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Spring 2002
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Assisted
Reproduction in a Woman with Strong Religious Beliefs
**Assisted
reproduction
**Survival and morbidity in very low-birth-weight infants
**Directive versus non-directive counseling
Jessica is a 33-year-old teacher who has been unable to become pregnant
after trying to conceive for the last 5 year. For the past two years,
she has been performing a series of tests for urinary luteinizing
hormone (LH) every m month in order to time sexual intercourse. She and
her husband Ted have an 8-year-old daughter and are anxious to have
another child, sot hey decided to be reviewuated at a nearby infertility
center that was recommended by Jessica’s gynecologist.
After both Jessica and Ted were fully reviewuated, they were told that
no apparent cause of infertility can be found in either, and hat theirs
is a case of “unexplained infertility” in Jessica, who is nine years
older than when she conceived her fist child. It is possible that
Jessica will respond to medications that stimulate her ovaries and
increase her chances of conception. The doctor explained that she is not
too old to have a successful pregnancy, but the older she gets the less
likely she will be able to conceive, even with the latest methods.
At the infertility clinic, Jessica often chats with other patients in
the waiting room and has befriended another woman, who is a practicing
Catholic like Jessica. Both women are opposed to abortion and discuss
the possible religious objections they might encounter regarding
infertility treatment. Jessica has spoken to her priest, who told her
that the church had no objection to medications that stimulate
ovulation, but tat most other methods, such as in vitro fertilization (IVF),
or “test tube babies”, were not permitted. He did caution her about
the possibility of multiple births if she became pregnant, and that the
issue of reducing the number of embryos might arise. This, he says, is
strictly forbidden, because it is tantamount to abortion.
Concerned about her “biological clock”, Jessica was anxious to
proceed as soon as possible. She was offered a course of gonadotropins
to induce “superovulation”, and she agreed enthusiastically. It was
explained to her that after a baseline pelvic ultrasound, she would need
to give herself a daily injection of recombinant follicle-stimulating
hormone (FSH) for a week or more, and would require from five to seven
visits to the office in the first month to monitor hormone levels in the
blood and receive additional ultrasound examinations.
When sufficient mature follicles are noted on the ultrasound, Ted will
have to give her a precisely timed, intramuscular injection of human
chorionic gonadotropin (HCG) in the buttocks. This will trigger
ovulation and, about two days later Jessica would have to return to the
office where her husband’s prepared sperm would be inserted into eh
uterus via the cervix. Jessica agreed to everything, but had religious
objections to the unnatural method of artificial insemination. The
physician sys they can use the “Natural method” (coitus), but adds
that she should also have artificial insemination the next day, because
this will improve the precision of the timing and circumvent any
unidentified problem with the cervix, such as problems with the cervical
mucus. Still, Jessica rejected that option.
During her first cycle, ultrasound and blood tests revealed a suboptimal
response, and Jessica did not become pregnant during that cycle. She
became discouraged because she expected the great expense and
considerable inconvenience associated with the regiment o yield success.
Three months later, her husband persuaded her to return to the
infertility center for another round. This time she was told, she would
receive a higher dose of FSH to increase her chances of becoming
pregnant.
This time Jessica has a vigorous response and ultrasound revealed
multiple mature follicles. Although at first delighted, Jessica and her
husband are dismayed about the options they are now given. The options
include forgoing the HCG injection (“canceling the cycle”) and
waiting until the next month when the response might be less vigorous;
to “coast,” or wait for the estrogen levels to decline before giving
HCG, although the likelihood of pregnancy would be lower; or to receive
HCG, and attempt to become regnant. Unfortunately, because Jessica’s
estrogen levels are quire high, she has an enhanced risk of developing
the ovarian hyperstimulation syndrome (OHSS) if she selects the last
option. In addition, the physician explains, there is a very real
possibility of mulitfetal pregnancy. If this were to occur, multifetal
reduction would be strongly recommended, ad this is not permitted
according to Jessica’s religious beliefs.
All of these options are troubling to Jessica and her husband. While she
thinks they may have been described to her before she began the process,
she is now faced with the stark set of considerations. Jessica is most
keenly aware that the likelihood of pregnancy and delivery will decline
rapidly as they months go by. She decides she wants to complete this
cycle, saying that whatever happens she is in God’s hands. She is
willing to take the risk, citing a highly publicized case of healthy
septuplets that she had seen on television.
Could some of the
dilemmas now facing Jessica and her physician have been considered
during an informed consent process?
- Is selective
reduction an ethically justifiable response to the dilemma of
multifetal pregnancy?
- What financial
pressures may influence the choices of patients undergoing ART?
From: Ahronheim JC, Moreno JD,
Zuckerman C. Ethics in Clinical Practice, 2nd Edition.
Aspen Publication, Maryland, 2000.
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Course
Overview