when do we say "no"?
http://www.100md.com
《英国医生杂志》
1 Hewitt Centre for Reproductive Medicine, Liverpool Women's Hospital, Liverpool L8 7SS tomaust@doctors.org.uk
Tommy's doctors made the right decision to support her in trying for a natural pregnancy by optimising her diabetic treatment and advising her of the risks of becoming pregnant.1 This is because many patients will carry on and conceive with or without their doctors' blessing. After all, we would prefer it if drug misusers didn't inject heroin, but if they must we would rather they use clean needles.
Tommy's request for assisted conception was a different matter because all complications of assisted conception are, by definition, iatrogenic. Her doctors had to consider whether they would be prepared to help her produce a potentially damaged child or even kill herself in the process. As reproductive physicians we are never absolved from this moral responsibility, even when patients have given their consent and fully understand the risks.
One respondent felt that Tommy's (fetotoxic) angiotensin converting enzyme inhibitor should not have been stopped while she was trying for a natural conception but continued until she became pregnant.2 I feel that if her remaining fallopian tube had been checked for patency and found to be blocked, her angiotensin converting enzyme inhibitor could have been continued to optimise her blood pressure control until she started treatment for in vitro fertilisation.
One rapid respondent suggested that only two rather than three embryos should be transferred to reduce the chance of multiple pregnancy and thus the risks of prematurity, pre-eclampsia, and miscarriage (among others).2 One could even have considered replacing a single embryo (and freezing any remaining embryos) to reduce this risk even further. In Sweden, where mandatory single embryo transfer has been introduced, excellent pregnancy rates have been reported but with a much reduced twinning rate.3
The ovarian response at the time of egg collection often gives an indication of the risk of developing ovarian hyperstimulation syndrome. The decision to freeze or replace embryos (and risk worsening ovarian hyperstimulation syndrome if a pregnancy occurs) around this time is difficult as the success rates after replacement of frozen embryos tend to be poorer.4 Unfortunately, recent legislation changes in Italy have removed this option for safety5 and would drastically alter Tommy's management if she were treated today.
Many of the rapid responses point out that there is a paucity of evidence of the risks of ovarian stimulation and pregnancy for people like Tommy. Even if all the risks were quantifiable, they may be ignored by couples whose lives become dominated by their desperation for a child. In reproductive medicine we see couples who risk their relationships, jobs, homes, and health for an attempt at in vitro fertilisation. At what level of risk do we say no?
Competing interests: None declared.
References
Piccoli GB, Mezza E, Grassi G, Burdese M, Todros T. A 35 year old woman with diabetic nephropathy who wants a baby: case outcome. BMJ 2004;329: 900.
Rapid responses. Piccoli GB, Mezza E, Grassi G, Burdese M, Todros T. A 35 year old woman with diabetic nephropathy who wants a baby: case presentation BMJ 2004. bmj.com/cgi/eletters/329/7467/674#74885 (accessed 1 Oct 2004).
Sundstrom P, Saldeen P. Good results of single embryo transfer after in vitro fertilization. The first follow-up report after the introduction of a new regulatory guideline . Lakartidningen. 2004;101: 2476-8.
Braude P, Rowell P. Assisted conception. III--problems with assisted conception. BMJ 2003;327: 920-3.
Turone F. Italy to pass new law on assisted reproduction. BMJ 2004;328: 9.(Thomas R Aust, research f)
Tommy's doctors made the right decision to support her in trying for a natural pregnancy by optimising her diabetic treatment and advising her of the risks of becoming pregnant.1 This is because many patients will carry on and conceive with or without their doctors' blessing. After all, we would prefer it if drug misusers didn't inject heroin, but if they must we would rather they use clean needles.
Tommy's request for assisted conception was a different matter because all complications of assisted conception are, by definition, iatrogenic. Her doctors had to consider whether they would be prepared to help her produce a potentially damaged child or even kill herself in the process. As reproductive physicians we are never absolved from this moral responsibility, even when patients have given their consent and fully understand the risks.
One respondent felt that Tommy's (fetotoxic) angiotensin converting enzyme inhibitor should not have been stopped while she was trying for a natural conception but continued until she became pregnant.2 I feel that if her remaining fallopian tube had been checked for patency and found to be blocked, her angiotensin converting enzyme inhibitor could have been continued to optimise her blood pressure control until she started treatment for in vitro fertilisation.
One rapid respondent suggested that only two rather than three embryos should be transferred to reduce the chance of multiple pregnancy and thus the risks of prematurity, pre-eclampsia, and miscarriage (among others).2 One could even have considered replacing a single embryo (and freezing any remaining embryos) to reduce this risk even further. In Sweden, where mandatory single embryo transfer has been introduced, excellent pregnancy rates have been reported but with a much reduced twinning rate.3
The ovarian response at the time of egg collection often gives an indication of the risk of developing ovarian hyperstimulation syndrome. The decision to freeze or replace embryos (and risk worsening ovarian hyperstimulation syndrome if a pregnancy occurs) around this time is difficult as the success rates after replacement of frozen embryos tend to be poorer.4 Unfortunately, recent legislation changes in Italy have removed this option for safety5 and would drastically alter Tommy's management if she were treated today.
Many of the rapid responses point out that there is a paucity of evidence of the risks of ovarian stimulation and pregnancy for people like Tommy. Even if all the risks were quantifiable, they may be ignored by couples whose lives become dominated by their desperation for a child. In reproductive medicine we see couples who risk their relationships, jobs, homes, and health for an attempt at in vitro fertilisation. At what level of risk do we say no?
Competing interests: None declared.
References
Piccoli GB, Mezza E, Grassi G, Burdese M, Todros T. A 35 year old woman with diabetic nephropathy who wants a baby: case outcome. BMJ 2004;329: 900.
Rapid responses. Piccoli GB, Mezza E, Grassi G, Burdese M, Todros T. A 35 year old woman with diabetic nephropathy who wants a baby: case presentation BMJ 2004. bmj.com/cgi/eletters/329/7467/674#74885 (accessed 1 Oct 2004).
Sundstrom P, Saldeen P. Good results of single embryo transfer after in vitro fertilization. The first follow-up report after the introduction of a new regulatory guideline . Lakartidningen. 2004;101: 2476-8.
Braude P, Rowell P. Assisted conception. III--problems with assisted conception. BMJ 2003;327: 920-3.
Turone F. Italy to pass new law on assisted reproduction. BMJ 2004;328: 9.(Thomas R Aust, research f)