Does insertion hurt (always, depends on dr, yes, but it goes away, etc?)

Insertion of an IUD will be different for everyone, depending on personal sensitivity and provider skill. The more honest the provider is with the patient regarding expectations, the better. I would never tell someone “itâ€s not bad” or “it wonâ€t hurt.” Hereâ€s what I tell my patients, more or less: “Youâ€ll feel things that Iâ€m doing, but I will tell you before I do anything. No surprises. There is a pinch, followed by 2 big cramps, and then itâ€s done. I do this a lot and it will be very quick, but at any point if you want me to stop, I will stop. You are in control.” Being open and honest about what they will feel often puts people more at ease, lessens any fear, and they are able to cope with the procedure better.

What happens if you keep an IUD in longer than you should?

There have been studies showing that IUDs can be effective past their expiration date so it is not dangerous that they stay in longer. However, out of concern of IUD failure and an unplanned pregnancy occurring I recommend removing and/or replacing the IUD before 2 years past its expiration date. There is no direct harm from the IUD by leaving it in longer, but the main concern would be it failing to protect against pregnancy.

Are there any disadvantages to removing it right away?

The only disadvantage of removing it right away that I can think of is missing out on an excellent form of contraception. There is an adjustment period to having an IUD, which varies from person to person. Again, if the health care provider sets up expectations appropriately I find that people are patient during the adjustment period and are more likely to keep their IUD.

Can you take it out yourself?

There are clinical trials under way looking at exactly that. There is no magic to removing an IUD: one pulls on the strings and it comes out. However, for someone to pull out their own IUD may be logistically difficult. Also, the strings may be difficult to grab and pull with sufficient force using only fingers. So, yes, it is possible, but it may be difficult.

There seem to be tons of side effects, are some more commonplace than others?

This depends on the IUD. For example, the copper IUD tends to make oneâ€s periods heavier and crampier, but this is often alleviated with over-the-counter medication like ibuprofen. The hormonal IUD often makes oneâ€s periods lighter, sometimes making them go away entirely, which is perfectly fine and has no health risks. This IUD may also help with endometriosis, though exactly how is not well understood yet. The hormone works locally on the uterus and cervix, but it may not help acne or hair growth if the person has issues with those things.

How often do people need to “shop” for a different brand?

Since there are only 2 types of IUDs, and one available form of each, once someone has decided which one they prefer there should not be a need to shop around. (Of note, there are 2 forms of the hormonal IUD, but the only difference is size and duration of use, not brand or method of action, or side effect profile.) 

Is it more painful to have it inserted/not as good of a form of birth control if you’ve never had a child?

Iâ€ve placed IUDs in teenagers and adults who have never had children and I have noted as much variety in their experiences as I have placing IUDs in women who have had children. There is no difference in how well it works regarding whether or not the person has had children. There is no effect on future fertility after use is stopped. I tell my patients: “Once the IUD is removed, you go back to being as fertile as you ever were.” Itâ€s an immediate return to their baseline fertility, which is different from other forms of contraception. (Of note: this is also true for the implant.)

I also direct my patients to bedsider.org for general information regarding different contraceptive methods. It’s a nice site to explore, especially if you’re uncertain which kind of contraception is the best method for you.

Breast cancer screening with mammography has reduced the number of deaths from breast cancer. When breast cancer is detected early, it is often curable with surgery alone and 98% of women diagnosed with an early cancer will survive more than 5 years after their diagnosis. That is essentially a cured cancer, though it is important to be vigilant and have regular medical check-ups. Your health care provider should refer you for a mammogram every 1-2 years once you turn 40 years old, unless you have significant risk factors that would mean you need mammograms sooner.

Significant risk factors for breast cancer that might mean you should have mammogram screening before age 40 include first-degree relatives with breast cancer (mother, sister, daughter), a male relative with breast cancer, or multiple family members that have had various cancers including breast, colon, uterine, or ovarian. These are cancers that tend to be hereditary and your health care provider should ask about these cancers in your extended family in order to understand if you are at increased risk of an inherited cancer such as breast cancer. Health care providers should be using breast cancer risk tools such as www.cancer.gov/bcrisktool to determine the appropriate breast cancer screening for you. The U.S.Preventive Services Task Force also has a recent publication on risk assessment and genetic testing.

Self-breast exams or clinical breast exams in the health care providerâ€s office may or may not help in the detection of breast cancer. There is no agreed upon opinion of whether or not women should be performing their own breast exams or if providers should be as well. In general, I tell my patients that if they can remember to do a self-breast exam every month when their period starts and then pay attention to any changes in their breast tissue, that may be helpful. (The timing at the beginning of a period is important because hormonal changes affect breast tissue and it is at this time that there is least likely to be a finding of an abnormality which is actually not something to be worried about.) Of course, if you no longer have a period then I recommend the 1^st day of every month.

With proper detection, breast cancer can be manageable and lives can be saved. Please see your health care provider about when to start mammogram screening, especially if you are 40 or more years young. Be well!

Q&A from Twitter:

@LeahNTorres How vigilant do we really have to be? Get BRCA test if no family history? If test shows no predisposition?

— Robyn Swirling (@RSwirling) September 16, 2014

Only after discussion with a health care provider should genetic testing be pursued. The aforementioned tool can help guide your provider in whether or not to refer you to a Genetics Counselor, an important step before any genetic testing is performed.

@RSwirling @LeahNTorres would be curious about protection of info if bcra positive how do you protect yourself with insurance, employment — MDRSWRJ (@MDRSWRJ) September 16, 2014

That is a great question! The way I would approach this, because all insurances are different, is before performing any testing, call the insurance company and ask what their policies are. I would ask these questions specifically: “Do you cover genetic testing for breast cancer?” and “Will I have coverage for breast cancer surgery and treatment if I am found to have the BRCA gene?” Then you may want to ask about premiums, annual cost adjustments, etc. After you call your own insurance company, especially if you do not like what you hear, I would call others and inquire about their coverage options.

@LeahNTorres • part v full mastectomy (+/-) • long term tamoxifen use (cataracts?) • genetic & environmental influences (e.g. downwinders)

— I’m Rich but I’m not (@ichypants) September 16, 2014

These are issues best discussed with the surgical oncologist and are individualized case-by-case. In general, tamoxifen used to reduce risk of developing breast cancer is not used longer than 5 years. That said, I found an interesting article in the Journal of Clinical Oncology that may be helpful. My review of the literature leads me to concur that there is a small risk of developing cataracts and regular eye exams should be performed, particularly in women over 50 years of age, but that the benefit of this therapy likely far outweighs the risk of cataracts.

@LeahNTorres this is most certainly silly: someone told me that mammograms are much more painful for women addicted to caffeine. True? — Me (@mschingler) September 16, 2014

There is no such thing as a silly question… I think. I have no evidence to support that this is true. However, if people believe this to be true, it may be a self-fulfilling prophecy because our brains are powerful things. I did find an article stating that women with more fibrocystic breast tissue may experience more pain during a mammogram, but there was no relation to caffeine intake. [Note: I did not have access to the full article and could not critique their methodology.] This was fun to research!

@LeahNTorres Just because of your bio, I’d be interested in reading about sex after breast cancer. No one ever touches that topic.

— Roxanne (TeamRoxy) (@TeamR0XY) September 16, 2014

I am so glad you asked this because you are absolutely right: we don’t talk about this. This is a very complex issue given the effects of receiving the diagnosis of breast cancer and the toll that takes on someone and their family emotionally, let alone all of the medical side effects of surgery and treatment. While I cannot go into all of the possibilities regarding this subject, I feel compelled to emphasize this: talk about it. Talk about it to your doctor, to your partner, to your family members. Our society tells us not to talk about sex, but at the same time the social messaging tells us that if we don’t want sex 24-7 there’s something wrong with us. This topic becomes much more complex in the face of the challenges of being diagnosed with breast cancer and all that comes after. Find a sex-positive health care provider who recognizes that sex during and after treatment MATTERS and is willing to help in all ways possible. Do not settle for “this is normal.” As I always say to my patients regarding the topics of sex, sexuality, and sexual activity: if it bothers you, it merits investigation and further discussion. Hopefully that helps to empower people to initiate the discussion.

1. American College of O-G. Practice bulletin no. 122: Breast cancer screening. Obstet. Gynecol. Aug 2011;118(2 Pt 1):372-382.

First, contact your Senators and House Representatives. This can be as easy as a phone call or a brief email:

“Hello, my name is ______________. I am a voter in your district and I would like to ask that you please support the Women’s Health Protection Act.”

Depending on whether you are contacting a Senator or a Representative, it will be helpful to leave the appropriate bill number so they know exactly to which bill you are referring. For example, if I am contacting my Senator, I will add: “This is known as S. 1696.” If I am contacting my House Representatives, I will add: “This is known as H.R. 3471.”

Contact them regularly (daily, weekly, however often you can) via email and or phone calls. It is OK to leave messages as well as your contact information. After all, legislators work for YOU to represent YOU.

This is a critical election year, too. Inform yourself of local and state elections to ensure that you and your values are being represented federally. This Op-Ed was motivated by the fact that state and federal laws prevent me from providing the highest quality of health care scientific evidence has to offer. This is harmful to my patients, their families and to families all over the country.

Perhaps the MOST IMPORTANT thing you can do if you cannot contact your legislators is to make informed decision on candidates and VOTE! This November is a critical election time.

Not sure who to vote for? Want to know what bills are making their way through Congress? Go to GovTrack to find out your representatives’ voting records and other key legislative information!

For additional resources on important bills, laws, and how to getting politically involved, please visit:

American Civil Liberties Union

Center for Reproductive Rights

American Congress of Obstetricians and Gynecologists

Physicians for Reproductive Health

“Framing Disease: The example of female hypoactive sexual desire disorder“ by A. Jutel

*As always, please be respectful and withhold vulgar language or I will be unable to post your comment/question. Thank you.

Health care providers are sometimes the sole advocates for patients and should speak out against laws that limit access to safe, evidence-based health care. We have seen such laws being passed in Texas, North Carolina, Ohio, and several other states. Some examples of these harmful policies are:

1. The Mandated Use of Ultrasound
2. Bans on the Use of Telemedicine
3. Regulation of Outpatient Clinics as Ambulatory Surgical Centers
4. Mandated Waiting Periods and Gestational Age Limit Bans
5. Requirements for Admitting Privileges to Local Hospitals
6. Parental Notification Mandates

1. The Mandated Use of Ultrasound

Legislators have decided that they know better than doctors when and how ultrasounds should be used in abortion care. Some laws require a woman to receive written information regarding her right to see the ultrasound, some obligate her to see the ultrasound, and some not only force her to see the image but also obligate the physician to describe the image to her in detail. Research shows that ultrasound mandates donâ€t change a womanâ€s mind, because a woman has usually thought long and hard about her decision to terminate her pregnancy. I am currently required by law to ask my patients if they would like to see the ultrasound. In my own experience, many say yes; however, none of my patients have changed their minds after seeing the image. The mandate only serves to increase health care costs by subjecting women to unnecessary tests in these instances. There are many versions of these laws, depending on the state in which the physician practices. How and when a doctor performs an ultrasound prior to an abortion depends on these laws, not what is medically relevant to provide the best health care to the patient.

Ultrasounds are used by womenâ€s health professionals for valid medical reasons, including ruling out ectopic pregnancies and determining how far along a pregnancy is. This test is performed prior to the abortion, but there is no medical reason for it to be performed on the same day as the abortion. Ultrasounds should not be used for political or other purposes that fall outside of a standard of medical necessity.

We routinely show the patient an ultrasound image if she asks or if she agrees to view images for educational purposes. Laws that require women to view or hear her ultrasound against her will violate her rights and presume that she is uneducated about what pregnancy means. In no other area of medicine are doctors required to show patients images of their bodies or organs.

2. Bans on the Use of Telemedicine

Many areas of the country have few or no physicians, and health care resources are scarce. In these areas, the ability to counsel patients using modern technology such as video conference calls can actually mean the difference between receiving health care and not. Restrictions on the use of telemedicine means a woman may not have the opportunity to speak to a doctor regarding her pregnancy options: continuing the pregnancy and becoming a parent, continuing the pregnancy to ultimately place the child up for adoption, or terminating the pregnancy. Women deserve to be informed of all of their options in a timely manner, especially when a pregnancy is in question, and this may be safely done via phone or web interface. I see women who have traveled upwards of 500 miles to have an abortion, which is not easy for most women when you consider travel expenses, child care, and time off work. Similar to mandated waiting periods, having women make more than one trip when a tele-consult would suffice is a considerable burden in many areas of the country. It does nothing to promote patient safety or quality of care.

Physicians often counsel patients — their own patients and patients of other physicians if on-call — over the phone regarding symptoms, medications, and therapy options. Doctors also deliver the babies of their colleagues†patients as a standard practice, despite childbirth being 14 times riskier than a first trimester abortion. Abortion care is no different than other health care in this way. Legislative requirements for same-provider counseling or in-person counseling donâ€t advance patient safety or quality of care and only create roadblocks to getting needed care.

In some innovative telemedicine programs, nurses dispense medical abortion medication after an initial, earlier visit with a physician to establish the pregnancy and discuss options. There is no safety reason why women should not be able to receive these medications in a separate office from a nurse after tele-approval by a physician.

3. Regulation of Outpatient Clinics as Ambulatory Surgical Centers

A variety of states have imposed requirements that outpatient clinics conform to the same or similar regulations as an operating room in a hospital. These requirements can include anything from having wider doorways to having equipment in the room for general anesthesia (even though it is not used). These laws force the conversion of a perfectly safe outpatient clinic into a surgical suite that has features above and beyond the needs of the procedures being performed. Imagine going to have a hair cut but instead receiving a hair transplantation procedure. Better? Sure. Necessary? Absolutely not. In many areas of the country, such as mine, requiring abortion clinics that are already up to code and medical standards to meet additional ambulatory surgical center standards will leave those clinics destitute, resulting in women with fewer options for safe care (including many procedures unrelated to abortion care, such as cancer screenings).

Abortion is a procedure that is generally safely done in an outpatient setting. Its potential complication risks are no different than many other outpatient medical procedures performed in a providerâ€s office. State laws should not require abortion care to be performed in settings that meet ambulatory surgical center standards as other medical procedures with similar risk-profiles do not face the same requirements. None of the practices in which these other medical procedures are performed (colonoscopy, for example) are required to adhere to more complex surgical center standards.

Hysteroscopy and many assisted reproductive technology procedures such as taking a look inside the uterine cavity with a camera are performed in outpatient clinics that are not surgical centers. The procedures use instruments inside the uterus with the same risks of perforation, hemorrhage, and infection as an abortion procedure. Truth be told, the surgical management of a miscarriage is exactly the same as a first trimester surgical abortion. Exactly the same. I am permitted to perform a dilation and curettage in my clinic as long as it is in the context of a miscarriage, however this is not so in the case of the termination of an otherwise normal pregnancy. The only difference is a discrimination against the pregnant personâ€s fertility desires.

4. Waiting Periods and Gestational Age Limit Bans

Despite federal law upholding legal access to an abortion procedure up to 24 weeks of gestation (except in cases of incest/rape or lethal fetal anomalies where no gestational age limit applies) many states are passing their own laws that reduce the gestational age limit for legal abortion procedures. Depending on the state in which she lives, a woman may have an abortion only before 20 or 22 weeks, effectively reducing the time she has to make her life-altering decision. A variety of states have also imposed waiting periods: the length of time between receiving informed consent for an abortion and the time of receiving the actual procedure which may range anywhere from 24 to 72 hours. These may seem like conflicting concepts, and that’s because they are. One law intends to require a more expedited decision process so as not to exceed the reduced gestational age limit, while the other requires a woman to wait longer under the guise of allowing her to make a more thoughtful decision. I take care of many women whose pregnancies have been diagnosed with horrible diseases and conditions incompatible with life, and these women must endure the knowledge of their very desired babyâ€s diagnosis. Often these traumatic diagnoses are made after 20 weeks. She may have the diagnosis near (or past) that stateâ€s gestational age limit, which would require her to go to another state to terminate or to carry a pregnancy full-term, undergoing the risks of pregnancy and childbirth, only to watch her newborn suffer and die. Pregnancy, like other conditions such as cancer or heart disease, is time-sensitive and requires expedited treatment, not arbitrary delays imposed by the state.

My state, like many others, requires a waiting period before a woman can have an abortion. These laws are especially intrusive for women seeking pregnancy terminations. They presume women havenâ€t considered their pregnancy options carefully and need “extra time” to be sure. If this is the case, much more dangerous procedures such as organ transplants, brain surgery, plastic surgery, etc. should also require waiting periods. Additionally, these unnecessary regulations and their exceptions are often confusing and may result in requiring a victim of rape or incest to suffer longer because she is waiting for the procedure to be allowed. Being forced to delay the provision of abortion care can also increase the cost and risk of the procedure and thus further delay it, sometimes pushing the pregnancy into the next trimester and bumping up against gestational age bans.

5. Requirements for Admitting Privileges to Local Hospitals

A recent defeat in Texas upheld unconstitutional legislation that requires abortion providers to have admitting privileges to a hospital located within 30 miles of their clinic. To understand why this is problematic, it is necessary to understand that, in order to practice medicine at a given hospital, a physician must have admitting privileges to that hospital. This allows the patients a doctor takes care of to be admitted to and cared for as an inpatient of that hospital. Admitting privileges, however, are not required to practice medicine at an outpatient clinic as an outpatient clinic — by its definition — does not have the capacity to provide inpatient care. Many other states have placed similar regulations on abortion providers, resulting in shortages of legal abortion providers when hospitals decide not to or, in many cases, are disallowed from granting “those” physicians with admitting privileges. There is no medical justification for this policy and it is a danger to womenâ€s ability to access care.

Once again, in no other specialty are physicians required to have admitting privileges to a hospital in order to perform outpatient procedures. For decades, abortions have been provided safely in an outpatient setting and, if complications arose, the physician would call for an ambulance to take the patient to the hospital. Patients taken to a hospital emergency room are treated whether their provider has admitting privileges or not. With these laws, hospitals wind up under tremendous pressure to deny privileges to abortion providers. In the case of Mississippi, the last clinic may close because the only abortion provider in the state is being denied admitting privileges, leaving women in that state with no in-state provider. Recent legislative efforts in Texas would close several rural clinics in already under-served areas, leaving many women hundreds of miles from care.

6. Parental Notification Mandates

A variety of states require minors to inform their parents (or legal guardians) of their decision to have an abortion. This is a discriminatory practice when dealing with abortion care. Only when a teenager seeks an abortion do these laws dictate that the teen must notify their parents about their pregnancy and decision to terminate said pregnancy before an abortion may be performed. In contrast, no law requires parental notification of a teenâ€s sexual activity, pregnancy planning, positive pregnancy test, or the decision to carry a pregnancy to term and have a baby. It is only if the teen desires to terminate a pregnancy that some states feel it is necessary for the parents to be involved under the guise of “protecting” the minor. If a minor can be trusted to engage in sexual activity as well as make the decision to become a parent or carry a pregnancy to term to place a baby up for adoption, doesnâ€t it seem that the minor should also be trusted to make the decision not to become a parent or to undergo the risks that pregnancy and childbirth incur?

Adolescents under the age of 18 are considered minors, but most are capable of making decisions regarding their sexual health. In a Position Statement published in the Journal of Adolescent Health by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the Society for Adolescent Medicine their collective stance is clearly stated:

Federal and state laws should support physicians and other health care professionals and their role in providing confidential health care to their adolescent patients.

Each state has its own set of laws regarding parental notification for things such as contraception, sexually transmitted infection screening and treatment, prenatal care, adoption, etc., but parental notification requirements can be problematic, prohibitive of care, and at times unsafe. Some teenagers do not have contact with their legal guardians, some are victims of abuse, and some may be estranged or geographically far from their parents. These realities may delay or prevent access to healthcare for such an important and time-sensitive health condition as pregnancy. The sooner a pregnant person can access care, the better the health outcomes.

SPECIAL THANKS TO THE GUTTMACHER INSTITUTE FOR PROVIDING FACTUAL DATA REGARDING NATIONAL AND INTERNATIONAL REPRODUCTIVE HEALTH

The topic of discussion was Hypocrisy from Pro-Life Lawmakers, and many excellent points were raised by the participants, including:

• On the day Texas executed its 500th prisoner, Texas governor Rick Perry made the statement that, “In Texas, we value all life.” One supposes he means “life only until time of birth.”
• The House of Representatives recently passed a modified version of the Farm Bill, stripping it of $20 billion dollars in food stamp support (SNAP) while maintaining subsidies for commercial agri-business.
• Much like the “pro-family” movement which is, at its heart, anti-gay, the “pro-life” movement actually began as a reaction to the feminism movement and sexual promiscuity of the 1960s. This point was raised by Frank Schaeffer, a relgious commentator with almost unparalleled access to information about the founding of the Pro-Life movement.
• Frank Schaeffer goes on to explain much of the pro-life movement as deliberate political manipulation to divide-and-conquer blue-collar Democrats — many of whom are Catholic or fundamental Protestant — appealing to social sensibilities to get them to vote against their own economic interests.

Unfortunately, due to technical difficulties, I was unable to respond to one of Alyona’s excellent questions:

We can talk about this as a political reaction against somebody else’s values, but it has very real life effects on women all across the country, especially a lot of this restrictive abortion legislation that we’ve seen in the last couple of years, in states across the country. […] What’s it like for you, because this is something that can be a very divisive — or is a very divisive [topic] — but can become very heated, especially when you talk to people online about it…?

Had my sound been cooperating, I would have responded:

Legislation restricting abortion access hits very close to home. I see every day how it impacts real people’s lives while I feel that everyone else is simply discussing a hypothetical situation. I couldn’t watch the live stream of what happened in Texas. It was too painful. I was infuriated listening to unqualified people make medical decisions for women they didn’t know but who I knew were very real with very real lives and families.

No one’s opinion or belief on the topic of abortion matters except that of the woman facing this unimaginably difficult decision. My opinion doesn’t matter, your opinion doesn’t matter, nor the opinion of legislators who don’t even know how a Pap smear is done. This is a fight about a woman’s autonomy and I fight every day to protect her from scorn, shame and guilt over what can only be one of the most difficult decisions she will ever face. I fight to protect her free will and her ability to ensure her own health and well-being. Only she can know what is best for her and her family. Pro-life? Yes, I am. I fight every day to protect her life from harmful legislation that is rejected by medical professionals and supported by political zealots.

Further Reading

• 10 Things You Can’t Do and Still Call Yourself “Pro-Life” by Benjamin Corey
• How Can a “Pro-Life” Legislator Fight to Gut SNAP? by Sheila Bapat
• How I Lost Faith in the Pro-Life Movement by Libby Anne

1. Everyone wants fewer abortions.
2. Abortions will always be needed.
3. When abortion care is legal and accessible, it is safe.

Everyone wants fewer abortions.

A woman who finds out she is unexpectedly pregnant faces one of the scariest and most difficult situations of her life. Chances are, she has taken several precautions to prevent having an unplanned pregnancy, yet no birth control method is perfect and remaining abstinent goes against human nature. She must consider every possible consequence of continuing the pregnancy — with or without rearing the child — and of discontinuing the pregnancy, as well. She must consider her current health, her family situation, her financial situation, and many other aspects of her life and the lives of loved ones to decide the best course of action. This is not something she ever wanted to face. She never wanted to consider having an abortion yet, despite having taken all precautions, not everything in this world works out the way we plan. Thus, what I mean by “everyone wants fewer abortions” is that, beginning with the woman who is facing an unplanned pregnancy, everyone wants fewer abortions. We must encourage and support comprehensive sexual health education and access to highly effective contraception (see Pregnancy and Birth Control 101) in order to lower the rate of abortion. The importance and benefits of doing so have been shown in a large study out of St. Louis, MO: The CHOICE Project.

Abortions will always be needed.

Mother Nature isn’t perfect. She, too, makes mistakes. When I see a patient experiencing a devastating miscarriage from a desired pregnancy, my heart breaks for her, and I do everything within my power to comfort her. When a pregnancy is desired, that pregnancy is a child riding their bike for the first time, getting on the bus for their first day of school, and going off to college the minute the “+” sign appears on the home pregnancy test. Having a miscarriage and losing a pregnancy can be devastating. When I encounter these women, I generally tell them the following:

This is not your fault, there was nothing you did or did not do to cause this. This is Mother Nature’s way of helping you to have a healthy pregnancy next time.

I explain to her that, when cells multiply and divide such as they do during pregnancy, that it is a very complex process that goes smoothly most of the time. Sometimes, however, something zigs when it should have zagged, and the blueprints are no good. A miscarriage is simply nature’s way of sparing a woman from continuing an abnormal pregnancy for 9 months. That said, Mother Nature is not perfect. She doesn’t always get it right, and an abnormal pregnancy might not result in a miscarriage. Women sometimes receive the devastating news that their pregnancies are abnormal and will not result in a birth of a child that will live long after delivery, or that the fetus may die while she is still pregnant. This is when women need an abortion. Women can become very ill during pregnancy if the pregnancy continues into the second and third trimesters, possibly risking their own lives as well as the well-being of the pregnancy or any future pregnancies. This is also when women need an abortion. Even in a perfect world with perfect birth control that works perfectly every time, history has shown that, whether out of need or desire, women will continue to seek and acquire abortions.

When abortion care is legal and accessible, it is safe.

I will not rehash the entire Gosnell trial here, but for the record, he is not an example of how abortion is or should be performed; he is a monster who is shunned by the entire medical community and should be punished for the atrocities he committed. Anyone desiring to make an example of him to portray how abortion care is provided may as well make an example of Dr. Mengele to portray how all medical researchers conduct scientific research. I will also not recount the horrific tragedies of maternal deaths before abortion became legal in this country in 1974, but you should read about it if you have not already. There is evidence, however, that when abortion is legal and accessible, women are safer. A modern day example of what really happens to women when abortion is illegal can be seen here, courtesy of Al Jazeera: Right to Life.

How do we reduce the need for abortions?

The answer is simple: we must provide pre-teens with comprehensive sex education and provide people of reproductive age with highly effective methods of contraception. We must reduce the number of unplanned pregnancies in this country, the percentage of which has been an incredibly high 49% for more than 20 years. When pregnancies are planned, not only are they are primed for being healthy, but they are also much less likely to result in abortion. We must work to ensure that the only abortions are those that are necessary (because Mother Nature cannot be controlled) and that those abortions are legal and accessible, thus making them safe.

Enemas and clits and libidos!

Pups

1. Ovulation
2. Fertilization
3. Implantation

Even if all of these steps go perfectly, there is no guarantee that a woman will remain pregnant. But let’s pretend she does remain pregnant and that it’s an unplanned, undesired pregnancy. So she goes to the doctor… like me, for example:

“Hello, I understand you’re pregnant.”
“Yes.”
“How are you feeling about this news?”
“I don’t want to be pregnant.”
“OK, I understand. Please let me take the time to explain all of your options with this pregnancy. You may continue the pregnancy such that you will have a new baby in your family, you may continue the pregnancy and when you give birth place the baby in adoptive care, or you may end the pregnancy by having an abortion.”

This is a simplified version of how I personally counsel all of my patients who are newly pregnant with an unexpected pregnancy about which they are uncertain. (Note: women who answer the first question with “I’m very excited and can’t wait to have my baby!” do not receive counseling on the other options for obvious reasons.)

But, wait a minute! If people use birth control, there should be no such thing as an unplanned pregnancy!

Ah, if only more than just death and taxes were 100% in this world…

BIRTH CONTROL: HOW it works and how WELL it works

Methods that prevent Step #1: Ovulation

• Nexplanon implant: >99% effective with typical use
• DepoProvera injection: 94% effective with typical use
• The Patch, the Ring, and the Pill (AKA combined oral contraceptive pills): 85% effective with typical use
• Lactational Amenorrhea Method (breast feeding): 98% effective with perfect use in first 6 months postpartum
• Emergency Contraception (Plan B, ella): the sooner after unprotected intercourse the better! 56-89% effectiveness, though studies are limited. It is ineffective if ovulation has already occurred, thus it is NOT an abortifacient

Methods that prevent Step #2: Fertilization

• Sterilization (male and female): >99% effective with typical use
• Mirena IUD (progesterone): >99% effective with typical use
• ParaGard IUD (copper): >99% effective with typical use
• Condoms: 80-90% effective with typical use
• Natural Family Planning methods (withdrawal, calendar, basal body temperature): 75-80% effective with typical use

Methods that prevent (or disrupt) Step #3: Implantation

• NONE

So, you see, no method works perfectly every time. Human beings are sexual beings and we will have sex. Even when we do everything right to prevent an unplanned pregnancy, our technology is not such that it can be prevented 100% unless one is not sexually active. But what’s the fun in that?

For more info, check out the links on the right under “Knowledge is Power.” Also, the CHOICE Project out of Washington University in St. Louis has a great video on the different methods and how to use them!

Resources: Contraceptive Technology by Hatcher et al, Practice Bulletins by the American College of Obstetricians and Gynecologists

What would you do if a premature baby, so premature that it didn’t have working lungs yet, were suddenly born right in front of you?

A) I would give it comfort care until it passed away on its own.

B) I would put a tube down its throat for breathing and insert multiple needles into it to place lines for fluids and medicines knowing that there was a 99% chance it would die anyway and a 100% chance that it would be severely incapacitated, possibly vegetative, if it lived.

C) I don’t know because I’m neither a doctor nor a person who has ever had to face that situation.

This is the impossible question posed to a Planned Parenthood representative in the video posted below that has made its way around the Internet. There are a few things you should be aware of prior to watching it:

1) The Partial-Birth Abortion Ban Act of 2003 ensures that any physician who desires to continue practicing medicine will not allow a live birth of an aborted fetus.

2) Asking someone who is not a physician what they would do in a clinical scenario is like asking someone who is not a pilot what they would do if the right jet engine went out. It is unfair and akin to trying to squeeze water from a stone.

The video:

http://www.youtube.com/watch?feature=player_embedded&v=qEv1afKaLhA

This woman was not qualified to answer medical questions, regardless of how they are phrased. That being said, it was no wonder she was uncertain 1) what they were asking and 2) how to answer.

I, however, am qualified to answer their questions and I will.

During an abortion in the 2nd trimester, specifically after 22 weeks, it is general practice to perform feticide (injection of a lethal medicine into the amniotic cavity or into the fetal heart) to essentially euthanize the fetus prior to the dilation and evacuation (D&E) procedure. It is therefore not alive once the abortion procedure is started. This is routine practice due to the Partial-Birth Abortion Ban Act passed in 2003 and requires physicians to perform the invasive procedure of intra-amniotic injection (putting the woman at risk of injury and infection) prior to the D&E. That being said, for an abortion to be “botched” (which is an unprofessional and inappropriate term to use) and the “baby to be born alive” will not happen. It cannot happen if the physician wishes to stay out of jail and continue practicing medicine. The baby cannot be born alive during an abortion because of the Partial-Birth Abortion Ban Act. The entire discussion in this clip is moot.

I’ll tell you what I would do if this impossible scenario were to happen, however: I would do whatever the patient wanted me to. The newborn would be unable to make medical decisions for itself and therefore medical-decision making would legally fall to the parents. There comes a difficult legal area, however, and if the infant were able to survive outside of the womb (> 24 weeks), were able to be resuscitated, the pediatricians may presume control over the care of the newborn if its life were in danger due to the parents’ decision. This gets into a whole legal battle I am not qualified to speak to, however, as previously stated, the scenario of an incomplete abortion with the fetus being delivered alive would not happen.

Even in cases of 3rd trimester abortion, the fetus is euthanized. This is not only due to the Partial-Birth Abortion Ban Act, but it is also humane medicine. It would be very traumatic to the mother, father (if present), and caregivers (physicians, nurses, etc) if during the induction of the abortion the baby were born alive then left to die. How horrific! Despite popular opinion, we are not monsters. We are physicians who seek to minimize the trauma of this difficult decision. In the rare cases of 3rd trimester abortions that are most commonly performed because of severe, lethal fetal anomalies that would not allow the newborn to live for very long (and suffer significantly if/while it did live), the fetus is euthanized and therefore not born alive.

As an OB/Gyn who takes care of women who are young and old, pregnant and not pregnant, my responsibility is to my patient. In the case of a pregnant woman, my responsibility is to her. When a woman comes to me for an office visit and her pregnancy test is positive, my first response is: “How do you feel about that? If you are not sure, I want to talk to you about all of your options which include continuing the pregnancy and keeping the baby, continuing the pregnancy and giving the baby up for adoption, or terminating the pregnancy by having an abortion.” If she desires I care for her and her pregnancy, I will do so and provide her with the best prenatal care I can so that she can have a safe, healthy pregnancy and childbirth experience. If my pregnant patient wishes to have an abortion, I will perform that as well so that she may have a safe procedure and termination of her pregnancy. My responsibility is to provide safe, evidence-based, comprehensive medical care, and that is what I do.