Autonomy futility and good business in reproductive medicine Is the slope getting more slippery

William David Schlaff, M.D.

Volume 103, Issue 3, Pages 626-627


“I’ve thought about this a lot, and I think I’m stuck” (Anonymous)

  • JannaCrm

    I can say for sure that US offer the most expensive medicine. I suffer infertility for long years. Many families can`t afford surrogacy service there. Last year I was in Ukraine and was in shock. People from America are ready to come there just to have a baby. Despite the fact, that it`s rather far from the US. I`m infertile and together with my husband we wanted to have children. We are pressed for money. So we could not use surrogacy service in the US. We came to Ukraine as they offer the lowest price in Europe. Their workers are so polite and friendly. There I met one woman, who is one of my best friends now. No matter that I`m from France, and she`s from Spain. Surrogate mothers from that center gave birth to our children. She has a boy, and I`m a happy mother of twins. They changed my life. Now it seems to be not senseless. As it used to be before my girls were born.

  • Emily

    Surrogacy has become rather popular method of childbirth nowadays. And I think that no one cares very much the politicians’ opinion on this matter. But they have the political force. And they have an opportunity to change and adopt laws. I think that childbirth, parenting and the way in which it happens – these are a private matter of each of us. I mean that it is so private that we have no right to compare surrogacy with something else. Of course some countries have a kind of madhouse in the surrogate motherhood sphere. And first of all we need to prescribe a good legislation concerning this issue. A great number of people are involved in the surrogacy process. I know that in Ukraine all kinds of reproductive medicine methods are legal. Moreover, prestige clinic in Kiev protected their surrogate mom. And the law places no limits on the amount that can be paid. They get fixed paid and may earn good money for their family. And it’s so good that people have such opportunity to solve both problem with childless and pressure for money. Also it can be seen that the society is mostly wants the surrogacy to be. Maybe someday officials will follow the voice of the people.

  • globetrotter

    Some people will be angry with this comment. There have to be higher guidelines for IVF practices. 50% below age 35 is easily achieved. 55% of eggs in those under 35, and even 40% in the 38-40 population of blasts biopsied are normal. Those below 40% really should have to have an retrospective look at what is going on with their labs. SOme are clearly better than others. These secrets need not exist…they don’t with cancer therapy, why should they with IVF? There are protocols used by high achieving practices…these need to be studied and replicated and become standard of care. Too much art and kitchen sink approach is involved

  • Guest

    I read this article with great interest and feel the same way. Though I work at a public institution, where 70% of my patient are medicaid and have no infertility benefits, the pressure to be “productive” as an REI creates an uncomfortable tension. Just the other day I had a 46 year old G3P3 come in requesting a tubal reversal because her new fiance didn’t have any children. Additionally, she has menorrhagia and a fibroid uterus. I counseled her that her best chances for pregnancy were egg donation after an abdominal myomectomy. The patient and her partner were not interested in egg donation. Furthermore, I counseled that with a tubal reversal or IVF with her own eggs, her chances of taking home a baby were less that 1% and in my judgement “futile,” and that I was unwilling to offer a tubal reversal or IVF with her own eggs. This patient did have the financial resources to pursue treatment but I told her I could not justify payment on a procedure that more than likely would not result in a live birth. I also cited the ASRM ethics committee opinion on futile care. And though this is one example, I can site many more that occur on a weekly basis ( the 47 year old who decides it is finally time to have a baby, the 45 year old that has been attempting conception for 10 years). Though I did not feel remorse or ambivalence, what was still in the back of my mind, was the idea from the productivity mindset, that I was once again passing up the opportunity to add to the bottom line of my division. Additionally, in my circumstances, I might also define futility as the provision of services that are unlikely to benefit the patient i.e. prescribing clomid or other oral fertility medications for multiple cycles because patient’s don’t have the finances to pursue other options including testing like HSGs, sperm analysis, or IVF for tubal disease.
    I have been practicing as an REI for over 22 years and as an OB/Gyn for over 27 years. The longer I practice, the more I see the need for comprehensive counseling and for psychologists to be involved. However, there is very limited availability for mental health counseling with a very long waiting list in my environment. And the more I see the “slipper slope” of bottom line thinking and the need to generate clinical dollars attempt to impeded or impair judicious ethical clinical practice. One thing that I and a colleague have started to do ( she has a MS in Bioethics) is we started a reproductive ethics committee and to review charts when I have concerns or delimmas such as these. Furthermore, because I work in an environment where infertility evaluation and treatment are not covered benefits ( Ohio is not a mandated states) I always have the uncomfortable discussion about the costs of care with patients.
    Thank-you for putting this out there. It’s good to see that other’s are also grappling with this issue.
    Lori-Linell C. Hollins, M.D.
    Division Director REI
    Metorhealth Medical Center
    Assistant Professor Reproductive Biology
    Case Western Reserve University School of Medicine
    Cleveland, Ohio

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