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If you knew you only had a 1% chance of surviving tomorrow, would you consider that a death sentence? What about 2%, 5%, 10%… at what point would your odds of survival be good enough you wouldn’t feel doomed? And what if you had to purchase your fairly slim chance at survival by risking the life of another? When would you do it? What balance of risk would just barely escape counting as doom?
What if you were the other whose life was risked on the slim hope of avoiding someone else’s death sentence? When would that hope be worth it, and when would it be a forlorn one? How effective must our efforts to lift another’s doom be in order to merit the price?
Welcome to the world of ectopic pregnancy. 96% of ectopic pregnancies are tubal pregnancies, risking death of the mother if the tube ruptures. While it’s possible to treat ectopic pregnancies with EM (“expectant management” — watching and waiting, in hopes of a safe, natural miscarriage), current standard practice is to treat only a select few ectopic pregnancies with EM — those pregnancies most likely to naturally miscarry safely, typically only those pregnancies where “the baby [already] appears to be miscarrying and hCG levels are dropping.”
Through carefully choosing which pregnancies are eligible for EM, EM appears to be astonishingly successful at permitting ectopic pregnancies to terminate without intervention, safely and naturally (according to this table, an 88% success rate when β-hCG <1000). We couldn’t expect so much success if EM were used on all ectopic pregnancies, though. Looking up the success of EM on a typical ectopic pregnancy is hard precisely because it’s standard practice only to use EM on a select few. According to the only study I could find addressing EM nonselectively, only 40% of all hemodynamically stable ectopic pregnancies (that is, ectopic pregnancies that haven’t already become a circulatory emergency) resolve on their own. The American Family Physician is more optimistic, estimating up to 68-77% of ectopic pregnancies resolve on their own. Altogether, that means somewhere between 23 and 60% of ectopic pregnancies do not safely terminate on their own.
What happens to that 23-60%?
I’m not sure. I do know, though, that it’s tempting for some fantasists to trumpet those rare miracles — freakish cases where an ectopic pregnancy either starts outside the tube or relocates outside the tube through some happy accident (like the tube rupturing without causing the mother to die of hemorrhage), survives past viability (a miracle even for abdominal pregnancies), then is surgically delivered alive and without killing the mother — as aspirations ectopically-pregnant women should reasonably hope to achieve, despite these aspirations piling improbability upon improbability. What, these fantasists seem to reason, can such women really expect to sacrifice along the way, especially if the encouraging success rate of selective EM makes it seem as if their choice isn’t risking themselves for a baby already sentenced to near-certain death before birth, but between a healthy “miracle baby” and a safe, natural miscarriage?
Heck, even if the mother does rupture and bleed out, there’s always emergency autotransfusion to save the day! As long as the rupture is caught in time, autotransfusion seems to have great odds of success! Like better than an appendectomy (a surgery justified to avoid a 50% chance of death)! As long as the rupture is caught in time…
One reason ectopic pregnancies are as lethal as they are — the leading cause of maternal mortality in the first trimester — is that they often aren’t caught in time. Emergency autotransfusion treats major trauma. It’s normal for victims of major trauma to die from minuscule delays in treatment. Passively waiting till you need major-trauma treatment isn’t routine medical care.
But what if… What if an ectopic pregnancy weren’t merely caught in time, but were caught so early surgeons could remove the tiny stray intact from its doomed divagation, relocating it safely home in the womb?
Surely, if we weren’t an abortion-minded culture, surgeons would have already perfected this homecoming, at least for those few lucky strays caught early enough? Surely the problem is doctors not having tried? No, doctors have tried. And overwhelmingly, it seems they’ve failed. Reports of successfully relocating ectopic pregnancies to the womb are the most isolated of anecdotes. Wishful thinkers still cite a report from 1917 — not because successful relocation is so simple it merely requires WWI-level surgery, but because of the dearth of successful reports since then. I know of only two other reports of success, one from 1990 (a secondhand case report about what some other surgeon did in 1980) and one from 1994, which was later retracted.
The 1994 report prompted Professor JG Grudzinskas to publish, “Relocation of ectopic pregnancy to the uterine cavity: a dream or a reality?” after Grudzinskas himself had tried three relocations — and failed. In a 1994 Letter to the Editor of Human Reproduction, Grudzinskas summarized,
I was a little disappointed that no mention of relocating the tubal pregnancy into the uterus was made [citation including retracted article]… This procedure has been reported [before 1994] on two occasions (Wallace, 1917; Shettles, 1990) and attempted in recent years in Norway and London, but not reported. The vaginal birth at term of an infant after a successful relocation of an ectopic pregnancy at 5 weeks gestation in utero by one of my colleagues in London [this colleague appears to be the one who would retract later] will renew the interest in the field. This department has unsuccessfully relocated unruptured tubal ectopic pregnancy on three occasions to the uterus, but we shall continue our efforts with renewed vigor in women desirous of fertility.
prompting his correspondents to reply,
[A]t present, the main goal in treating ectopic pregnancy is to avoid major surgery, thus minimizing the risk of patient morbidity. Surgical handling in embryo transfer from the tube into the uterus, as described by Shettle (1990), clearly does not apply to this basic therapeutic principle. Furthermore, the ‘relocation technique’ would be only possible in intact, very early ectopic pregnancies, just where laparoscopic surgery and medical therapy afford the best results. Finally, Dr Grudzinskas will agree with us that two anecdotal case reports — one dating from 1917! — of a ‘technique’ with no available data on side-effects for the embryo cannot be placed in the same bracket as the other widely used forms of treatment of ectopic pregnancy
Not even those rooting hardest for surgical relocation seem able to cite any reported success past 1994, much less reports of success between 1917 and the 1990s. So perhaps surgical relocation is like cold fusion — always 25 years away. Then again, perhaps it isn’t. Still, we can’t just assume it’s only for lack of trying.
The reports I’ve cited on the happy accident of natural tubal-pregnancy relocation and the sparse anecdotes of surgical relocation are the very same reports others cite optimistically, to make it sound as if natural relocation of tubal pregnancies to somewhere more viable is common, surgical relocation is proven, and the risks of ectopic pregnancy are trivial. For example, here is Johnston describing natural relocation:
“Embryo Transfer In Vivo” demonstrated that, in a tubal pregnancy, the rupture of the fallopian tube does not kill the preborn child. In many cases, the child will detach from the ruptured tube on his own and reattach on another surface in the pelvis or abdominal cavity. This has made it possible for a significant number of tubal pregnancies to result in live births.
By “does not kill”, he appears to mean “does not always kill”. The words “many cases” only convey that many such rarities can be collected given sufficient time (in this case, 44 cases over a 30-year period, resulting in only 9 live births), not that such rarities aren’t rare. What’s “significant” about the “significant number” isn’t anything like statistical significance, but merely the newsworthiness of the rarity — the significance of the news testifies to the insignificance of the likelihood: children who survive being born this way have defied all the odds!
And here is Johnston describing surgical relocation,
As far back as 1917, a procedure was successfully performed transplanting the tubal-implanted embryo into the uterus. This life-saving procedure was first reported in the Harvard medical journal Surgery, Gynecology and Obstetrics and as recently as 1980 [in the 1990 report] in the American Journal of Obstetrics and Gynecology. In 1994, British professor Dr. J. G. Grudzinskas authored a paper published in the British Journal of Obstetrics and Gynecology entitled, “Relocation of ectopic pregnancy to the uterine cavity: a dream or reality?” wherein he discusses recent attempts to transplant the ectopically-implanted human embryo into the mother’s uterus.
Conveniently forgotten is the dearth of any reported success between 1917 and those mere two reports in the 90s, along with the self-reported failure of Grudzinskas’s own attempts. Much less the 1994 retraction Grudzinskas’s own ruminations prompted.
The desire to save innocent human life is obviously laudable. But a sense of proportion is laudable, too, including the sober realization that some pregnancies are doomed to be maybe babies, indeed even almost-certainly-not babies.
True, many maybe-babies (30-40% of all conceptions) are miscarriages, often happening so painlessly early in a pregnancy that women may not even know they’re pregnant. (I say “painlessly” but even miscarriage too early to ever be discovered may create the heartache of barrenness.) Ectopic pregnancies, though, cannot be confidently expected to resolve on their own with a safe, natural miscarriage (EM) unless selective conditions are met. Nor can they be expected to result in a live baby: the freakish concatenation of circumstances resulting in the delivery of a live ectopic baby to a live mother is anything but expected. In between EM and the miraculous outliers lies the valley of the shadow: a shadow hazardous to the mother, hopeless for the baby; a wasteland pro-lifers are sensible to acknowledge.
And I think most pro-lifers do acknowledge it. At least, Johnston complains they do,
If killing the preborn baby is necessary to save the mother’s life—it is argued—then the abortive remedy is unfortunate and regretful, but not murder.
The scenario that seduces most pro-lifers to succumb to this fallacious argument is ectopic pregnancy. But what if it is not necessary to kill the ectopically implanted baby to save the mother’s life? What if the mother and the baby can both be saved?
Oh, yes, Johnston, what if… what if…
A pregnancy enters the world as a life already on life support — the organic life support of the mother’s body. Healthy unborn babies are expected to “recover” from life support: at some point, we “pull the plug” on them by letting them be born, and we reasonably expect they’ll survive. A pregnancy with vanishing odds of surviving birth, though, is a life that’s not expected to recover.
Medical care is now advanced enough that many of us have lived through deciding when to “pull the plug” on a fully-grown loved one who cannot reasonably be expected to recover. We know there’s a point past which tender regard for life sickens and turns ghoulish, into merciless lust for mere subsistence, no matter how squalid and hopeless, at the expense of everyone’s well-being. The theologian David Bentley Hart, in quite another context, observed,
[F]or creatures who exist only by finite participation in the gift of existence, only well-being is being-as-gift in a true and meaningful sense; mere bare existence is nothing but a brute fact, and often a rather squalid one at that, and to mistake it for an ultimate value is to venerate an idol (call it the sin of “hyparxeolatry,” the worship of subsistence in and of itself, of the sort misers and thieves and those who would never give their lives for others commit every day).
The well-being of an unborn child consists in becoming a born one: this is, in fact, why so many are pro-life. A mother who would value her own mere existence over her child’s well-being would be the miser Hart describes, while a mother who sacrificed for her child’s well-being instead would be a hero. But the ectopically pregnant are tragically unlikely to be either mother: the odds against their unborn having any well-being to sacrifice for are simply too remote.
We can hope that technology changes this (although even with advanced technology, there are limits to how closely we could or should monitor women on the off chance they have an ectopic pregnancy to rescue). We can rejoice in the improbable concatenation of circumstances surrounding some ectopic pregnancies that spare the child (and hopefully the mother, too) almost certain demise. And if a woman were determined to believe her ectopic pregnancy would be the one to defy all current odds, she should not be forced to act otherwise. But for the pro-life movement to treat ectopic pregnancies differently from viable pregnancies, rather than asserting almost-certainly-not-viable is still a kind of viable, is only sensible, compassionate, and honest. The accusation that those calling themselves pro-life are callously indifferent to the mother’s life is almost always vicious slander, and it does the pro-life cause no favors to engage in a level of improbable fantasizing which would tend to prove this vicious slander true.
On a personal note, my firstborn began life as a suspected tubal pregnancy. Truthfully, I didn’t find the prospect frightening — in that I wasn’t afraid for myself. I merely found the prospect grim: if it were a tubal pregnancy (though I had good reason to doubt the suspicion), I would have had to pull the plug on a life that never even had the chance to begin. If it were a tubal pregnancy, I knew the choice was realistically between a scheduled miscarriage under medical supervision or uncontrolled, unsupervised miscarriage, with chance of rupture and death, and no way to ensure quick emergency care. I worried deliberately scheduling my miscarriage might feel like choosing death, but not because I had any illusions about life being the realistic alternative. If the pregnancy were ectopic. Fortunately, it wasn’t.