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Case Report No. 5

Ana (30) and Miguel (34) are a couple who began their study of infertility after three years of trying without success. Two centers have come years of reproductive medicine clinic itaria univers.

been told in all the same. Have the diagnosis of unexplained infertility. All tests so far have been normal. In the last consultation poses the possibility of IVF and in this center prevents multiple pregnancy and ovarian hyperstimulation syndrome, through the freezing of spare embryos from a single procedure for induction of ovulation. It also has this procedure, the addition of being cheaper than the subsequent induction of ovulation.

They crave to be parents, but had not raised the possibility of frozen embryos.

QUESTION 1: Check biological aspects of the clinical situation at hand and indicate which are the points where they still are not clear. Try to answer as you know or you manage to check with your teacher

infertile couple is defined as the couple who has not achieved pregnancy after a year of sex without using contraception. Infertility is a couples issue, so their evaluation should be both.

Among the causes of infertility should be differentiated from the woman (female factors) and man (male factor).

Within the female factor is divided into factors: endocrine, gonadal, cervical tuboperitoneal, and cancer.

The male factor can be identified factors: testicular, seminal tract obstruction and disorders of ejaculation.

are specific treatments for each disorder, and among them hormone treatments to induce ovulation, surgical correction of anatomical abnormalities and assisted reproduction.

assisted reproduction is to use mechanisms to egg implantation in the endometrium ignoring the act of intercourse. Among them are:

• artificial insemination, where sperm are introduced trained to the uterine cavity.
• in vitro fertilization, where eggs are taken from the ovary by ultrasound-guided puncture, fertilized in the laboratory with sperm from a partner or donor, then, brought into the uterine cavity.
• Introduction of gametes (sperm) to the uterine tube
• intracytoplasmic sperm injection (ICSI), where a metaphase II oocyte is injected with the body of a sperm into the cytoplasm.

QUESTION 2: addition to the dilemmas arising from the freezing of embryos What other situations (legal, social, economic, family) must meet a couple who sought assisted reproductive technologies (ART)?

Today

come into play property protected by the law: to life, rights of children, parentage, inheritance, etc ... and new reproductive rights, where one is free to choose how or method that parents want to use to get it.

Thus, independent of moral issues involving the freezing of embryos, they must deal with the legality and law. There has been talk of "Human Rights of 3 rd generation", which lays down the respect for life to be born, and the dignity of procreation, mainly advocated by the church doctrines, then the estates law raised by the protection to the embryo. So come to consider not only the rights of the living person, but also of future generations not yet born.
is why it has generated a stir, that may mean for some groups such as unusual or out of the basic nature, condemning those who practitioners. This can cause family breakdown, should be very rigid families to past concepts, or very fervent in their religious practice.

Of course we can not consider the economic implications, which in this case should make us think that, regardless of whether a family with many or few resources, remains a method that does not comply with the principle of Justice, since not all those who wish to exercise their reproductive rights may do so.

today is becoming increasingly more mainstream the issue of assisted reproduction methods, however the company still does not assimilate as natural, and there are still divisions that support these practices, and other than repudiate. This creates a fear and uncertainty about the social acceptance that they can have this couple and their new son, making it look even "artificial person."

QUESTION 3: What is your ethical reflection on these techniques?

on a subject as fertile ground for bioethical debate is impossible to obtain unequivocal opinions.

We as a society established that human beings have the right to reproduce using the means to do so. From this point of view, assisted reproduction is beneficent and respects the autonomy of individuals who undergo it, allowing them to achieve rather than for one reason or another are prevented from getting through natural means. Also achieved, in a sense, justice for those with fertility problems compared to the rest fertile.

However, it is undeniable that there are multiple spaces ambiguous on this issue. Although there is the technical capacity of assisted reproduction, their preparation is not equal and that often depends on economic resources, transforming a human right into a private good. This calls into question the fairness of the method, and while some are limited by their genetic condition or not to procreate accidental, others have the tools to overcome these difficulties.

The situation becomes even more questionable when considering the embryos as subjects of law. By incorporating the perspective of the unborn and future generations, is controversial practice of preventing development, and ultimately the lives of many in order to ensure the development of one, being all equal and legal ethics.

The current situation allows these acts, in which goods are traded potential (fertility) for ambiguous evil (injustice). Is then properly inform couples seeking fertility, so they can decide according to their values \u200b\u200bif the option of assisted reproduction is valid or not.

Case developed by: Daniel Ramos, Nicolas Reyes, Javier Rios and Carlos Sáez

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Case Report No. 3

female patient of 15 years, emergency consultation at the maternity clinic. Is carried by their parents who report accuses her daughter go because strong abdominal cramping pain in lower abdomen two-day, associated with genital bleeding. History of dysmenorrhea grade II to III, from menarche. Vital signs, BP 120/80, pulse 110 x min, FR 16 x min, T ° 37.5 ° C.

care In the box, out of sight of their parents, the patient reported that he had no periods since the summer, when that had sex with her boyfriend. Not been controlled by fear of their parents.

The review found a gravid uterus of about 2 ° month of pregnancy. The speculoscopy a gaping neck, by which POC out smelly, and regular blood in quantity.

QUESTION # 1 What

is (the) assessment (s) more likely (s) of the patient?

• Incomplete Abortion spontaneous Abortion
• Septic Abortion Abortion complete Abortion caused
Threatened abortion

This patient is no longer pursuing a threatened abortion, and has pain and metrorrhagia , to which an associated alteration of the neck and the expulsion of products of conception, both indicators of an abortion in progress. Nor has hemodynamic, or a fever marked as to say she is on a septic abortion. Therefore likely diagnoses are full-Abortion incomplete, should be studied with ultrasound to confirm or exclude the presence of products of conception in the womb. Making a difference if it is spontaneous or provoked, it is important to note that the patient has no lacerations in the vaginal canal or neck, indicating some kind of manipulation, and the history of dysmenorrhea may indicate a physical problem in the child. Now, given the history of hiding the information to their parents, should not rule out the possibility of having committed to a method of inducing abortion, so it is important to continue investigating the matter. Therefore, so far most likely to be a spontaneous Abortion, failing to confirm if it is complete or incomplete.

Once the patient is only asked the doctor who treats you that do not communicate the diagnosis to their parents. But you need to make additional examinations and gynecologic ultrasound, for which should be hospitalized.

QUESTION No. 2

What should the doctor do?
Located in a very complicated situation, where for "protocol" should speak with parents, since it is a minor who presents a picture which is an OB-obstetrical Urgency, in which life child is potentially at risk. Examination should harmless to the body, but to better define the picture she presents, and will guide us in the treatment and prognosis. We are facing a girl who puts a lock us in our actions, but we must take into account. Despite being an obstacle, it is important to take the weight means to her, and not withdraw. It is imperative to achieve a partnership with the girl, giving all information strictly necessary to understand the seriousness of his painting and the importance of telling their parents, offering support in this process.

What do you see values \u200b\u200band principles that are in conflict? They are in conflict
nonmaleficence v / s Autonomy. Nonmaleficence is presented to be as necessary to do a test to confirm the diagnosis we can treat it, and that failure to do so (both the examination and subsequent treatment) for withholding information, it puts us in a situation of malfeasance for with the girl, and we should perform a procedure, and we are not doing. On the other hand, is a girl who has every chance of being a mature enough to make decisions, and if your choice is to keep the information in defense, has the autonomy to do so, and we can not threaten it.

As our duty is to protect life in all circumstances we tend to predominate the absence of malice, but not against the autonomy, but it by exerting their autonomy, to understand the importance of the review will mean the difference between life and death.


Question 3 What would you
. which are the physician's obligations to ...?

With What rights do parents have?
Parents have a right to know what happens to your daughter, what a physician's obligation to give information.
With patient
What rights?
The patient is entitled to receive adequate treatment, diagnosis and treat their disease. You have the right to receive it as an adult, without discrimination. It also has the right to express their autonomy and this is welcomed.

With Duties of society "to an abortion doctor?
A physician has a duty to prevent abortion, and promoting the care of a pregnancy, regardless of age, or socioeconomic status, so as not to cause an abortion. This is important because it must protect the life of the unborn, demonstrating and human dignity.

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Case No. 2

Prenatal Control

A pregnant 37, enrolled in a pregnancy of 13 weeks is taken to the emergency room during the night. Her husband is on the way home from work, very upset, crying because the ultrasound was performed in birth control, told him he had a high risk of having a child with Down syndrome. The patient did not request that she received no special consideration during the scan and asked for his consent to be informed.

attending the clinic to have a new ultrasound machine, with a group of highly qualified doctors and continuous improvement in a referral center for maternal-fetal medicine college.

• Know you think is "risk of aneuploidy?

aneuploidy risk corresponds to a calculation based on ultrasound and biochemical variables to determine a probability of aneuploidy the patient to be tested.

• What are the markers of aneuploidy?

ultrasound findings are associated with the presence of aneuploidy, and in combination with the "risk of aneuploidy" to lessen the rate of false positives, in addition to a presumptive diagnosis of aneuploidies early without invasive methods. However, accurate diagnosis of aneuploidies is only possible through invasive methods.

• What risk does this patient? Do you know how to define the number of false positives in this situation? According

parameters analyzed at 13 weeks, this patient has a high risk that your child has an aneuploidy, however, when considering only aneuploidy markers evaluated the first trimester of pregnancy false positive rate reaches 5% .

• What medical, legal, ethical, experiential, do you think there are associated with the case presented?

Concerning

case referred to various problems arise.

First is the question about the diagnosis of aneuploidy. In calculating the risk of aneuploidy can not make a definitive diagnosis, even when the risk is high, since it represents a chance and will need to use invasive methods, which carry a 1% risk of reproductive loss to confirm the diagnosis.

And when we certify the diagnosis of aneuploidy that arises the question about the course of further action, since abortion is illegal in our country, besides being ethically reprehensible.

the question also arises about whether fully justified risk to the fetus using invasive methods to confirm the diagnosis, which I think should be analyzed case by case, according to the treatment options and possible benefits that could determine in any particular case the definitive diagnosis of aneuploidy versus a high suspicion at birth.

is important to ask about the patient's emotional response on the news. For any pregnant woman, the expectations for your child are high, and during the antenatal attachment is formed an idealized image of the child, to be contrasted with the real child when finally know. Taking this into consideration is important to analyze the impact that a diagnosis of this type, or only suspected, may have on the patient and the damage it can cause in the relationship of the mother-baby, in addition to the emotional harm to the mother.

• What other tests can be derived from this clinical situation? What are the risks? What would you advise?

From known facts, it would be important to evaluate them in relation to the markers that could be seen on ultrasound in the second semester to have a lower chance of false positives. Having assessed these parameters and determined the risk of aneuploidy, could raise the option of using invasive methods such as amniocentesis or chorionic villus sampling, to have a diagnosis.

Having assessed the patient using all available noninvasive methods, would talk to her about the existence of invasive methods, explaining their risk and also explain that through non-invasive methods is only a "risk" and not a definite diagnosis. I think the patient with proper emotional support and, ideally, with his partner, who must decide on the use of an invasive method, knowing what the possible benefits justifying the use of them.

• Comment or investigate the following concepts:

• verbal iatrogenic

is for the damage done when they say you should not say, either ignorantly say something false, when it is appropriate to say, put it empathy necessary to speak in a language incomprehensible to the patient or say when there is no time to allow the patient understands what is said.

right to be informed

patient has the right to receive information regarding their own person from the health personnel, in accordance with the principle autonomy.

• right not to know

A patient has the right to receive information regarding your medical condition, because that knowledge has emotional implications that the patient is entitled to avoid, in accordance with the principles of autonomy and personal health must respect this choice, preventing iatrogenic verbal, according to the principle of nonmaleficence.

Carlos Sáez Muñoz