Year : 2018 | Volume
: 11 | Issue : 2 | Page : 91--92
Provision of fertility services for women at increased risk of complications: Ethics opinion
Nalini Mahajan1, Duru Shah2, Madhuri Patil3,
1 President FPSI; Director and Child Hospital; Scientific Director Ferticity Clinic; Founder Secretary ASFP; Board Member, ISFP, Delhi, India
2 President Indian Society for Assisted Reproduction 2017-18; Director Gynaecworld the Center for Womenís Health and Fertility, Mumbai, Maharashtra, India
3 Editor, Journal of Human Reproductive Sciences; Clinical Director and Principal, Dr. Patilís Fertility, Bengaluru, Karnataka, India
Indian Society for Assisted Reproduction, Flat No. 23 A, 2nd Floor, Elco Arcade, Hill Road, Bandra (West), Mumbai . 400 050, Maharashtra
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.
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Mahajan N, Shah D, Patil M. Provision of fertility services for women at increased risk of complications: Ethics opinion.J Hum Reprod Sci 2018;11:91-92
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Mahajan N, Shah D, Patil M. Provision of fertility services for women at increased risk of complications: Ethics opinion. J Hum Reprod Sci [serial online] 2018 [cited 2022 Aug 10 ];11:91-92
Available from: https://www.jhrsonline.org/text.asp?2018/11/2/91/238219
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 and infant mortality rate is 34/1000 live births in 2016, which is much higher than that of many developed nations. A maternal mortality survey conducted by the FOGSI  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.” Counseling for complications should be an integral part of ART.
Risk assessment is critical in considering these requests for ART including the following:
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.
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.
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 harmsA 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 treatmentThe 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 understandingPartner and family counseling to understand the risks of undertaking these procedures needs to be promotedInformed consent and counseling must always be based on the best information and clinical judgment without succumbing to personal or social bias regarding ageThere is no obligation for health professionals to offer treatment that is of no benefit, or likely to cause harm without substantial benefitsClinicians 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 desiredAlternative options should be discussed, such as third-party reproduction or adoptionIf a decision for ART is made, any modifiable risks should be corrected before starting treatmentThe number of embryos transferred is recommended to be limited to one, given the significant risks of multiple pregnancy worsening the underlying medical conditionsPregnant patients should be managed in a tertiary care center with experience in high-risk maternal and neonatal careThe 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.
This report was developed by the Ethics Working Group of the Indian Society for Assisted Reproduction as a service to its members and other practicing clinicians. While this document reflects the views of members of that Committee, it is not intended to be the only approved standard of practice or to dictate an exclusive course of treatment in all cases. This report was reviewed by the Ethics Committee of the American Society for Reproductive Medicine and their input was considered in the preparation of the final document. We acknowledge Joanna Cain, Former Chair of the 'FIGO International Ethics Committee' for participation during the development of the ethics opinion as an International Advisor.
The following members of the Ethics Working Group have contributed to the development of this document: Duru Shah, Madhuri Patil, Sujata Kar, Nalini Mahajan, Sadhana Desai, Ameet Patki, (Indian Society for Assisted Reproduction), Manohar Motwani (Private Practitioner), Sanjay Chauhan (Scientist F, ICMR-NIRRH), Hitesh Bhatt (Medico Legal Advisor), Amit Karkhanis (Legal Advisor), Anushree Patil (Scientist D, ICMR-NIRRH), Flavia Agnes (Lawyer and Activist), and Subarna Ghosh (Reproductive Activist).
We thank Abbott India Limited for their logistic support during the preparation of the Ethics Opinion.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
|1||SRS Statistical Report; 2013. Available from: http://www.censusindia.gov.in/vital_statistics/mmr_bulletin_2011-13.pdf. [Last accessed on 2018 Mar 01].|
|2||State/UT-wise Infant Mortality Rate during; 2015-16. Available from: https://www.community.data.gov.in/stateut-wise-infant- mortality-rate-during-2015-16/. [Last accessed on 2018 Mar 01].|
|3||Konar H, Chakraborty AB. Maternal mortality: A FOGSI study (Based on institutional data). J Obstet Gynaecol India 2013;63:88-95.|
|4||Ethics Committee of the American Society for Reproductive Medicine. Electronic address: ASRM@asrm.org; Ethics Committee of the American Society for Reproductive Medicine. Provision of fertility services for women at increased risk of complications during fertility treatment or pregnancy: An Ethics Committee opinion. Fertil Steril 2016;106:1319-23.|
|5||The Assisted Reproductive Technologies (Regulation) Rules-2005. New Delhi: Indian Council of Medical Research New Delhi, Ministry of Health and Family Welfare Government of India; 2010.|