Provision of Fertility Services for Women at Increased Risk of Complications: Ethics Opinion.

Certain medical conditions can increase the risk to the mother during pregnancy. This can increase the risk of maternal morbidity or severe morbidity. If pregnancy is decided upon after expert counseling, a multidisciplinary team should provide care.

OVERVIEW

The introduction of assisted reproductive technology (ART) has not only helped many young and healthy infertile couples to achieve parenthood, but it has also ignited the desire of women at an advanced age and those with significant medical conditions to attempt conception. Advanced maternal age and preexisting medical conditions such as hypertension, diabetes, deep vein thrombosis, heart disease, and renal dysfunction increase the risk of maternal and fetal morbidity and mortality. Cancer survivors seeking pregnancy with cryopreserved gametes with medical complications from their treatment also may have increased risks. Fetal growth restriction, small-for-date babies, and premature and extreme premature births contribute to increased Neonatal Intensive Care Unit admissions and an increased neonatal mortality. The associated financial, emotional, and physical burden can be devastating for the couple.

In India, societal pressures and the status of women increase the desire to have a child at any risk or cost. A childless woman is often ostracized, faces abandonment, and has the possibility of losing an inheritance. Women may seek to address this with ART but with significant risks. There have been many publicized cases in India of women in their 60s and 70s going through ART to produce an heir. It is notable that it is the child who may pay a lifelong price because of the parental advanced age. Loss of a mother who does not live through their childhood to parent them or suffer the consequences of prematurity and other complications of birth will affect the child lifelong.

As per the Registrar General of India-Sample Registration System (RGI-SRS), maternal mortality ratio is 167/100,000 live births in the period 2011–2013[1] and infant mortality rate is 34/1000 live births in 2016,[2] which is much higher than that of many developed nations. A maternal mortality survey conducted by the FOGSI[3] revealed that the leading causes of deaths were hypertension (29.4%), hemorrhage (21.56%), sepsis (15.05%), and medical disorders (12%). Although we do not have data on the exact contribution of ART to these figures, it is likely to increase as more high-risk women seek and are offered ART services. Guidelines for offering ART to women who are at an increased risk of pregnancy complications should be based on the ethical principles of beneficence and nonmalifecence. Both the maternal and fetal consequences should be considered bearing in mind that the goal of ART is a “healthy baby born to a healthy mother.”[4] Counseling for complications should be an integral part of ART.[5]

Risk assessment is critical in considering these requests for ART including the following:

'High-risk' women

Advanced maternal age and pre-existing medical conditions (e.g., hypertension, diabetes mellitus, heart disease, immunological disorders, active treatment for cancers, thrombophilia, deep venous thrombosis, obesity, congenital anomalies of uterus, polycystic ovarian syndrome with metabolic syndrome, and psychiatric disorders) should be evaluated to assess the risks in pregnancy.[4]

Inherent risks in assisted reproductive technology

ART has its own risks which add to those of medical risks. These include threatened abortion, placenta previa, placenta accreta/percreta, premature rupture of membranes, ectopic pregnancy, pregnancy-induced hypertension, gestational diabetes mellitus, operative delivery, and fetal and neonatal risks.[4]

Recommendations

Assessment of treatment risk before, during, and throughout pregnancy, including risk to neonate, must be carried out for all patients seeking ART to balance the benefits and harms

A multidisciplinary approach is essential. Patients with medical problems should be evaluated by the respective specialists. Medical clearance for ART must be obtained from them before starting treatment

The patient can only make an informed choice when she understands the risks as well as the potential benefits, including the long-term risks to the child as well as herself. Due to the intense desire for pregnancy and potential coercion from family or partner, diligent counseling of the woman is critical to assure understanding

Partner and family counseling to understand the risks of undertaking these procedures needs to be promoted

Informed consent and counseling must always be based on the best information and clinical judgment without succumbing to personal or social bias regarding age

There is no obligation for health professionals to offer treatment that is of no benefit, or likely to cause harm without substantial benefits

Clinicians should counsel against or even decline ART if the risk of morbidity or mortality is high. Patients should be encouraged to seek a second opinion as desired

Alternative options should be discussed, such as third-party reproduction or adoption

If a decision for ART is made, any modifiable risks should be corrected before starting treatment

The number of embryos transferred is recommended to be limited to one, given the significant risks of multiple pregnancy worsening the underlying medical conditions

Pregnant patients should be managed in a tertiary care center with experience in high-risk maternal and neonatal care

The stigmatization of infertility causes suffering for couples and can create inappropriate pressure to reproduce even when medically inadvisable. Advocacy and education to reduce the social stigma of infertility is an important responsibility of knowledgeable health professionals.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.