Medical Examiner

The Other Medical Treatment Endangered by the Fall of Roe

The concept of “fetal personhood” extends beyond abortion.

A person in scrubs points to blastocysts shown on a monitor surrounded by equipment in a fertility clinic lab
IVF in process at a fertility clinic in Johannesburg. Luca Sola/AFP via Getty Images

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If Roe v. Wade gets overturned, it won’t just affect women who need an abortion. For people seeking fertility treatment and their doctors, the big concern is the foundation of the fight against abortion: fetal personhood. If a fetus is a person, it raises all kinds of questions.

This is not a paranoid fear. Six states have introduced fetal personhood bills this year. A few months back, Sen. Rand Paul sent a fundraising letter to his constituents in which, after arguing “the time to grovel before the Supreme Court is over,” he asked for their support for the federal Life at Conception Act. It would declare fertilized eggs to be “persons.”

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Natalie Crawford, an OB-GYN and reproductive endocrinologist in Austin, Texas, deals with fertilized eggs all the time. A normal round of in vitro fertilization means creating lots of them, watching them develop into embryos, and then implanting one or more right back into the uterus. On Thursday’s episode of What Next, I spoke to Crawford about how Roe helped pave the way for IVF and its acceptance, and how attacks on reproductive rights are already affecting her work. This conversation has been condensed and edited for clarity.

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Dr. Natalie Crawford: IVF has allowed us to do genetic testing for aneuploidy, which is the top reason why it’s harder to get pregnant after age 35. That means random chromosome abnormalities. And so with IVF and genetic testing of embryos, we’re able to know which embryos have the highest chance of turning into a live-born baby, which ones are going to result in miscarriage or genetic abnormality.

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Mary Harris: And you make choices based on that.

Exactly. So you might be 40 and you might send off eight embryos, but only two of them may actually be genetically normal. You don’t want to worry about the other six. You don’t want to be forced to transfer the other six. You’d like to transfer the one that’s genetically normal and save another one for a future child. And if none of them are normal, you’d probably want to do another cycle and not be transferring abnormal embryos.

One scenario we could see is that all genetic testing is now off limits. How do you remove five to eight cells from an embryo if it’s its own independent life and has rights?

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I wonder if you began thinking about the way limiting abortion rights could impact you as a practitioner way before the last week or two. Can you take me back to when the six-week ban passed in Texas? What were you thinking at the time?

So definitely at the time I was already thinking about how it’s impacting a lot of my patients. Infertility patients have highly, highly desired pregnancies. … I had a patient who conceived naturally right before she was going to do an IVF cycle and the pregnancy ended up being genetically abnormal, and she was told this child wouldn’t survive. She could carry it to term and try to give birth, or she could terminate the pregnancy. This was right before the ban went into place. And so she was able to choose for her and her partner that termination was the right choice. That also allowed us to fast-track her onto getting to IVF sooner, you know, figuring out which embryos are genetically normal.

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You have your own story that you decided to go public with in the wake of S.B. 8. Can you tell me about your story and why you wanted to go public with it?

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I had an ectopic pregnancy, and what that means is a pregnancy in the fallopian tube.

Nonviable.

Nonviable, highly desired. I had three miscarriages before that. This was my fourth pregnancy. I was an infertility fellow. I was very excited. And it was devastating.

The choices at that time were twofold. It was to either get it surgically removed or to try and use methotrexate, which is a chemotherapy agent that kills rapidly dividing cells and so essentially terminates the pregnancy so that you don’t have it rupture in your fallopian tube and so that you can recover from the situation, because there is no scenario where you could take a pregnancy from your fallopian tube and implant it in the uterus. I know there are people saying that there are, and there’s states trying to pass that. And I swear, if that was an option, I would have gone to the moon to have it done. I would have had anybody do that. But that’s not an option. Once that pregnancy starts to implant, it’s creating a blood connection. It created a blood connection in my fallopian tube. The fallopian tube does not have the muscular support of the uterus to get a strong enough connection.

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And if that had happened to me, many hundred years ago, I would have just died, and that would have been the end of my story. That’s what happens. It ruptures and you bleed to death. So I was able to get methotrexate. It was terrible. It was emotional. Physically it’s a terrible injection of a chemotherapy medication. You feel like you got hit by a truck. But I was able to do that, and I was eventually able to go on and have my two kids. And if I hadn’t been able to receive that medication that terminated that pregnancy, I wouldn’t have been able to keep on and have my children later on.

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You compared yourself to a woman in South Texas.

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Yes. Who had to travel out of state.

What happened to her?

This was right after S.B. 8, when there was a lot of fear in Texas that people would be turned in or would be prosecuted. And she went to an emergency room in South Texas, was diagnosed with an ectopic pregnancy, and she was told they couldn’t do anything about it. And so she got in her car and drove out of state, I believe to New Mexico, and was able to receive treatment there. So she ended up being fine. But that’s an extremely dangerous situation. It could have ruptured while she was in the car, she could have died on the way, she could have had a medical emergency.

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Seems like a life-threatening situation to me—there are supposed to be workarounds for that.

You should be treated right away. And under S.B. 8, you should be able to treat somebody for the life of the mother. It does have that exclusion. However, who decides that? In this scenario, the person in the ER who saw her was too fearful because of S.B. 8 to treat her, and sent her in her car across the state of Texas to another state, risking her life for that treatment. And that to me is just the Wild West of medicine.

We have a treatment that could save her life. And because of fear, because of this bill, a provider, somebody who saw her, sent her away. That is just so beyond what is appropriate medical care. And we’re going to see more and more stories like that, especially as states are [enacting] felony laws and limiting access to some of the early medical treatments we use to aid in miscarriage or for early termination of pregnancy.

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Once Roe v. Wade is overturned, there’s going to be some confusion about what the law means and how people can act. And it means that individuals will have a weird amount of power, like the person you meet in the ER who just says, I guess I’m not allowed to do this procedure now. Or the prosecutor who’s like, I think I should charge you with something now. Like there was a case in South Texas of a woman charged with murder for self-induced abortion in the last month.

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Right. It ended up getting dropped, but she got charged with it. I mean, that is mind-boggling, and you’re correct that there’s going to be so much uncertainty that individuals are going to be left up to decide what they think. It’s going be trial by error, what they think is best, and then things will start being taken to court. And if that woman who was charged for her own self-abortion, if that had stood, you know, what kind of precedent are we setting? What kind of charges are we starting to see?

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And I’ll even just say, as somebody who’s a fertility doctor, one of the medications I prescribe, misoprostol, I use those to soften the cervix before surgery. So sometimes I do surgery called hysteroscopy. These are on nonpregnant patients who want to be pregnant. I put a camera through the cervix, into the uterus, look around, fix scar tissue, take out polyps or fibroids. This medication makes it a lot easier of a procedure. It’s easier to get the camera through the cervix. It’s safer. It makes the procedure carry less risks.

Well, that is also a medication that could be used for an early abortion, a medical abortion. And pharmacies here now do not want to fill the medication. Even though my patients aren’t pregnant, even though I’m using it for a different indication—and we’re seeing the same thing with physicians who use medications for conditions not related to pregnancy. But if you use methotrexate for an autoimmune disease or misoprostol prior to surgery or misoprostol to help somebody who’s already in the process of a miscarriage, their baby’s lost a heartbeat, pharmacies are now refusing to fill those medications because pharmacists have the power. They don’t feel comfortable under these current laws. And so we are starting to make medical care for women much more dangerous. …

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And in Texas it’s like a $10,000 fine. It’s not a felony, like it might be in certain states. That’s going to really start to make people trigger-shy to fill or prescribe or to help people who need help.

How common is IVF?

Two percent of the U.S. population is conceived from IVF. So it’s not a small number. Millions of people access IVF to grow their family. And we need to be really loud about how this technology has enabled so many more people to be parents and what that means.

You’ve also noted that this common medical procedure has only ever been available in a post-Roe America. No one imagined doing this fertility work without abortion protections. And if you go back to the early days of IVF, you can see the same language that’s now being used against abortion being deployed against people who sought fertility treatment and their doctors. The industry had to adjust to it.

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Our oldest IVF baby is only in her early 40s. Roe v. Wade was well around before that. And these people who went through IVF early, they were hugely stigmatized. People protested outside their houses. It was a very different world, and we’ve made huge progress in getting IVF to all over the country and helping people grow families. But we really changed people’s viewpoint on how they felt about it. …

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This is why I tell people all the time: You’re allowed to have your own personal beliefs, and sometimes those impact how we do your IVF cycle. Forget all these laws—if you believe life begins at fertilization and you don’t feel comfortable freezing any embryos, that’s what we do. We do it the way that you feel comfortable about it to help you grow your family. And we talk through, well, it might cost more, take longer, but if that’s what you feel comfortable with, then that is absolutely what we do. And I think every fertility doctor has been in that situation.

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I wonder if that history with fertility treatments gives you a little bit of hope for where things might go now, just because it’s evidence that people’s minds can change about something big.

It is hope. I do think that when we step back and we look at IVF, what are we trying to do? We’re trying to help people have families, and how is that inherently a bad thing? Maybe you believe that it is, but to me, I feel like overall we should want each other to be happy and to have the family we want when we want it. … And I feel strongly that we really don’t want to be rolling back the clock and limiting this for people. We want to help people get to that next step and have a child.

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We really need to be amplifying, trying to get people in the position of power who value that a person has the right to choose their own reproductive future, because that extends to all reproductive rights and not just abortion. It’s a much bigger issue than only abortion.

Back in 2011, Mississippi was trying to pass a fetal personhood amendment and it was going through a ballot initiative. And a lot of people said, oh, this will fly through. They just assumed this is a very conservative state, very anti-abortion, this will just happen. But it was rejected by 58 percent of the state’s voters. And part of the reason was a group called Parents Against 26. It made ads basically outlining how this bill would make fertility treatments unavailable. It strikes me you’re in a little bit of a powerful position for this next round of the battle. But I wonder if you feel like that.

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I’m happy to hear you say that. I’ll admit, it’s a fight I never foresaw would be in my future when I went into this field. I became a doctor to help people, to help people get pregnant, because I liked reproductive medicine. And I really feel like there’s nothing you can do that changes the course of a person’s life as much as help them conceive a child that they so very much want and have a hard time.

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Being in Austin, do you talk politics with your patients?

Early in my career, I think we’re all trying to cut our teeth, but I was really hesitant to talk anything political with patients. It was a message that I got when I was an employee in a prior practice: You shouldn’t talk politics because you’ll alienate people who don’t want to come see you. And I’m like, I don’t have to be for everybody, but I think there’s more good that can come from it than harm. And if you’re not gonna be comfortable seeing me because I’m advocating for your reproductive rights, then that’s OK. I’m probably not going to be a good fit of a doctor for you. And I’m fine accepting that I don’t have to see everybody.

But I do think some physicians are scared about how their patients will take it, or they don’t want them to think bad of them, or they don’t want to limit people who will walk in their doors. So they’re just staying silent. And silent’s not a neutral position. Silent is in the vote of whatever the majority is at the moment.

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