Dobbs decision leaving broad imprint on reproductive medicine

NEW ORLEANS — The annual meeting of the American Society of Reproductive Medicine is usually a buoyant, shiny parade of new science, fresh technology products, and promises that together they will provide more people with more options than ever before for taking control of how and when, and if, they have children.

This year’s event still bore the familiar trappings of hope — 8-foot-high photos of parents holding newborns bathed in rays of sunshine, a verdant “wishing wall” bedecked with crepe-paper flowers crumpled around wishes made on behalf of patients experiencing infertility. But as thousands of leading reproductive health researchers and clinicians from around the world descended on The Big Easy, they couldn’t escape the big, dark, Dobbs-decision-shaped cloud hanging over it.

“The United States is now in the same league as countries that we don’t ordinarily regard as role models when it comes to health policy, namely Poland, Nicaragua, and El Salvador,” Anita Allen, a professor of law and philosophy at the University of Pennsylvania, said in a plenary talk that kicked off the conference Monday morning.

That’s thanks to the U.S. Supreme Court’s Dobbs decision last June, ending 50 years of constitutional protection for abortion. Since then, more than 20 states have enacted bans or legal restrictions, creating a patchwork of access to the surgical procedure, which is also used for other health conditions, such as miscarriage management and treating ectopic pregnancies. It’s also changing the fertility industry.

In her talk, Allen described conversations she’d had with fertility doctors who’ve seen an uptick in patients asking for pre-implantation genetic testing — a costly but unproven screening tool sold as a way to improve the odds of having a healthy baby. Prospective parents are taking such measures out of the hope that it minimizes the chance of a fetal anomaly that might put them in the position of having to decide whether or not to have an abortion.

“Can you imagine being afraid to get pregnant?” Allen asked the audience. “To be so afraid that you invest thousands of dollars in pre-implantation testing in order to avoid getting caught up in the abortion prohibition mess?”

It’s not just anecdotes. Data presented this week at ASRM underscored how broadly and deeply that decision is now impacting the field of reproductive medicine — from changing where the next generation of doctors decide to train and practice to costly decisions patients are being forced to make to minimize the risk they might need to seek care that is no longer legal where they live.

One theme that showed up repeatedly was the fallout for abortion-restrictive states in terms of the physicians they are able to attract to residency and fellowship programs.

“You want to get as much experience in training as possible so you can then provide the best possible care to patients,” said Marisa Gigg, who was a resident at Tulane University when the Dobbs decision came down. She knew she wouldn’t have the opportunity to learn and practice procedures that are vital to managing miscarriages and other threats to pregnant people’s health. She reassessed her options and chose a fellowship at the University of Southern California where she could.

“When you care for a patient that you’re helping to get pregnant, if there is something that is wrong or endangering to their health, being able to help them out of a situation that you facilitated them getting into is something that’s important to me,” she said. “And I was wondering if anyone else felt the same way.”

When Gigg surveyed the doctors who applied to the same OB/GYN fellowship the following year, she found she was not alone. More than two-thirds of respondents said they had either canceled interviews in states with restrictive abortion laws or changed how they ranked programs they were applying to as a result of the Dobbs decision. For some of the doctors, it was about the training, but for many others, the reason for avoiding those states was more personal — they wanted more control over their ability to make family planning decisions for themselves and their partners.

New data also show the new legal landscape is not just affecting women’s health care. Researchers at Rutgers and the University of Washington surveyed male and female applicants to urology fellowships in 2023. They found that one-quarter of respondents reported that abortion access was an important factor in their decisions on where to seek training. One in five said they had completely eliminated any programs in abortion-restricted states.

It looks like the early stages of a worrying “brain drain” said Chloe Peters, who led the research, which adds to a recently published study that found similar trends among female urology residents. “We know that over half of residents stay in that state where they do their residency,” she said. “If they’re changing where they apply, that changes where they train, and down the road impacting where they work.”

America is already facing a significant shortage of urologists — 60% of counties in the U.S. don’t have any. And the counties with the fewest physicians also have the strictest abortion laws. On top of that, one-third of practicing urologists are over the age of 65, and the challenges to access are only slated to get worse over the coming decade.

“Who’s going to do your prostate biopsy if you live in Alabama and there’s no urologist for 100 miles?” Peters said. “You’re kind of screwed.”

One way people are responding to this contraction of care is to take preemptive and permanent measures to prevent pregnancy in the first place.

Researchers from the University of Utah analyzed a national database of medical procedures for over 183 million de-identified patients comparing the rates of permanent contraception surgeries from July to December 2021 to the same time period in 2022. Post-Dobbs, all states saw a significant rise in people undergoing vasectomies, with the sharpest increase in single patients under the age of 30 living in states with laws hostile to abortions. They observed similar trends for patients undergoing tubal sterilization, but not as dramatically.