It is ethical to recommend against assisted reproductive treatment for women with a high body mass index

Abstract

Ethical judgements in medicine in general, and assisted reproductive technology (ART) in particular, can be difficult to make. This is particularly so outside of a hospital environment where diverse skills and opinions are more difficult to obtain. The four classical principles that guide ethical judgements -respect for autonomy, beneficence, non-maleficence and justice -usually have multiple dimensions. For example, it is possible to argue that discouraging treatment of women with a high body mass index (BMI) from having ART is unethical because it contravenes the principle of justice. It may be argued that women with a high BMI have similar or, in many cases, higher chances of a live birth than women in an older age group. Thus patients in a similar position are not treated in a similar way and therefore denial of treatment is unjust.On the surface this argument seems reasonable, but the reasoning is flawed for two important reasons. First, patients' ages are not reversible -an older patient in a poorer prognosis group cannot become younger -whereas a high BMI is potentially reversible. Second, offering ART to women with a high BMI may contravene the ethical principles of beneficence (balancing the treatment risks against the desired outcome) and nonmaleficence (avoiding harm to the patient, or ensuring harm is not disproportionate) especially when the wellbeing of any child is considered. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists statement C-Gyn2 poses the question, 'Is ovarian stimulation appropriate in women with a BMI greater than 35?' and provides the opinion: It is inappropriate to recommend ovarian stimulation (including in vitro fertilization (IVF)) as part of first line therapy in the female with a BMI >35 unless there are exceptional circumstances. Ovarian stimulation in these circumstances should be deferred until appropriate weight loss by appropriate measures (eg diet, exercise, bariatric surgery, etc.) has occurred. This is expected to improve general health, may restore normal ovulatory function and enhance pregnancy outcome. 1The advice in C-Gyn2 is accompanied by an important caveat: 'This information is intended to provide general advice to practitioners, and should not be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of any patient.' It is indeed obvious that the effect of having a high BMI on the chance of having a live baby is less than that of advancing age. Whereas age is inviolable, with support and patience many women may be assisted to return to a normal weight range. RISKS TO THE WOMAN UNDERGOING ARTImportantly, women with a high BMI face greater risks procedurally and with pregnancy outcomes. 2 Oocyte retrieval procedures are more challenging in women with high BMI and obese patients may have difficult venous access. 3 Anaesthesia or sedation of oocyte retrieval can be more hazardous since response to sedation

Successful weight loss interventions before in vitro fertilization: fat chance?

“…Limited resources have also led to health care providers clamping down on subsidised treatment of patients going through IVF. This approach has been criticized on ethical and medical grounds (12,15), although it is defended by others (16).…”