors) means.

Therapeutic abortion Abortion Expulsion of the product of fertilization before completing the term of gestation and without deliberate interference. Spontaneous Abortion is the termination of pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care as a therapeutic measure when the life of the mother is in danger.

Note:

• Medically, the term abortion Abortion Expulsion of the product of fertilization before completing the term of gestation and without deliberate interference. Spontaneous Abortion simply refers to termination of a pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care and includes spontaneous abortion Abortion Expulsion of the product of fertilization before completing the term of gestation and without deliberate interference. Spontaneous Abortion, which is referred to colloquially as a miscarriage Miscarriage 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.
• When used alone, the term abortion Abortion Expulsion of the product of fertilization before completing the term of gestation and without deliberate interference. Spontaneous Abortion often implies an elective procedure.

Indications

• Patient desire to end a pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care.
• Other reasons to consider abortion Abortion Expulsion of the product of fertilization before completing the term of gestation and without deliberate interference. Spontaneous Abortion (assuming the pregnant person agrees):
  • The pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and 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 Artificial insemination Artificial introduction of semen or spermatozoa into the vagina to facilitate fertilization. Infertility.

Contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation

• Abortion Abortion Expulsion of the product of fertilization before completing the term of gestation and without deliberate interference. Spontaneous 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 Ethical issues Clusters of topics that fall within the domain of bioethics, the field of study concerned with value questions that arise in biomedicine and health care delivery. Healthcare System

• Abortion Abortion Expulsion of the product of fertilization before completing the term of gestation and without deliberate interference. Spontaneous Abortion is a unique example in medicine where there are 2 “ patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship,” 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 Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles 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 Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast?
  • With organogenesis/heartbeat?
  • At viability?
  • At birth?
  • This question is often at the heart of debates regarding abortion Abortion Expulsion of the product of fertilization before completing the term of gestation and without deliberate interference. Spontaneous Abortion and is highly influenced by a person’s personal religious/spiritual beliefs.
• Autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles of the pregnant person: The right to control one’s own body is paramount in medical ethics 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. Medical Ethics: Basic Principles.
  • What if the pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care is the product of rape or incest?
  • What if the pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care has a high risk of maternal mortality Mortality All deaths reported in a given population. Measures of Health Status?
• Does the health and/or viability of the fetus weigh into the decision-making process?
• Autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles of the clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship/staff:
  • Just as patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship have autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles over their own bodies, staff have autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles 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 Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles 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 Antigen Substances that are recognized by the immune system and induce an immune reaction. Vaccination 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 Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy to support a fetus.

Nonmaleficence Nonmaleficence Not acting with the intention to do harm. Medical Ethics: Basic Principles:

• Pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care carries much higher risks of serious morbidity Morbidity The proportion of patients with a particular disease during a given year per given unit of population. Measures of Health Status and mortality Mortality All deaths reported in a given population. Measures of Health Status than abortion Abortion Expulsion of the product of fertilization before completing the term of gestation and without deliberate interference. Spontaneous Abortion procedures.
• In cases of known anomalies incompatible with life, an abortion Abortion Expulsion of the product of fertilization before completing the term of gestation and without deliberate interference. Spontaneous 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 The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and 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 The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and 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 Abortion Expulsion of the product of fertilization before completing the term of gestation and without deliberate interference. Spontaneous Abortion is that the embryo Embryo The entity of a developing mammal, generally from the cleavage of a zygote to the end of embryonic differentiation of basic structures. For the human embryo, this represents the first two months of intrauterine development preceding the stages of the fetus. Fertilization and First Week/fetus has a right to life, regardless of gestational age Gestational age The age of the conceptus, beginning from the time of fertilization. In clinical obstetrics, the gestational age is often estimated as the time from the last day of the last menstruation which is about 2 weeks before ovulation and fertilization. Pregnancy: Diagnosis, Physiology, and Care.

• An abortion Abortion Expulsion of the product of fertilization before completing the term of gestation and without deliberate interference. Spontaneous Abortion can be viewed as violating the principle of nonmaleficence Nonmaleficence Not acting with the intention to do harm. Medical Ethics: Basic Principles 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 Abortion Expulsion of the product of fertilization before completing the term of gestation and without deliberate interference. Spontaneous Abortion of a potentially viable infant and homicide?

Clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship 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 Legislation Works consisting of the text of proposed or enacted legislation that may be in the form of bills, laws, statutes, ordinances, or government regulations. Patient-Doctor Confidentiality (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 Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship, nurses, and pharmacists have the right to not participate in abortion Abortion Expulsion of the product of fertilization before completing the term of gestation and without deliberate interference. Spontaneous Abortion care.
  • If a clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship is not willing or able to perform an abortion Abortion Expulsion of the product of fertilization before completing the term of gestation and without deliberate interference. Spontaneous Abortion (or prescribe medications), they should make referrals to other clinicians who are willing to do so.
  • A clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship should not deceive the patient in any way that may prevent her from obtaining a legal abortion Abortion Expulsion of the product of fertilization before completing the term of gestation and without deliberate interference. Spontaneous Abortion, for example:
    • Stalling until she is outside the legal gestational window
    • Referring her to a pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care crisis center while leading her to believe they can help her with abortion Abortion Expulsion of the product of fertilization before completing the term of gestation and without deliberate interference. Spontaneous Abortion services

Case

A 40-year-old G1P0 at 19 weeks of gestational age Gestational age The age of the conceptus, beginning from the time of fertilization. In clinical obstetrics, the gestational age is often estimated as the time from the last day of the last menstruation which is about 2 weeks before ovulation and fertilization. Pregnancy: Diagnosis, Physiology, and Care 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 Anencephaly A malformation of the nervous system caused by failure of the anterior neuropore to close. Infants are born with intact spinal cords, cerebellums, and brainstems, but lack formation of neural structures above this level. The skull is only partially formed but the eyes are usually normal. This condition may be associated with folate deficiency. Affected infants are only capable of primitive (brain stem) reflexes and usually do not survive for more than two weeks. Neural Tube Defects (no cerebral hemispheres), an anomaly incompatible with life the moment the umbilical cord Umbilical cord The flexible rope-like structure that connects a developing fetus to the placenta in mammals. The cord contains blood vessels which carry oxygen and nutrients from the mother to the fetus and waste products away from the fetus. Placenta, Umbilical Cord, and Amniotic Cavity 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 Empathy An individual’s objective and insightful awareness of the feelings and behavior of another person. It should be distinguished from sympathy, which is usually nonobjective and noncritical. It includes caring, which is the demonstration of an awareness of and a concern for the good of others. Psychotherapy, and recognize that your patient may have very strongly held beliefs regarding the topic of abortion Abortion Expulsion of the product of fertilization before completing the term of gestation and without deliberate interference. Spontaneous 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 The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care to term and delivering versus terminating the pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and 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 IVF An assisted reproductive technique that includes the direct handling and manipulation of oocytes and sperm to achieve fertilization in vitro. Infertility)) if she were to abort now rather than wait until after delivery.

For some patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship, 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 The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care is safer the earlier in gestation it is performed. From a purely physical, medical standpoint, terminating the pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care now is the safest option for the woman. The primary ethical principle of nonmaleficence Nonmaleficence Not acting with the intention to do harm. Medical Ethics: Basic Principles 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 Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship, 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 Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles should be respected and the pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and 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 Umbilical cord The flexible rope-like structure that connects a developing fetus to the placenta in mammals. The cord contains blood vessels which carry oxygen and nutrients from the mother to the fetus and waste products away from the fetus. Placenta, Umbilical Cord, and Amniotic Cavity. 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?

In both cases, patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship 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 Ovulation The discharge of an ovum from a rupturing follicle in the ovary. Menstrual Cycle induction with either:
  • Timed intercourse
  • Intrauterine insemination Intrauterine insemination Artificial introduction of semen or spermatozoa into the vagina to facilitate fertilization. Infertility ( IUI IUI Artificial introduction of semen or spermatozoa into the vagina to facilitate fertilization. Infertility)
• 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 IVF An assisted reproductive technique that includes the direct handling and manipulation of oocytes and sperm to achieve fertilization in vitro. Infertility):
  • Oocytes Oocytes Female germ cells derived from oogonia and termed oocytes when they enter meiosis. The primary oocytes begin meiosis but are arrested at the diplotene state until ovulation at puberty to give rise to haploid secondary oocytes or ova (ovum). Ovaries: Anatomy and sperm are obtained:
    • Sperm are isolated from semen samples provided via masturbation.
    • Oocytes Oocytes Female germ cells derived from oogonia and termed oocytes when they enter meiosis. The primary oocytes begin meiosis but are arrested at the diplotene state until ovulation at puberty to give rise to haploid secondary oocytes or ova (ovum). Ovaries: Anatomy 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 Embryo The entity of a developing mammal, generally from the cleavage of a zygote to the end of embryonic differentiation of basic structures. For the human embryo, this represents the first two months of intrauterine development preceding the stages of the fetus. Fertilization and First Week(s) are placed back into the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy (known as reimplantation).
• Intracytoplasmic sperm injection Intracytoplasmic sperm injection An assisted fertilization technique consisting of the microinjection of a single viable sperm into an extracted ovum. It is used principally to overcome low sperm count, low sperm motility, inability of sperm to penetrate the egg, or other conditions related to male infertility. Infertility ( ICSI ICSI An assisted fertilization technique consisting of the microinjection of a single viable sperm into an extracted ovum. It is used principally to overcome low sperm count, low sperm motility, inability of sperm to penetrate the egg, or other conditions related to male infertility (infertility, male). Infertility):
  • An additional technique used during IVF IVF An assisted reproductive technique that includes the direct handling and manipulation of oocytes and sperm to achieve fertilization in vitro. Infertility 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 Genetic Testing Detection of a mutation; genotype; karyotype; or specific alleles associated with genetic traits, heritable diseases, or predisposition to a disease, or that may lead to the disease in descendants. It includes prenatal genetic testing. Myotonic Dystrophies done on embryos created during an IVF IVF An assisted reproductive technique that includes the direct handling and manipulation of oocytes and sperm to achieve fertilization in vitro. Infertility 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 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
• Genetic parenthood for same-sex couples
• Ability to do PGD:
  • Avoid passing on genetic mutations Genetic Mutations Carcinogenesis 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 Cystic Fibrocystic Change fibrosis Fibrosis Any pathological condition where fibrous connective tissue invades any organ, usually as a consequence of inflammation or other injury. Bronchiolitis Obliterans, BRCA).
  • Avoid pregnancies with fetal aneuploidy (e.g., trisomy 21 Trisomy 21 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 (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 Sex The totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism. Gender Dysphoria selection Selection Lymphocyte activation by a specific antigen thus triggering clonal expansion of lymphocytes already capable of mounting an immune response to the antigen. B cells: Types and Functions of a fetus

Arguments in favor

• Beneficence Beneficence The state or quality of being kind, charitable, or beneficial. The ethical principle of beneficence requires producing net benefit over harm. Medical Ethics: Basic Principles (do good): Allow couples who desire it to become biologic parents.
• Alleviate psychological pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways and social/cultural/religious stigmas associated with childlessness.
• PGD:
  • Removes the component of random chance that a couple carrying known genetic mutations Genetic Mutations Carcinogenesis will have a child with a potentially serious, life-limiting diagnosis
  • Significantly reduces the likelihood of aneuploidy

Ethical issues Ethical issues Clusters of topics that fall within the domain of bioethics, the field of study concerned with value questions that arise in biomedicine and health care delivery. Healthcare System

• Ownership of gametes or embryos used in ART 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 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. Medical Ethics: Basic Principles of using PGD solely for sex Sex The totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism. Gender Dysphoria selection Selection Lymphocyte activation by a specific antigen thus triggering clonal expansion of lymphocytes already capable of mounting an immune response to the antigen. B cells: Types and Functions
  • Theoretically allows couples to select embryos based on certain desirable genetic characteristics
  • PGD on a population scale Scale Dermatologic Examination could be considered eugenics.

Clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship obligations

• For patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship who desire fertility treatments and/or PGD → refer the patient to a fertility specialist (i.e., reproductive endocrinologist).
• 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 Sex The totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism. Gender Dysphoria selection Selection Lymphocyte activation by a specific antigen thus triggering clonal expansion of lymphocytes already capable of mounting an immune response to the antigen. B cells: Types and Functions, etc ETC The electron transport chain (ETC) sends electrons through a series of proteins, which generate an electrochemical proton gradient that produces energy in the form of adenosine triphosphate (ATP). Electron Transport Chain (ETC). in place to ensure that treatment between patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship is fair and consistent.
• Be sure to follow local laws regarding reproduction.

Cases

Case 1: IVF IVF An assisted reproductive technique that includes the direct handling and manipulation of oocytes and sperm to achieve fertilization in vitro. Infertility 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 (Trisomy 21), given her age. She reports she would almost certainly terminate a pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care complicated by aneuploidy. The patient was doing some research Research Critical and exhaustive investigation or experimentation, having for its aim the discovery of new facts and their correct interpretation, the revision of accepted conclusions, theories, or laws in the light of newly discovered facts, or the practical application of such new or revised conclusions, theories, or laws. Conflict of Interest online and was reading up on PGD. The couple is interested in pursuing IVF IVF An assisted reproductive technique that includes the direct handling and manipulation of oocytes and sperm to achieve fertilization in vitro. Infertility with PGD. She has a history of one prior pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and 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 The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and 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 IVF An assisted reproductive technique that includes the direct handling and manipulation of oocytes and sperm to achieve fertilization in vitro. Infertility 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 Abortion Expulsion of the product of fertilization before completing the term of gestation and without deliberate interference. Spontaneous Abortion, there is a question of how the rights and autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles 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 Embryo The entity of a developing mammal, generally from the cleavage of a zygote to the end of embryonic differentiation of basic structures. For the human embryo, this represents the first two months of intrauterine development preceding the stages of the fetus. Fertilization and First Week, and personal opinions on this matter can vary widely. All 4 ethical principles come into play here.

In general, medical ethics 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. Medical Ethics: Basic Principles principles primarily favor the living couple rather than the embryos.  IVF IVF An assisted reproductive technique that includes the direct handling and manipulation of oocytes and sperm to achieve fertilization in vitro. Infertility 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 Beneficence The state or quality of being kind, charitable, or beneficial. The ethical principle of beneficence requires producing net benefit over harm. Medical Ethics: Basic Principles and autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles. Although the case may be weaker for patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship 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 IVF An assisted reproductive technique that includes the direct handling and manipulation of oocytes and sperm to achieve fertilization in vitro. Infertility, it is still widely accepted and done based on principles of autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles.

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 IVF An assisted reproductive technique that includes the direct handling and manipulation of oocytes and sperm to achieve fertilization in vitro. Infertility starting after age 37, given the increasing risk of aneuploidy with age. 

The use of PGD raises ethical questions because it requires a judgment Judgment The process of discovering or asserting an objective or intrinsic relation between two objects or concepts; a faculty or power that enables a person to make judgments; the process of bringing to light and asserting the implicit meaning of a concept; a critical evaluation of a person or situation. Psychiatric Assessment call on the part of clinicians (and patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship) 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 The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and 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 Trisomy The possession of a third chromosome of any one type in an otherwise diploid cell. Types of Mutations 13) are reasonably excluded for reimplantation because these children (and their parents) would have significantly increased physical (and emotional) pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways and suffering; avoiding this outcome is a reasonable choice based on the principle of nonmaleficence Nonmaleficence Not acting with the intention to do harm. Medical Ethics: Basic Principles. Trisomy 21 Trisomy 21 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 (Trisomy 21) is also a common reason for pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care termination, and if pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and 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 Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship must respect a patient’s autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles, 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 IVF An assisted reproductive technique that includes the direct handling and manipulation of oocytes and sperm to achieve fertilization in vitro. Infertility with PGD for aneuploidy testing is an ethically reasonable option for this couple.

Case 2: PGD for sex Sex The totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism. Gender Dysphoria selection Selection Lymphocyte activation by a specific antigen thus triggering clonal expansion of lymphocytes already capable of mounting an immune response to the antigen. B cells: Types and Functions

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 IVF An assisted reproductive technique that includes the direct handling and manipulation of oocytes and sperm to achieve fertilization in vitro. Infertility with PGD because they want to select a male embryo Embryo The entity of a developing mammal, generally from the cleavage of a zygote to the end of embryonic differentiation of basic structures. For the human embryo, this represents the first two months of intrauterine development preceding the stages of the fetus. Fertilization and First Week. How do you proceed?

Discussion

The use of PGD solely for the purpose of sex Sex The totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism. Gender Dysphoria selection Selection Lymphocyte activation by a specific antigen thus triggering clonal expansion of lymphocytes already capable of mounting an immune response to the antigen. B cells: Types and Functions is controversial. Is preimplantation sex Sex The totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism. Gender Dysphoria selection Selection Lymphocyte activation by a specific antigen thus triggering clonal expansion of lymphocytes already capable of mounting an immune response to the antigen. B cells: Types and Functions considered gender Gender Gender Dysphoria 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 Gender Gender Dysphoria not “bad enough” to justify IVF IVF An assisted reproductive technique that includes the direct handling and manipulation of oocytes and sperm to achieve fertilization in vitro. Infertility and PGD, while others feel that it is reasonable and will offer the procedure based on the principle of patient autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles. 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 Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship.

Note that in some cases, sex Sex The totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism. Gender Dysphoria selection Selection Lymphocyte activation by a specific antigen thus triggering clonal expansion of lymphocytes already capable of mounting an immune response to the antigen. B cells: Types and Functions may be beneficial to prevent transmission of recessive X-linked X-linked Genetic diseases that are linked to gene mutations on the X chromosome in humans or the X chromosome in other species. Included here are animal models of human X-linked diseases. Common Variable Immunodeficiency (CVID) genetic diseases (e.g., hemophilia A Hemophilia A The classic hemophilia resulting from a deficiency of factor VIII. It is an inherited disorder of blood coagulation characterized by a permanent tendency to hemorrhage. Hemophilia and Duchenne muscular dystrophy Muscular Dystrophy Becker Muscular Dystrophy).

Embryo, Oocyte, and Sperm Donation

Definitions and descriptions

• Oocyte and sperm donation:
  • The act of donating haploid Haploid The chromosomal constitution of cells, in which each type of chromosome is represented once. Symbol: n. Basic Terms of Genetics 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 Oocytes Female germ cells derived from oogonia and termed oocytes when they enter meiosis. The primary oocytes begin meiosis but are arrested at the diplotene state until ovulation at puberty to give rise to haploid secondary oocytes or ova (ovum). Ovaries: Anatomy are retrieved surgically after hormonal ovarian stimulation (identical to the procedure used in IVF IVF An assisted reproductive technique that includes the direct handling and manipulation of oocytes and sperm to achieve fertilization in vitro. Infertility cycles).
• Embryo Embryo The entity of a developing mammal, generally from the cleavage of a zygote to the end of embryonic differentiation of basic structures. For the human embryo, this represents the first two months of intrauterine development preceding the stages of the fetus. Fertilization and First Week donation:
  • The act of giving up or donating an embryo Embryo The entity of a developing mammal, generally from the cleavage of a zygote to the end of embryonic differentiation of basic structures. For the human embryo, this represents the first two months of intrauterine development preceding the stages of the fetus. Fertilization and First Week to be later implanted into a different, unrelated woman’s uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy for gestation
  • The mother carrying the embryo Embryo The entity of a developing mammal, generally from the cleavage of a zygote to the end of embryonic differentiation of basic structures. For the human embryo, this represents the first two months of intrauterine development preceding the stages of the fetus. Fertilization and First Week is considered the parent (terminology: she “adopted the embryo Embryo The entity of a developing mammal, generally from the cleavage of a zygote to the end of embryonic differentiation of basic structures. For the human embryo, this represents the first two months of intrauterine development preceding the stages of the fetus. Fertilization and First Week”).

Rights of oocyte, sperm, and embryo Embryo The entity of a developing mammal, generally from the cleavage of a zygote to the end of embryonic differentiation of basic structures. For the human embryo, this represents the first two months of intrauterine development preceding the stages of the fetus. Fertilization and First Week donors

• Anonymity (this is becoming more difficult with the widespread use of commercial DNA DNA A deoxyribonucleotide polymer that is the primary genetic material of all cells. Eukaryotic and prokaryotic organisms normally contain DNA in a double-stranded state, yet several important biological processes transiently involve single-stranded regions. DNA, which consists of a polysugar-phosphate backbone possessing projections of purines (adenine and guanine) and pyrimidines (thymine and cytosine), forms a double helix that is held together by hydrogen bonds between these purines and pyrimidines (adenine to thymine and guanine to cytosine). 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 Limitations Conflict of Interest of current testing capabilities 
• Potential complications of the procedures

Arguments in favor

• Reproductive autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles
• 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 Embryo The entity of a developing mammal, generally from the cleavage of a zygote to the end of embryonic differentiation of basic structures. For the human embryo, this represents the first two months of intrauterine development preceding the stages of the fetus. Fertilization and First Week adoption:
  • Opportunity for embryo Embryo The entity of a developing mammal, generally from the cleavage of a zygote to the end of embryonic differentiation of basic structures. For the human embryo, this represents the first two months of intrauterine development preceding the stages of the fetus. Fertilization and First Week rescue: implant embryos that otherwise would have been discarded 
  • Respects the life and personhood of the embryo Embryo The entity of a developing mammal, generally from the cleavage of a zygote to the end of embryonic differentiation of basic structures. For the human embryo, this represents the first two months of intrauterine development preceding the stages of the fetus. Fertilization and First Week

Ethical issues Ethical issues Clusters of topics that fall within the domain of bioethics, the field of study concerned with value questions that arise in biomedicine and health care delivery. Healthcare System to consider

• Donor compensation Compensation Respiratory Acidosis 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 Gamete Gametogenesis and/or embryo Embryo The entity of a developing mammal, generally from the cleavage of a zygote to the end of embryonic differentiation of basic structures. For the human embryo, this represents the first two months of intrauterine development preceding the stages of the fetus. Fertilization and First Week donation may conflict with personal religious/cultural beliefs of the clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship regarding:
  • Sharing of reproductive material or conception of a child outside marriage
  • Oppositions to same-sex marriage

Clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship obligations

• Refer patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship 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 The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care for another couple
• The embryo Embryo The entity of a developing mammal, generally from the cleavage of a zygote to the end of embryonic differentiation of basic structures. For the human embryo, this represents the first two months of intrauterine development preceding the stages of the fetus. Fertilization and First Week is typically created from gametes of at least one of the intended parents via IVF IVF An assisted reproductive technique that includes the direct handling and manipulation of oocytes and sperm to achieve fertilization in vitro. Infertility.
• Reasons couples may use surrogates:
  • Uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy of a female partner is unable to carry a pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care owing to abnormalities.
  • Individual or partners without a uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy
• Motivations of the surrogate:
  • Altruism Altruism Belief or practice of selfless concern for others. Defense Mechanisms
  • Monetary compensation Compensation Respiratory Acidosis

Arguments in favor

• Surrogate autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles: Surrogates are making informed decisions to participate.
• Allows couples to have biologically related children even if they do not have a healthy uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy
• Surrogates are frequently known to the intended parents.

Arguments in opposition

• Concern for true surrogate autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles:
  • How is her decision influenced by the potential for (possibly significant) financial compensation Compensation Respiratory Acidosis?
  • Does she truly appreciate the risks associated with pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care and how they might impact her body long term?
• Complex legal relationship of the surrogate mother with the child

Clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship obligations

• The general practitioner should redirect care to a fertility expert (e.g., reproductive endocrinologist).
• Counsel patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship 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 The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care may be beneficial in some cases.
  • If asked unexpectedly in the office, at least inform patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship 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 Embryo The entity of a developing mammal, generally from the cleavage of a zygote to the end of embryonic differentiation of basic structures. For the human embryo, this represents the first two months of intrauterine development preceding the stages of the fetus. Fertilization and First Week using IVF IVF An assisted reproductive technique that includes the direct handling and manipulation of oocytes and sperm to achieve fertilization in vitro. Infertility and the embryo Embryo The entity of a developing mammal, generally from the cleavage of a zygote to the end of embryonic differentiation of basic structures. For the human embryo, this represents the first two months of intrauterine development preceding the stages of the fetus. Fertilization and First Week was implanted in their surrogate.  

Situation A: During the surrogate’s pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care, she decided she no longer wanted to be pregnant and terminated the pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care.

Situation B: During the surrogate’s pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care, she decided she wanted to keep the child as her own.

Discussion

Individual autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles is paramount when considering medical ethics 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. Medical Ethics: Basic Principles. In Situation A, although this may be viewed as a significant betrayal on the part of the surrogate, the surrogate has autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles over her own body and cannot be forced to carry the pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and 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 Authority Medical Ethics: Basic Principles. 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 IVF An assisted reproductive technique that includes the direct handling and manipulation of oocytes and sperm to achieve fertilization in vitro. Infertility, 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 The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care was conceived “naturally,” the woman and man whose gametes created the embryo Embryo The entity of a developing mammal, generally from the cleavage of a zygote to the end of embryonic differentiation of basic structures. For the human embryo, this represents the first two months of intrauterine development preceding the stages of the fetus. Fertilization and First Week will usually have parental authority Authority Medical Ethics: Basic Principles 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.