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PBL: Tracy and Dylan difficulty to conceive - Coggle Diagram
PBL: Tracy and Dylan difficulty to conceive
Affordable Care Act: federal care in 2010 that expanded medicaid
Is IVF covered under ACA?
which tests will ACA insurance cover?
Are current politics going to make getting infertility treatment more difficult?
Learning issue 1: What is the nature of the changing landscape of the ACA in regards to fertility treatments:
In CT, private insurance companies must include coverage for fertility treatment. However, HUSKY only covers diagnostic care but not any fertility treatment.
A single round of IVF costs $15,000-30,000 out-of-pocket. Maybe Tracy should inquire into obtaining insurance through her work.
Options for fertility treatments
What have Tracy and Dylan tried so far? What are they open to trying?
Center for Advanced Reproductive Services
Infertility: inability to conceive after 12 months of regular unprotected sexual intercourse
over 35 years old: if not conceived after 6 months
What are tests for infertility?
sperm count and motility
Learning Issue: What is the process of choosing a sperm donor, what's available, pricing, and accessibility?
$400-$2000 per vial, recommended 2-3 vials
decide whether sperm will come from a bank or a known donor
if choosing a known donor, it is recommended that the patients have the donor get genetic testing and have a conversation about parental rights, etc
if choosing a bank, genetic testing, parental rights, etc have been decided
AMH level is 4.7
hormone produces by follicles in ovary that measures total eggs/ovarian reserve woman has remaining.
PCOS can cause high AMH
normal value woman of 35: 1.5
egg retrieval
learning issue 4: What is the nature of fertility testing for women? What makes a woman eligible for IVF and what is the process of undergoing IVF?
Steps of fertility testing
Counseling / Medical History: explaining risks and benefits of procedures, treatment options, obtaining a full obstetric and gynecologic history and medical history from each parent
Fertility blood testing: measures levels of progesterone, estradiol, TSH, prolactin to monitor egg production and maturation
Ovarian Reserve Testing: combined blood test and transvaginal ultrasound, measures anti-Mullerian hormone to determine # of eggs relative to normal for the patient's age
Ovarian Stimulation & Egg retrieval: aspiration procedure to obtain eggs, performed under anesthesia at a surgical center, requires ovarian stimulation with LH and FSH injections to produce enough eggs for retrieval
Fertilization: egg and sperm will be added to a petri dish for fertilization after the egg retrieval and sperm collection
Embryo Transfer: if successfully fertilized, the embryo will be transferred into the uterus for pregnancy
Additional tests: genetic testing, pelvic ultrasounds to check for physical abnormalities that affect fertility
IVF can take up to 6-8 weeks for one full cycle
Health history
small infant 21 years ago, now healthy
how are Tracy/Dylan's health?
How will Dylan's smoking history affect ability to carry child?
even with donor egg, still has low fetal growth, impaired placenta risk
no greater risk of villitis because the immune system of the carrier is what causes villitis
Twins have 20% chance with her age w/ 2 embryo transfer
age of Dylan: 46. Does this affect ability to carry?
Chronic inflammation of the placenta
intrauterine growth restriction: fetus does not grow at normal rate, fetal rate below 10th percentile for gestational age
what are the several disorders associated with chronic inflammation?
Learning issue 5: What is the pathophysiology of villitis, and what is the chance of future recurrence?
Infectious villitis
- less common and less common risk of recurrence, caused by pathogens crossing the placenta and inflammatory cell signaling responding to the infection
Villitis of unknown etiology (VUE)
- more common risk of recurrence 30%, VUE occurs when maternal cytotoxic T cells attack the blood vessels of the placenta, alloimmune response, CD8 T cells and Haufbaer cells
maternal grandparent with Type III spinal muscular atrophy
can this be inherited?
Tracy carries SMH
how likely is child to get SMH?
autosomal recessive inheritance
learning issue 3: What are the ethical issues to be considered when conceiving as someone with an inheritable disorder? How do these issues change with respect to the nature of the disease in question?
Disease severity
SMA has five subtypes of variable severity, ranging from mild leg weakness to fatal complications after birth
Inheritance pattern
Autosomal recessive pattern indicates that two carriers have a 25% chance of passing on both copies of the SMA-related gene
Carrier rate
In certain groups, the SMA carrier rate could be as high as 1 in 50
Genetic testing costs
Prices range from $100 to over $2,000, without coverage from public insurance
Genetic testing accuracy rates
High specificity and sensitivity for the most common methods
Risks of prenatal screening
Prenatal mortality is possible for every 1 in 150 births after prenatal screening
Social stigma
SMA requires many accessibility changes and is a visible disability, which can be challenging socially
Life expectancy
Life expectancy can vary depending on subtype, from a few weeks to a normal, healthy lifespan
Accessibility barriers
Wheelchair accessibility and other issues
menarche at age 10, regular menses, normal vitals, normal pelvic/physical exam
Learning issue: In what ways do the health status of the egg donor and the surrogate mother influence fetal development and pregnancy outcomes?
increased BMI of donor and surrogate=worse outcome
reciprocal IVF=worse outcomes
surrogate levels of CoQ10, antioxidants, folate are positively associated with embryo's outcomes
Ethics
HIPPA violation to tell his girlfriend about this patient?
What are the laws for fertility specialists to refuse to give care if pregnancy is unlikely?
is it ethical to make someone go through fertility treatment?
expensive
unlikely to get pregnant
right to self-determination
Learning issue 2: What are the boundaries to the physician-patient relationship when it comes to conception planning?
4 elements of consent: 1) specific 2) voluntary 3) informed 4) decisional capacity
Study that showed 74% of women experiencing infertility prefer shared decision making model
Doctor can deny care if 1) medically inappropriate 2) violates a protected entities well-being (child) 3) violates autonomy of physician
Politics
How will current politics affect same-sex couples ability to use fertility services?
Learning issue: what are the legal rights of the sperm donor, egg donor, and surrogate mother in terms of parental rights of sperm donor?
Parental rights of genetic parent and surrogate parent?
Connecticut Parentage Act (CPA): can establish parental rights with legal documentation "Acknowledgement of Parentage"
Case in Kansas where Sperm donor was sued for child support
Can a doctor deny treatment to a same sex couple?
Learning issue: What is the nature of a doctors right to deny care based on personal beliefs?
Church Amendment states that physicians may refuse as a form of conscientious objection. Ethical guidelines state to give advanced notification, refer to a willing clinician, and treat in an emergency.
Learning issue: What happens to remaining healthy embryos? Legal rights of an embryo?
donation to science, disposal, compassionate transfer
prioritizes patient wishes and requires written consent prior to documentation