Why our ethics demand canceling in vitro fertilization - for now

Extraordinary times call for extraordinary measures. Recent directives to cancel elective surgeries and procedures will place significant burdens on patients and health care professionals. But these rationing efforts are ethically necessary to preserve our short supplies of PPE and other essentials.

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Author:

Louise P King, M.D., J.D.
Director of Reproductive Bioethics 
Harvard Medical School


Recently, the Surgeon General advised to postpone elective surgical procedures whenever possible. The American College of Surgeons issued a strong statement in support encouraging surgeons to “plan to minimize, postpone, or cancel at this time.” (https://www.facs.org/about-acs/covid-19/information-for-surgeons) The American College of Obstetricians and Gynecologists, the American Association of Gynecologic Laparoscopists, American Society for Reproductive Medicine, the American Urogynecologic Society, the Society of Family Planning, the Society of Gynecologic Surgeons, the Society for Maternal-Fetal Medicine, and the Society of Gynecologic Oncology all followed suit. (https://www.acog.org/news/news-releases/2020/03/joint-statement-on-elective-surgeries)

The recommendation to hold all non-urgent surgical cases is a reasonable and ethical rationing response. It is not simply the OR space and personnel but also equipment and specifically gowns and masks that need to be conserved. Our essential personnel  are currently restricting to 1 mask per day and in some cases trying to make their own PPE from various scraps severely impacts their ability to safely care for patients. This shortage is presenting well ahead of others that are predicted including shortage of antibiotics, blood and anesthetics - all of which could potentially be used during elective cases or if complications occur. Whether your current area is affected or not at the moment, your use of these resources affects the country's supply as a whole.  

The reasoning above applies equally to invasive procedures including IVF. (https://www.sart.org/news-and-publications/news-and-research/press-releases-and-bulletins/asrm-issues-new-guidance-on-fertility-care-during-covid-19-pandemiccalls-for-suspension-of-most-treatments/) Any procedure that uses our scarce resources during these crucial moments is a burden we simply can’t afford as a nation. Moreover, any non urgent contact with patients in the context of a 30% asymptomatic rate and lack of adequate rapid screening is not mindful of our need to socially distance and flatten the curve.  

Of course cancelling procedures will be exceptionally difficult. The decision to cancel procedures or surgeries is a burden to patients who have been waiting months In some instances and must continue to wait. (https://www.theatlantic.com/science/archive/2020/03/patients-whose-surgeries-are-canceled-because-coronavirus/608176/)  It is a severe burden financially to private and public programs large and small.  But, it is still necessary and ethically required. Labor law attorneys are well versed in legal remedies to help businesses and their employees in times of crisis. State and federal programs offer assistance and more are being announced each day. Massachusetts' governor has issued a law requiring insurers to reimburse for telemedicine visits. If this is not available in your state you should bombard your governor with letters demanding they to do the same.

The claim that these efforts to preserve important resources both by cancelling non urgent procedures and flattering the curve are “herd mentality” is belied by the situations in Italy, Spain and Iran. We will not regret over-reacting if we can avoid what they are facing. That said, given the burden these measures put on patients and providers, any decision to hold IVF should be periodically and frequently revisited. The situation is changing rapidly. If we are able to address shortages and flatten the curve we can reconsider these decisions.

At the very least, think of your ER and hospitalist colleagues. A leader in hospital medicine in Italy recently died and officials in Italy have hypothesized that his death was related in part to a lack of protective equipment. (https://www.euronews.com/2020/03/18/italian-doctor-dies-of-coronavirus-after-working-without-gloves-due-to-shortage)Even if only a fraction of our population becomes infected, a very large number will need hospital care and we currently have only enough PPE for less than one week.  You should defer elective procedures with this in mind if nothing else.

Go to the profile of Fertility and Sterility

Fertility and Sterility

Editorial Office, American Society for Reproductive Medicine

Fertility and Sterility® is an international journal for obstetricians, gynecologists, reproductive endocrinologists, urologists, basic scientists and others who treat and investigate problems of infertility and human reproductive disorders. The journal publishes juried original scientific articles in clinical and laboratory research relevant to reproductive endocrinology, urology, andrology, physiology, immunology, genetics, contraception, and menopause. Fertility and Sterility® encourages and supports meaningful basic and clinical research, and facilitates and promotes excellence in professional education, in the field of reproductive medicine.

4 Comments

Go to the profile of Alexander Quaas
Alexander Quaas 18 days ago

This is an excellent summary of the ethical perspective of the COVID-19 pandemic with regards to its impact on IVF. As has been mentioned elsewhere, this is a situation where specific interests of a segment of the population are weighed against overall public health.  Potential benefits of treatments for a subset of patients are offset by their effects on morbidity and mortality of the entire population.  

In other words, the ethical concepts of patient autonomy and "do no harm" are clashing, and it is challenging to decide which one carries more weight.

As the pandemic is unfolding, it is becoming more and more apparent that a large number of people will be affected, and as a consequence many people all over the world will lose their lives due to COVID-19. Any measures proven to prevent loss of life should be taken, including deferring elective procedures if necessary, as hard as it may be for patients and providers affected.  

Go to the profile of Luis Hoyos
Luis Hoyos 18 days ago

Thank you for providing us with this perspective. I do agree with the need to hold on any IVF for now and I think they key lies in the following statement "given the burden these measures put on patients and providers, any decision to hold IVF should be periodically and frequently revisited". The situation is very fluid and we should be reassessing it frequently, but for now we should all do our part as members of society.

Go to the profile of Guido Parra
Guido Parra 18 days ago

Gracias por colocar una excelente perspectiva de las responzabilidades  que como medicos y recordando el juramento hipocrático tenemos frente a la sociedad y en especial en nuestra especilidad con el futro de las madres y de los hijos por nacer ( que al fin y al cabo tiene estercha relación con la supervivencia de nuestra especie ) .

Asuminendo esa responzabilidad nuestra Asociación de Centros Colombianos de Rerpoducción Humana (ACCERH) emitio unas Guias hace  4 dias sobre el actuar de nuestros centros frente a la pandemia y nuestroa actuar con responzabilidad frente a nusteros pacientes.

Seguramentev tendremos oportunidad de ire revisando est herramienta casi que dia a dia para adaptarla a situación tan aceleredamente cambiante.

Go to the profile of Luis Hoyos
Luis Hoyos 18 days ago

Thanks to Dr. Parra for participating in this conversation. He agrees with the fact that doctors, by virtue of their hyppocratic oath, have a responsability to society. Because of this, the Colombian association of fertility centers have recently released recommendations to guide centers on how to face the pandemic as well as care for patients during this time with responsability. They will be revising them almost daily to adapt them to the rapidly changing situation.