Roe v Wade and IVF/PGT
Author: Rosemary Kirk, MD
Key words: Fertility, in vitro fertilisation (IVF), Abortion, Roe v Wade, Genetics, Pre-implantation Genetic Testing (PGT)
The US Supreme Court decision to revoke the constitutional right to an abortion has been widely and rightfully condemned. This decision will increase morbidity and mortality through unsafe abortions or the carrying of unwanted pregnancies, infringes on the rights of pregnant people to make decisions about their bodies, and will disproportionately affect individuals from marginalised communities. One consequence that may not be immediately obvious is the impact on people who have experienced infertility or genetic conditions.
When the Roe v. Wade ruling was made in 1973, research into assisted reproductive technology (ART) was in its infancy. The first successful in vitro fertilisation (IVF) birth occurred in 1978, and IVF now accounts for over 2% of US births. A further technological gain alongside IVF has been pre-implantation genetic testing (PGT), first used in 1990, and used in 27% of US ART cycles in 2016. In PGT multiple embryos are produced through IVF, the embryos are screened for a pathogenic genetic variant or chromosomal abnormality, and only those embryos without abnormalities will be implanted. It is important to note that there are some ethical concerns associated with PGT, particularly when it is offered to screen for traits like embryo sex, or when polygenic-risk scores are used to judge lifetime disease risk or even intelligence (a poorly understood and ethically dubious science, and one that is not regulated in the US). However, when PGT is used appropriately in patients who are carriers for life-threatening genetic conditions such as Huntington’s disease, cystic fibrosis, or cancer-causing BRCA syndromes, it provides huge benefits. Patients who undergo PGT can not only prevent disease for their children, but for all subsequent generations of their family. This reduces both individual suffering and the societal costs of long term disease monitoring and treatment.
Despite the immense potential individual and societal benefits of IVF and PGT, they remain costly and relatively inaccessible in the US. There is no federal funding structure for IVF, and each IVF cycle costs an estimated $12,400-$24,000, with PGT an additional expense. As of 2018, 16 states had legislation mandating that insurers cover diagnosis and treatment of infertility, with only eight states specifically requiring that IVF be covered. Consequently, most IVF/PGT is paid for out-of-pocket, and is inaccessible to many.
At a time when the US should be making efforts to increase accessibility to these reproductive technologies, the overturning of Roe v. Wade is a step backwards. IVF typically involves multiple embryos being produced to increase chances of success, and generally only one embryo is implanted to reduce the risks associated with multiple gestations. Remaining embryos may be discarded, or stored with cryopreservation at great expense. The discarding of embryos is all but guaranteed when PGT is used, as some of the embryos produced will have life-threatening genetic variants. In states where abortion is banned from the time of fertilisation the discarding of embryos could become illegal, making it unfeasible for clinics to continue to offer IVF and PGT.
Even beyond fertilisation, the right to an abortion remains important throughout IVF pregnancies. Where IVF pregnancies result in a multiple gestation, either due to multiple embryos being transferred or due to embryos splitting, selective reduction may be used. This involves reducing the number of fetuses in order to reduce the risks of multiple gestation to the mother and remaining fetus(es). While this practice is declining as more IVF clinics perform only single-embryo transfer, it is still widely performed and will not be possible where abortion is illegal throughout pregnancy. Further, compared to other pregnancies, IVF pregnancies are higher risk for complications that can pose risk to both mother and fetus including placental complications, need for blood transfusions or ICU admissions, and preterm births. As such, abortion may be required to save the mother’s life or to prevent the suffering of a fetus with major abnormalities by carrying it to term. In states where abortion is illegal with no exceptions for cases such as these, the decision to undertake a higher risk IVF pregnancy will become significantly more complex, and potentially dangerous.
Legalising abortion increases women’s rights to choose; to choose not to have children, but also to choose to have children, or to choose to have children who are not at risk of genetic conditions. At a time when measures should be taken to increase access to IVF and PGT, the overturning of Roe v. Wade is a huge step backwards, not just for women’s rights, but for the fields of fertility and genetic medicine as a whole.
About the author: Dr Rosemary Kirk is a resident medical officer currently working at Westmead Hospital, Sydney, Australia. She is a 2022 Rhodes Scholarship recipient and will soon be commencing a DPhil at Oxford University studying genetic heart disease. She is passionate about the ethical and equitable use of genomic medicine. (Twitter: @DrRosemaryKirk)
