Controversies in Operating Reproductive Health Services

Above all, not to do damage;
Holiness of human life;
Helping the person in need;
To keep the professional secret;
Right to truth;
Access to informed choice;
Right to die with dignity.

Until recent times, ethical codes were inspired on a paternalistic role of doctors towards patients, with doctors having the protagonism. During the 60's this relationship changes and the patient becomes the center of it. At the same time, new social structures lead to a change in the doctor's social image.

The doctor is no more looked at as an apostle, but rather as a professional, who, like any other professional, has to earn his or her living. In addition to it, economic interests govern health politics. Technical advances make medical care each time more expensive. This new surrounding generates a relationship based on rights and duties. Sexual and reproductive rights are strongly incorporated by international organizations as well as by feminist and political organizations within others.

In order to analyze the controversies that have arisen in managing Reproductive Health Services, it is important to consider some major scientific "advances" in the field of reproduction. In the 50´s-60´s, mammalian IVF is first attained in the rabbit by Dauzier and Thibault (5), and in 1969 Edwards, Bavister and Steptoe (6) successfully fertilize in vitro the first human being. Around the same time, Rock and Pincus develop hormonal contraception. In 1978, nine years after human in vitro fertilization had started, Louise Brown is born. It is also in the 70's when abortion is legalized in the United States. In 1983 the first baby obtained from a frozen embryo is born and the real industrial era of human reproduction begins. Human beings can be produced in a petri dish in the lab so the communion of two persons is not a need for human reproduction anymore. This eliminates the personal "link" and paradoxically creates an "inexorable" need of the other. The well known era of "sex without babies and babies without sex" starts. The reproductive industry continues to develop with the generation of transgenic mice in 1980 (8-9), pre implantation genetic diagnosis in order to eliminate abnormal embryos and ICSI in 1992 (19). In 1993 Hall and Stillman (13) receive an award for the "cloning" of triploid human embryos. It is important to notice that what they did was embryo splitting; the novelty consisted in the manipulation of human embryos, demonstrating their potentiality for being cloned. It doesn't take long until in 1996 (27) Dolly is born and very soon Yanagimachi (25) successfully clones mice in his lab in Hawaii.

The need to manipulate human embryos makes it necessary to redefine the beginning of human life. Embryology texts had always considered that any particular being of a specie starts at the moment of fertilization. This well known concept is doubted and the question: When does a human being starts its own life cycle ? arises. Different alternatives are taken into consideration, and the beginning of life for the human being is considered at stages as eclosion, implantation, formation of the notochord, appearance of heart beats, organogenesis or even at delivery after cutting the umbilical cord. We believe that the statement of Donum Vitae (1987) (14) in which it is read "Recent findings of human biological science recognize that in the zygote resulting from fertilization the biological identity of a new human individual is already constituted", is correct. This means that from the moment when the plasma membrane of the sperm and the plasma membrane of the egg fuse, we have a new individual. Recent findings of Fiddler and coworkers (1995) (7) have demonstrated the presence of SRY transcripts in preimplantation human embryos, which means that from a very early stage in development there is sexually dimorphic gene expression.

This concept was reinforced by Gutierrrez- Adan et al.(1997) (10) who observed that in vitro produced male bovine embryos develop faster in culture than female embryos. The later findings support the idea of a very early functional genomic activation of the embryo. As there is a difference in size of female and male embryos, it discards the possibility of just a transcriptional burst.

An individual is defined according to the presence of three properties: coordination, continuity and graduality. These are the properties that characterize the whole epigenetic process, defined by Waddington (24) as the "continuos emergence of a form from the preceding stages". The embryo therefore, from the time the gametes fuse is a human individual, not a potential one. After fertilization, the embryo continues to develop and stages as the fusion of the pronuclear membranes and cell division cannot be but part of this continuum. As in any process of development the embryo will acquire different shapes and structures, like compactation when cells look and are closer. It is very difficult, if not impossible, from a scientific point of view to deny the status of living human being to the zygote. Terms like "cell at the pronuclear stage" and "pre-embryo" have been introduced, but they cannot be considered the beginning of any given individual. Another term that has recently been introduced is "the pre embryonic stage", which has been defined (FIGO)(28) as the period from fertilization up to the determinant of the primitive streak at the age of 14 days. This enables research on the so-called pre-embryos, genetic screening with its potential for the prevention and treatment of birth defects. It also allows non-reproductive cloning provided that development beyond 14 days does not occur.

Pregnancy has also been redefined (Cairo, 1998) as "that part of the process that commences with the implantation of the conceptus in a woman, and ends with either birth of an infant or an abortion". In this way, natural human reproduction is considered as a process in which the beginning of a new human life is not considered as the moment when the organisms acquires the rights of being treated according to its human condition. The new definition of pregnancy, not from fertilization but from implantation also redefines abortion and opens a window that makes it easier to eliminate or manipulate human beings during their first days of life.

Informed choice is a right of every patient and as it, it has been introduced before prescribing contraception. This is in order to allow women to freely make decisions about possible health intervention and places decision making in women's hands so that they can exercise their rights. The basis of informed choice is information, which should be accurate, unbiased, complete and comprehensible.

It is said that

"Respect for informed choice requires that certain information on contraceptive methods should be provided to every woman considering using them including,

Proper use
Contra-indications
Effectiveness in preventing pregnancy
Need to continue to protect against sexually transmitted infections
Possible side effects
Possible interaction with other drugs or conditions".

In analyzing the above quoted indications from FIGO (28) it would be necessary to consider the inclusion of post fertilization effects of oral contraceptives in the list. It has been proven (see review by Larimore and Stanford, 2000) (16) that while the primary effect of OC is the inhibition of ovulation, secondary effects are implicated at times of breakthrough ovulation.

These effects can occur at a prefertilization level (alterations in cervical mucus and changes in the endometrium and fallopian tubes that may impede normal sperm transport) or at a post fertilization level, in which case they would kill the embryo. The post fertilization level effects more clearly demonstrated are alterations in the endometrium (thickness and cellular structure) and in the expression of integrins from endometrial samples of women taking OC. These effects are mentioned in the Physicians Desk Reference, but not always to the patient.

Possible side effects should also be informed to the patient. For example, when someone is to be given anesthesia for an elective surgery the related deaths to the procedure are explained. They have an incidence less than 1 in 25,000. in the case of emergency contraception there is an increased risk of thromboembolic disease, especially on carriers of factor v leiden mutation (2/100 women), on acquired activated protein c resistance and on the incidence of the antiphospholipid syndrome. recently girls presenting with pco and hiperinsulinemia have also been considered as high risk of thromboembolic disease (17). despite this, there is a tendency to freely prescribe and to have available without medical counseling the morning after pill. informed choice in the case of contraceptive medication should be enhanced.

We must consider that the reproductive industry, as all industries, follows the supply and demand law, being efficiency in the productive process its goal. Women are sometimes seen more as a target market group than as women, with a specific vocation and mission given by their personal essence. For the contraceptive industry this is an important group: it has been estimated that for year 2025 there will be 2500 million women of reproductive age.

Another women's health industry that has also grown is the abortion industry. Since the legalization of abortion, for example in the US the number of abortions per year has increased from 190 thousand to 1 million 200 thousand in year 2000. In the world, 52 million abortions per year are done. It is reasonable to think that such an industry is based more in economical goals than in preserving the lives of the children to be born. Actually if we do a search in Internet there are about 300 thousand Reproductive Health Services. Of them, around 15.000 are identified as Catholics and 900 as pro-life. If we look at the services offered by Reproductive Health Services world wide, 86% of them offer contraception, emergency contraception, sterilization and abortion. It is interesting to consider that most pro- life centers lack reproductive care other than counseling and sometimes natural family planning.

Regarding residency training programs in OB/GYN, most of them offer training in the following areas:

Obstetrics
Pregnancy complication
Congenital malformations
Normal labor and partum complications
Disorders of puerperium
Obstetrics operations and procedures
Social and cultural factors
Gynecology
Menstrual cycle
Puberty and menopause
Pelvic infections and STD
Genital tract tumors
Endometriosis
Infertility
Contraception and sterilization
Urogenital dysfunction and prolapse
Pelvic pain
Gynecological surgical procedures
Ethical and medical legal aspects

With the exception of contraception, all other areas could be looked at without noticing how the culture of death is getting into women's health care.

The data shown above enhances the need to train doctors willing to respect human life within their practice. But, it is also necessary to have reproductive health services oriented towards a culture of life rather than to contraception, sterilization, IVF and abortion. We need to create centers where woman can get the reproductive health care they really need. Ideally these centers should work together or in association with the bioethic centers. It is urgent that we can reach the millions of women asking for a comprehensive medical care not being reductionist and that should include the multitude of factors affecting it, including physical, social, spiritual and emotional well-being. A good quality of life should be offered looking at motherhood and life as a gift and not a burden. Illnesses affecting women at different ages should receive more attention. The main controversies that exist nowadays in Reproductive Health Services are basically derived from the view each one has towards human life and the human person. Is human life a transcendental life or is it just one more living being in our planet?

Do we have the right to be created within an act of personal communion between a man and a woman or can this personal act be replaced by a technical act?

Are we gifts or products?

In summary, the changes introduced in our culture have confronted OB/GYN with ethic dilemmas, especially important in areas dealing with human life, procreation and embryonic and genetic manipulation. It becomes necessary to reinforce the dignity of human life, not just because it is a living organism, but because of its humanity. The new reproductive technologies that separate the sexual act from procreation have originated an industry for "making human beings". This denies the right to be procreated within the frame of personal relationships. Having a son is considered a right, not a gift. The unwanted pregnancy is considered a threat to the mother's life, denying the embryo's right to live.

Nowadays the quality of life is evaluated in terms of its duration and physical, social and economic well being and not because of the person's vocation. This has lead to the consideration that it is appropriate to enhance the reproduction of those genetically better gifted and to prevent the birth of ill people. We need to help men to recognize their real vocation: to love and to be loved.

We as OB/GYNs need to help bring back women's maternal vocation in order to re enchant the world with the gift of life, eternal life. We need to re enchant men with their caring for the mother and the helpless child. It is in our daily work with the mother, the father and the child to be born that we will become the doctors we have always dreamed of, fulfilling our vocation through the sincere self-giving to others.

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