In both the United States and Europe, over one third of pregnancies are unintended, according to the New England Journal of Medicine. An unintended pregnancy presents a missed opportunity to address underlying health concerns that may affect individuals or their pregnancies prior to gestation, allowing for a broader range of interventions that may improve outcomes for both pregnant women and the resulting children. In contrast, for the many individuals and couples who face infertility, there is a window of opportunity during which preexisting health risks can be identified. This allows both patients and physicians time to address diseases and risk factors that may affect the health of the patient or the pregnancy, and to intervene during the preconceptual window.
These health risks can be subdivided into ones that are modifiable and ones that are not. This distinction guides the management of these risks for those seeking reproductive care, as outlined in a paper in Fertility and Sterility. Modifiable risks allow for interventions that may improve outcomes. Among the modifiable risk factors are ones that are behavioural such as tobacco, drug and alcohol use. Others modifiable health conditions can be optimised prior to conception, including obesity and diabetes. While every effort should be made to reduce modifiable risk factors prior to conception, there will be cases in which patients are unwilling or unable to alter their risks. Counselling with specific outcomes data for both the pregnant person and the resulting child are critical, and an understanding of the extent of risk reduction is an important tool as a starting point of a process that optimises preconceptual health.
In contrast to modifiable risk factors, risk factors such as pulmonary hypertension and thrombophilias can be managed but not modified. Some non-modifiable factors both increase risk to the pregnant person during gestation and also present a potential risk to the offspring. These include inherited diseases such as Marfan's which is associated with aortic dissection during pregnancy and the transmission of disease to the resultant child, as a paper in the Annals of Cardiothoracic Surgery outlined.
While those initiating a pregnancy naturally may choose to take upon themselves any level of risk that they feel appropriate, patients requiring fertility treatment need involve an outside party in their reproductive journey. As such, physicians at times may find themselves in situations where they deem the risk to the intended parent or resulting child too high to justify proceeding with fertility treatments. Such judgments must be made in an equitable manner and without bias. This is particularly apparent with obesity, in which studies have highlighted the possibility that physicians may be biased against patients who have obesity therefore impacting the quality of care they receive. A committee opinion published by the American College of Obstetricians and Gynecologists outlined how physicians should assess their own hesitations for considering denial of care and ensure that counseling is based in science and not in preconceived perceptions of risk.
The partners of pregnant women have interests in understanding risks to her and the resulting offspring. Open and honest conversations about risks should be encouraged. However, care should be taken to avoid coercion by either partner either in favor of obtaining care or refusing fertility treatment.
It should be noted that some risk factors can be minimised by decisions made during treatment. As an example, transferring more than one embryo increases the risk of twins and high order multiples. In most cases, single embryo transfer should be the default option (see BioNews 1132). Additionally, care should be taken to appropriately dose gonadotropins in order to minimise the risk of ovarian hyperstimulation syndrome, which can cause significant morbidity. When the risk of ovarian hyperstimulation syndrome is high, freezing embryos for later use (as opposed to immediate embryo transfer) will lessen this risk.
When underlying risk is potentially life threatening, and pregnancy without medical intervention is not possible, it is ethically permissible for physicians to decline to provide fertility care. Examples of such risks include Turner syndrome. In women with Turner syndrome, the risk of maternal death from aortic dissection is two percent, a study in Fertility and Sterility in 2003 showed. For those with pulmonary hypertension, mortality rates as high as 33 percent have been reported in European Heart Journal. Women with Turner syndrome would almost always require egg donation due to premature ovarian insufficiency. One can argue that providing fertility care in such situations is ethically problematic, and physicians may elect to decline to participate in reproductive care that places the pregnant person at exceedingly high levels of risk.
Given the intricacies of providing care to patients at increased risk to themselves or the resulting pregnancies, one must balance reproductive liberty with an obligation on the part of the physician not to harm their patients while maintaining their own autonomy. Individuals should be supported in making informed choices about whether and how to reproduce, and the infertile should not be unduly disadvantaged. Notwithstanding, physicians have an ethical duty to do no harm, and this should be carefully balanced with personal autonomy. The risk to offspring should be considered, and the burden on reproductive partners also plays a part. When risk is exceedingly high, this might lead to the pregnant person not surviving the pregnancy, leading their partner to face parenting alone. This may not be the choice the partner would have made if given the choice. Additionally, burdens on children must be considered when proceeding with care that may lead to health risks in the offspring.
While the delay to pregnancy caused by infertility allows time for assessment of risk factors that may affect pregnancy, care should be taken to avoid turning this potential benefit into an undue burden for those requiring reproductive assistance.