Reproduction in couples who are affected by human immunodeficiency virus: medical, ethical, and legal considerations.

There has been a transformation in the treatment of human immunodeficiency virus from the treatment of complications that define acquired immune deficiency syndrome to the maintenance of long-term health, with an expanding number of antiretroviral medications. Because human immunodeficiency virus infection now is considered to be a chronic disease, couples will be seen in greater numbers for preconception counseling. The ethical and legal implications, including the relevance of the Americans with Disability Act, are complex but support the assistance with reproduction of couples who are affected by human immunodeficiency virus in many instances. All couples who are affected by human immunodeficiency virus, whether fertile or infertile, who want to have genetically related offspring should be seen preconceptionally for counseling and testing. Intensive education involves a multidisciplinary approach to ensure that a couple is fully informed. Determination of whether to offer treatment should be based on the same criteria that are applied to couples who are affected by other chronic diseases. Medical treatment is dependent on the unique circumstances of each couple. In general, the affected partner(s) should be treated aggressively with antiretrovirals and then serum; if applicable, semen testing is required to document undetectable concentrations of human immunodeficiency virus (<50-100 copies/mL).

Patient refusal of treatment in obstetrics.

During the later half of the previous century, Clinical Ethics evolved from the iconoclastic and murky realm of philosophical dissertation into a practical and useful discipline to be applied to clinical dilemmas occurring in everyday practice. We have explored a brief exposition of prevailing ethical theories that are most commonly recognized. These include Consequentialism and Principlism, and we have applied them to actual cases as they might occur in clinical practice. It is our hope that this will help us all to facilitate decisions with which we will be comfortable and which will be compatible with the beliefs and values of our patients.

Gamete retrieval in terminal conditions: is it practical? What are the consequences?

There is an increasing interest in, and request for, gamete retrieval from recently deceased or near-dead subjects for the purpose of posthumous procreation. This usually arises in an emergency situation with little time for physicians to consider ethical ramifications. Advance planning is needed to help these physicians make thoughtful decisions. After considering the complexity of the issues involved, the Ethics Consult Service and the Ethics Committee at the University of Virginia requested that we develop a policy on gamete retrieval for subjects in terminal conditions, which would govern and guide involved providers should this process be requested. Our team consisted of members of the Ethics Consult Service and Ethics Committee, as well as personnel who might be intimately involved in the gamete retrieval process, including the director of the Human Gamete and Embryo Laboratory, a urologist, and a reproductive endocrinologist. In addition to reviewing the current literature describing the actual processes involved, we explored the ethical implications of gamete retrieval in these situations. A policy was developed and approved by the Ethics Committee at our institution, and is included in this article.

The accuracy of endometrial biopsy and saline sonohysterography in the determination of the cause of abnormal uterine bleeding.

OBJECTIVE: The purpose of this study was to determine the accuracy of outpatient endometrial biopsy and saline sonohysterography for the evaluation of abnormal uterine bleeding. STUDY DESIGN: Eligible participants included women aged 25 to 69 years who complained of persistent uterine bleeding, despite medical treatment. One hundred forty-four patients consented and were followed up prospectively: 1 patient did not successfully complete a saline sonohysterography because of discomfort, 143 patients underwent an endometrial biopsy and saline sonohysterography as outpatients, 113 patients underwent a definitive surgical intervention (hysteroscopy/dilatation and curettage or hysterectomy), 20 patients did not complete a gold standard measure, and 10 patients were lost to follow-up. RESULTS: The combination of endometrial biopsy and saline sonohysterography for the 113 patients who completed the study had a sensitivity and specificity for the detection of abnormal pathologic features of 97.0% (95% CI, 88.6-99.5) and 70.2% (95% CI, 55.0-82.2) and a positive and negative predictive value of 82.1% (95% CI, 71.4-89.5) and 94.3% (95% CI, 79.6-99.0) compared with hysteroscopy/curettage or hysterectomy. CONCLUSION: The high sensitivity and high negative predictive value of saline sonohysterography combined with endometrial biopsy make this technique useful for the evaluation of abnormal uterine bleeding. It may allow some patients to avoid more invasive operative procedures; however, it is important to recognize the limitations in the predictive value of this diagnostic modality.