When I got authorship privileges I mentioned I might occasionally write about topics related to ethics in clinical medicine, or just clinical medicine in general, based off my current experiences doing clinical rotations to complete my MD. Turns out, it's a little difficult because A) my schedule often sucks B) discussing specific cases with strangers is a biiiig no-no and rarely that interesting for non doctors C) most of the time my cases are pretty mundane and not very medically or ethically complicated. But this week I started my ob/gyn rotation and I spent this afternoon in fertility clinic, which really got my juices flowing (no pun intended).

Now for a bit of context: being in Canada, healthcare is "socialized". Basically all hospital services and medically required services outside hospitals are covered by the government (patients pay nothing out of pocket, doctors charge directly to the government via a provincial health insurance). There are private clinics and private hospitals but they are rare and not at all the norm. This makes medical resources more limited in many ways, but honestly the standard of care, quality of equipment/technology, competence of doctors, etc. are nothing to be frowned at. Delays can be longer, but nobody dies or suffers major complications because they could not get urgently needed care. There are still some things that need to be covered by private insurance, such as dental care, eye care, some psychotherapy, etc.

For a few years now, fertility treatments have been covered by government insurance in my province. This includes investigations for infertility, stimulation of ovulation, insemination, IVF. This allows access to such services for couples who couldn't have afforded it (although in my admittedly limited experience it's still very much middle and upper class couples who do it). It also allows for a certain control of the conditions in which treatments are done. For example, embryos to be implanted are limited to 1-2 so as not to produce extremely high risk pregnancies. Maternal age can also be somewhat controlled (quite honestly though I have no idea what the current limits are), etc. This may actually change soon, as our current Health Minister is trying to pass a bill that would majorly reform our provincial health care system. Among other things it would significantly tighten the restrictions under which IVF can be undertaken. But that's a whole other story.

Being in a system with limited resources, I am unsure what to think about the use of government resources for fertility treatments. On the one hand, if a medical service exists it should be offered equally to the whole population, that is the premise of our universal healthcare system and it is something I deeply believe in. I also believe it is completely justified to cover it but then limit the number of tries allowed and to make sure we aren't creating very high risk pregnancies, which would be irresponsible. On the other hand...this is not a medically required service at all. Wanting kids and not being able to conceive is heartbreaking, but it is not in and of itself a medical condition (of course medical conditions responsible for infertility should be investigated and treated as normally indicated, but that's not quite the same thing). Modern medicine does have the tools to help, but to what extent do public funds need to cover that? I truly have no answer to that myself. I am generally pro-government and pro-universal healthcare, I am not at all advocating for private practice to take a bigger chunk of the pie, but I do wonder about this from an "allocation of resources" point of view. Should this have priority over other underserved areas? I am trying to compare fertility services to other treatments that are not medically necessary, and on a similar level of complexity and invasiveness I can only think of reconstructive surgery, which usually serves the goal of either regaining function or overcoming serious disfigurement.

Which also brings up a related but different question, this one on a psychological level. How far should people go with fertility treatments before they explore other options? It is truly impressive to witness how many complicated and invasive tests and procedures some couples are willing to go through in order to conceive. I admit it is difficult for me to comprehend, because at this point in my life I could not really imagine having that big of a desire for biological children. I do not want to be that person who says "just adopt", I know it is not an easy option either, and not necessarily available to all, etc. I don't think couples struggling with infertility should be denied a shot at a pregnancy. But I think it's important to beware of taking it too far. Fortunately I think it's pretty rare.

Discussing fertility treatments, you also can't neglect to discuss how they relate to same-sex couples (more often lesbian couples), and how heteronormativity plays into the practice and perception of fertility services. Just this afternoon, I met two lesbian couples who were undertaking insemination. I actually heard somebody (working in the clinic no less!) comment privately on how it's "not natural". Now, I can't think of a single thing being done in that clinic that could ever be considered natural. By definition it's medicine taking over where the usual way of doing things hasn't worked. Why this is an issue specifically when lesbian couples require that service, I have no idea. There is absolutely no reason why insemination shouldn't be offered to two women if it is offered to a heterosexual couple. I was shocked to hear that comment (unfortunately at the time I was not in a position of discussing it with said person). However I think it really reflects what a lot of people think about fertility treatments, consciously or not. A heterosexual couple desperately wanting to conceive a child is considered completely normal, and usually gets sympathy and understanding. Their life project isn't unfolding the way everybody agrees it should, therefore they are right to get all the help they can to conceive. A same sex couple desperately wants a child, many people will say (or think) that they're simply not meant to have one and that they shouldn't fight it. Just find something else to fill your life, adopt, get a dog. Maybe try insemination from a sperm bank, but don't force it with IVF and the whole thing. It's depressing to realize there is still a lot of bias and prejudice when it comes to same sex couples having children. Fortunately I saw no such thing coming from the doctors or being expressed in any way to the patients. I can only hope it never happens.

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So yeah this was my first medical post. Sorry if my thoughts seem a little scattered. I still have a fair bit to say on the topic but won't scatter myself even more, at least not for now. This was written purely from my point of view and as an immediate reaction to my experiences of the day. It may still carry some unexamined bias, if so I apologize and appreciate comments/call outs.