What is an Abortion?

The term abortion means the early loss of a pregnancy. This can happen in various ways. By far the most common way is what is called a spontaneous abortion, or miscarriage. Spontaneous abortions occur frequently, in up to 30-40% of pregnancies, and typically between a few days and 12 weeks after the blastula/blastocyst implants into the lining of the uterus. (A fertilized egg turns into a blastula, a ball of cells that has the potential to develop into an embryo.) Thus, nearly a third of all women attempting pregnancy will suffer a spontaneous abortion during their reproductive years, and some will suffer several. Such spontaneous abortions, or miscarriages, are not the fault of the mother. The reasons they occur are many, including genetic abnormalities, hormonal imbalances, immunological abnormalities, and improper development of the early embryo. In most cases such abnormalities will result in the uterus expelling the failed pregnancy spontaneously in a bloody mess called a miscarriage. If all goes well, it is all expelled quickly, and the uterus clamps down and stops the bleeding. If things don’t go well, the miscarriage may only partially come out. This is called a failed partial miscarriage. In that situation the uterus cannot clamp down and stop the bleeding, so the woman may bleed to death. Sometimes the early embryo will simply die or be absorbed but there is no progression to discharge of the placental tissue and amniotic material; an ultrasound will show a tiny amniotic sac remaining in the uterus with nothing in it, or a tiny dead embryo. This is called a failed miscarriage. The presence of the material will prevent any new desired pregnancy from occurring. Some sort of intervention has to occur so the woman can try again.

In the past, the only way to treat a partial spontaneous abortion or missed spontaneous abortion (partial is dangerous due to retained tissue with bleeding and risk of infection; missed abortions can be monitored for a while, but problems such as bleeding and infection can occur later if one waits too long for treatment) was to perform a dilation and curettage, a D&C. This is a minor procedure. The woman is given a general anesthetic. After sterile preparation, the cervix of the uterus is grasped with an instrument and the opening in the cervix is probed with gradually enlarging dilators until the opening has been dilated to about a half inch. Then, a blunt curette – a smooth instrument with a little metal loop on the end – is inserted and gently swished around the inside of the uterus and retracted, pulling the miscarriage material out. The curette is passed a few times to be sure everything has been removed. The uterus is examined to make sure it has contracted down, and the cervix is observed to make sure there is no active bleeding. The specimen, consisting of a tiny placenta, remnants of the embryo (if it exists), the amniotic membrane, and the lining of the uterus (endometrium), is sent to the pathologist for analysis. Sometimes it can be determined why the miscarriage occurred based on study of the specimen, including DNA analysis. Most of the time, the cause remains unknown.

The treatment for a spontaneous abortion (miscarriage) should never be politically or religiously controversial. There is no living embryo in any such case, and treatment is required to protect the mother from bleeding to death or dying from infection. Treatment also preserves fertility so the woman can try again for a successful pregnancy. I have performed this procedure many times for women with partial or missed spontaneous abortions (miscarriages). It is routine surgical care.

More recently, hormones and medications have been used to help the uterus expel entrapped material from a partial or missed spontaneous abortion (miscarriage). The medications cause the lining of the uterus to detach (like a period) and stimulate the uterus to contract to push out the lining and the material left from the failed pregnancy. This is routine medical care that can be chosen as long as the patient is stable and meets necessary criteria. Again, in all of these cases there is NOT a living embryo in the uterus. It has already perished. This is why treatment is needed.

I want to be clear that in the case of any type of spontaneous abortion (miscarriage), the pregnancy has failed of its own accord. There is no life in the uterus – no blastula, no embryo, no fetus. The purpose of all treatments is to bring the mother back to good health and maintain fertility.

What’s an “”ectopic pregnancy?” An ectopic pregnancy is a pregnancy located outside of the uterus. The fertilized egg somehow manages to implant and begin to grow where it is not supposed to. Typically, such pregnancies are located somewhere in or on the “adnexa.” The adnexa is a term referring to the ovary, the fallopian tube, and the various ligaments that support those structures and the uterus in the pelvis. So, the blastula implants on an ovary, on a ligament, or on or in the fallopian tube. In even stranger cases, the blastula may implant within a c-section scar, on the intestine, in the liver, or on some other organ. By the time symptoms appear at a few weeks after implantation, there is a tiny embryo with an attached placenta that is invading the structure supporting the pregnancy. Often the very first symptom is sudden pain followed by severe bleeding within the abdomen, as the pregnancy has ruptured. This is an emergency. There is no such thing as an ectopic pregnancy that is viable if it has ruptured, i.e., none can survive. In other words, no such pregnancy can ever produce a baby – all it can do is kill the mother. Immediate surgery is the treatment if the patient is bleeding and unstable. If the patient is symptomatic or asymptomatic but not bleeding, a cancer treatment drug might be used to destroy the embryo and placenta, but usually surgery is necessary. Often an ovary or tube or both will need to be removed. I treated many ectopic pregnancies in my career as a surgeon. It is typically impossible to identify any embryo in the material removed; it is too small and degraded to even be visible. Every once in a blue moon a fetus manages to develop in an ectopic site and get to the age of viability – 23 weeks gestation. Such occurrences are incredibly rare. The situation is touch and go and has to be carefully managed by experts to try to save both the fetus and the mother. Surgical intervention is invariably required if an ectopic pregnancy gets that far.

Treating an ectopic pregnancy is like treating a miscarriage, but more complicated. It’s always either an emergency or an urgent situation. Some people seem to be confused about that. To be clear, treatment is not optional, it’s mandatory and medically required in order to save the mother’s life. This should not be politically or religiously controversial, and the subject is too complicated to be relegated to the whims of a legislature or congress.

When deliberate steps are taken to end pregnancy, the term used is induced abortion or early termination of pregnancy. This is done with the full knowledge that there is a living embryo (it is an embryo until ten weeks gestation) or fetus (defined as after ten weeks gestation when it takes on the form of a tiny one-inch human) within the uterus. The reasons for terminating a pregnancy, or having an induced abortion, are many. Two reasons are severe developmental abnormalities not consistent with life outside the uterus, and genetic abnormalities not consistent with life outside of the uterus; it is justifiable to recommend a medically induced abortion or surgical abortion (usually D&C) in such cases to reduce the risk of complications of pregnancy for the mother and to allow her to make another attempt at a successful pregnancy as soon as possible. It is hard for anyone to validly argue against abortions in such cases. Carrying a pregnancy just to watch a fetus or infant die in the mother’s arms is not more humane than an early termination, and such complicated pregnancies place the mother at additional risk for life-threatening complications.

And then there are more controversial circumstances, such as a pregnancy that is the result of a rape or incest. Often these cases involve minors and there is nothing wrong with the embryo. In many cases the victim is so young that carrying the pregnancy to term may be physically dangerous, not to mention psychologically and emotionally traumatic. If the victim is an adult, they may have a strong psychological and emotional aversion to giving birth to the child of the man who raped them. Either way, the decision to proceed with the pregnancy or not is highly complicated and is not something that can be easily relegated to legislation. Nevertheless, the argument is made that it’s not the fetus’s fault that it was conceived in violence. Some therefore think the mother should be forced to bring it into the world regardless, putting her once again at the (small) risk of death or physical harm and the higher risk of mental health and social consequences. The theory is that if she gives birth, she will bond to the baby and love them anyway or at least be able to give it up for adoption. For those who think the mother should be forced to maintain the pregnancy and deliver the baby, one is left to wonder why they think their viewpoint is relevant – they have no skin in the game. We all have feelings about this conundrum, but I can’t help but think that such feelings should be applied only to one’s own circumstances, not those of others.

And finally, there is the highly politically charged medically induced (almost all) or surgical (far fewer, and usually by D&C) abortions done by “choice.” These abortions are associated with unwanted pregnancies and pregnancies that may be inconvenient or burdensome to the mother/family due to economic, personal, professional, or social hardships. These are the abortions most people are talking about when they say they are “against abortion.” Most such induced abortions today can be performed by D&C but are usually not performed by D&C, as there are less invasive methods available. Rather they are induced by medication very early in pregnancy when there is only a fertilized egg, a blastula, or an embryo. The morning after pill is a special treatment that uses hormones as a precaution to prevent a possibly fertilized egg from implanting in the uterus – it prevents a pregnancy from occurring in the first place so cannot properly be called an abortion. (The vast majority of fertilized eggs in humans naturally don’t implant – they just come out with the monthly period.) Mifepristone and misoprostol are medications used throughout the embryonic phase (up to ten weeks gestation) to induce an abortion. A fetus, defined as 10 weeks and on, cannot live outside the uterus until they’ve reached 23 weeks gestation. The more premature the fetus, the less likely it will survive or survive without complications.

And then there is this other thing, the so-called “late term abortion.” The definition of “late term” is not settled, but it seems to be anything after fourteen weeks, or early mid-trimester. The reasons for performing such a procedure are typically extraordinary and related to the mother’s health, i.e. the mother has complications of pregnancy that are going to kill her if the fetus is not removed urgently. Such conditions could include a new diagnosis of an illness, such as cancer in the mother that must be treated right away with medications that cannot be taken during pregnancy, or conditions such as severe preeclampsia or eclampsia that are caused by the pregnancy and will kill the mother if the fetus is not delivered or removed. Women who develop cancer or another life-threatening illness after the first trimester will typically delay their own treatment until the fetus has reached viability (23 weeks or later) and simply undergo an induction of labor or a c-section to deliver the fetus early so they both have a chance of survival – this is not an abortion. It is delivery of a live fetus early in order to save both the fetus and the mother. Some women choose to sacrifice the fetus to save themselves if the age of viability is too far off for her to survive long enough to possibly save the fetus (they may be too ill to delay treatment or may have other children to raise or other reasons to make that decision). Typically, such a difficult decision would have to be made between 14 and 20 weeks gestation. The circumstances for when a late term abortion is necessary are so limited that they almost never happen. I have, in fact, never seen or heard of a single case of a late term abortion being performed in my nearly forty-year career as a medical professional. The political drama surrounding the concept is completely unsupported by the facts. The determination for the need of such a procedure should be only in the hands of the patient and her physicians.

Why am I writing all of this? Pregnancy is complicated and not infrequently dangerous for the mother, and in general, most people do not understand the process of reproduction and giving birth. They have no idea of the details – the physiology, the anatomy, the developmental embryology (how a fertilized egg turns into an embryo and then a fetus), the changes in the body of the mother, or the process of giving birth. They also don’t understand the meanings of the medical or biological terms that are used. Education surrounding reproduction in the United States is awful, a fact that has seriously contributed to the circumstances we now find ourselves in. If laws surrounding pregnancy are necessary, they have to be informed by science and based on facts, not assumptions, misrepresentations, or beliefs, all of which are all over the map and useless when it comes to making solid objective decisions. From my perspective, the government has no capability or legal standing to have a say in pregnancy matters at all. And neither does an individual outside observer or any group of people. It’s a personal matter that requires the input of a qualified physician and perhaps the input of a trusted religious advisor, a social worker, or a therapist.

Women are in a dangerous situation in the United States due to legislation designed to harm them during pregnancy. I am puzzled as to why legislators who write bills that are meant to directly interfere with patient care and physician decision making, which endanger the lives of women, are not being criminally charged for practicing Medicine without a license. Some women will die or be seriously injured as a consequence of these laws. Legislators and governors who write, support, and pass such laws are guilty of aiding and abetting the death of any woman who dies as a result and should be criminally charged. Unfortunately, there is no accountability for the politicians who are killing and maiming pregnant women in states where legislation has been passed to make life difficult for them. I firmly believe that politicians should be held accountable for the consequences of the bills they write and the laws they pass.

Because some laws restricting abortion seem to confuse a spontaneous miscarriage with an induced abortion, physicians have delayed interventions during and after miscarriage to avoid the risk of being accused of breaking the law and being thrown into prison. Surprisingly, legislators who support abortion bans are blaming the doctors for failure to intervene in a timely manner in these cases, claiming the doctors are at fault for not being courageous enough to take that risk. The legislators claim the doctors are guilty of malpractice if they don’t intervene soon enough to save the mother, but the legislators claim to be guilty of nothing in spite of their legal interference with the physician’s decision-making. Granted, it is up to the physician to decide when intervention is required but given the choice between a malpractice suit for waiting too long to intervene and a prison sentence for intervening too early, well, you’re damned if you do and damned if you don’t. This is the impossible position in which some of these laws have placed the doctor. In twelve states, charges can be brought against doctors that result in significant prison sentences, fines, and loss of the license to practice Medicine. That could, under certain circumstances, be the thanks they get for saving the life of a mother. And even though the doctor is held accountable to make the correct call at the correct time by the legal establishment, the doctor is not considered to be their own expert if a prosecutor brings charges against them. Rather, a Judge (also not trained in Obstetrics and Gynecology) and a panel of “experts” who were not present at the time of treatment and did not examine or talk to the patient are deemed to know more than the treating doctor about what should have been done. It is they who determine the doctor’s fate.

This situation is untenable. Doctors have been put between a rock and a hard place by bad laws, and patients have been put between a rock and a hard place regarding family planning, as they’ve lost control of the management of their own bodies and families.

One might easily predict the outcome of all of this. Many women are deciding not to have children at all rather than risk dying in the process of trying. Many men and women do not want to raise any daughters who might die as teenagers or adults as a result of foolish anti-abortion legislation. Many women who have had pregnancy complications in the past but wanted more kids have decided against it due to the added risk of loss of life these laws impose on mothers. Many women are leaving the United States permanently. And now, as expected, medical experts in Obstetrics and Gynecology are discontinuing obstetrics due to their personal risk of imprisonment for treating a patient who needs help. Furthermore, medical students are deciding not to go into the specialty. What does this mean for women in the United States? It means that pregnancy has just become way more dangerous and thus something to avoid entirely. This result applies across the board; pro-life women, conservatives and the religious are in just as much danger as everyone else. If you’re pro-life, you may lose your life thanks to these laws. Ironically, it’s precisely at this time that the men writing such laws are also putting in place legislation that makes it more and more difficult for women to work and maintain their autonomy while trying to force women to stay at home and be “traditional wives.” “Traditional” meaning pregnant and cooking and cleaning all of the time. The combination of anti-woman, pro-fetus legislation with forced cultural change will result in dead mothers, kids without a mother, and dads without wives.

Clinics that provide reproductive care to women have been closing left and right. Women who need to terminate a pregnancy may have to travel out of State. Such travels have been criminalized by some of those same States; they try to track them down by license plate or by using narcs to expose the patient. They file charges against obstetricians in other (safe) States and try to extradite them. All of this is a violation of privacy and a violation of HIPPA – the patient privacy act.

This is my philosophical stance: life does not begin at fertilization. Rather, life is a continuous line that never breaks. Life creates life. An egg is alive. A sperm is alive. So are the people who are making the eggs and the sperm, and they came from an egg and sperm. And so it goes, back in time, one continuous thread. And yes, of course, an infinitesimal number of eggs and sperm have been cast aside over the millennia – lots of literal dead-ends. All those extra sperm and eggs – an ocean of them, all potential people, had to die so that every once in a while, two could create just one life to maintain the line. Men dispose of five hundred million sperm with each ejaculation, all potential people. Women use up ten or so eggs with every menstruation, with all but one being reabsorbed by the ovary. All those potential people are not allowed to live every month. This is the result of how we were designed. A lucky single egg nominated to go down the tube may or may not meet a sperm it can get along with, and if it does, the resultant fertilized egg has less than a perfect chance of developing correctly or implanting in the uterus. If it doesn’t, it goes out with the menstrual blood. If it does implant, it still has a 30% chance of failure to produce a successful pregnancy due to the risk of miscarriage. This is basic biology.

If one is religious and thinks that life begins at conception, and that every fertilized egg is as important as an already existing human – such as the mother – then one is left to wonder why God thinks nothing at all of wasting eggs and sperm or of killing so many fertilized eggs, embryos, and early fetuses. It has to be intentional, if one believes that God is in charge. Would God murder children? Yes, He would. He did it all the time in the Old Testament Bible and in the Talmud and the Koran. He even ordered people to murder their own children. And other people’s children. And babies! By the way He designed the human body to work, He made sure of His plan to end most lives before they even get started, beginning with the sperm and eggs, and then moving on to fertilized eggs, embryos, and fetuses.

And this is true throughout nature. Other animals function reproductively in the same manner, wasting tons of sperm and eggs and losing a high percentage of embryos, fetuses, and babies. Plants produce gazillions of fertilized eggs – seeds – hoping for one out of a million to make it to adulthood to bring life to the next generation. This is how it is on earth. To have even a single life make it, millions and millions of potential lives have to be cast aside.

Today it is possible to make an embryo from any cell in the body by turning it into a stem cell. A stem cell is pluripotent – it can develop into any type of tissue for which it is genetically programmed, including an entire organism, given the right circumstances. Every time you scratch your back you kill billions of potential clones of yourself. Just think about that. Taking this line of thought to its natural conclusion, the only way to completely stop potential human babies from being destroyed is to kill ourselves. Break the thread of life. That’s how you stop miscarriages, abortions, ectopic pregnancies, and other complications of pregnancy – get rid of everyone. Only then will the loss of “possible lives” cease.

I have a certain practicality about the way I view reproduction and its politicization. I think the terms pro-choice and pro-life are purely political, meant to antagonize. The truth is, if one claims to be pro-life, they have to be pro-choice. They can’t claim that a fertilized egg matters more than the mother who is housing it. It doesn’t. They can’t claim that a fertilized egg is the same as a new-born baby. It isn’t. A fertilized egg is the size of the period at the end of this sentence. It is a potential human, yes. An actual human, no. Over 99% of the people reading this article would not be able to identify a human embryo up to ten weeks gestation if it was placed in a lineup with embryos of dogs, cats, whales, dolphins, cows, chickens, or even fish. Human embryos, like all embryos, go through a period of differentiation, that is, a gradual progression of development that finally ends with a recognizable appearance. If you wait a few days or weeks, you’ll be able to tell the chicken embryo from the human embryo, and vice-versa. They look the same through the initial stages of embryological development.

For humans, it’s ten weeks before you have a tiny human replica in place of the former embryo. It is fully differentiated now, with all its rudimentary organs and parts in place, measuring just one-and-a-quarter inches, and now all its organs and parts need to grow and mature to get ready to live outside the uterus in thirty more weeks. Modern Medicine allows some wiggle room nowadays, so any fetus that makes it to 23 weeks has a fighting chance at life, and any that get to thirty-two weeks before delivery are almost assured of a normal life without consequences. Modern Medicine has made this possible.

The technological advance of in-vitro fertilization has, for some, created another layer of religious, moral, and ethical conflict. To do in-vitro fertilization, you have to give the potential mother hormone injections to cause multiple eggs to “ripen” at once. Those eggs are then removed from their follicles (a little sac of fluid) on the ovaries with a tiny suction device. As many as twenty eggs or more can be removed at once in this manner. Once successfully captured, each egg is fertilized using one healthy looking sperm. The sperm is pulled into a tiny pipette, a glass tube with a pointed tip, and the tip is pushed through the egg capsule and the sperm gently flushed into the egg. The sperm meets the nucleus of the egg, and ta-da, fertilization occurs. The fertilized eggs are allowed to divide in a nutritious broth for a certain number of hours, and the resultant ball of cells (blastula) can then be tested for genetic abnormalities and frozen for later use. Many, if not most, of the blastulas/blastocysts will not survive long enough to be frozen for later use. Some will have genetic abnormalities that prevent use. Once the potential mother has been properly prepared with hormones to maintain a pregnancy, one of the remaining healthy blastulas/blastocysts can be carefully placed inside the uterus, again using a pipette. Most of the time they take initially, but again, the miscarriage rate is similar to the rate for a natural pregnancy, so often the mother will have to go through more than one cycle to finally have a successful pregnancy.

Sometimes there are frozen blastulas/blastocysts remaining in the lab after the parents have completed their family. They can’t be kept forever, and at some point, they are discarded. The little balls of cells can barely be seen with the naked eye, but some people seem to think they are the same as a person. They are not. Yet, they want laws to force the labs to keep the blastulas frozen forever. They will never be used, and eventually, they will perish regardless of being frozen, so such laws are not only useless, but from a practical standpoint, ridiculous.

The science behind the development of a life is vastly complex. I am always so surprised at how quickly a human creates itself considering that complexity. And it does create itself; it is genetically programmed to make itself into a human from a single beginning cell. The process is astonishing. The mother’s job is to stay healthy and prepare for delivery as that cell turns itself into a little person. She is not doing anything directly to get it to develop, it just does it, as long as nothing is awry. It is nothing short of miraculous that a cell can do that, or that a mother’s body can change enough in the process to accommodate it and then bring it into the world. Afterwards, the mother will never be the same as she was before. She is permanently changed.

In conclusion, I do not think congress or any legislature should have any say about how anyone manages any health issue, and certainly not how women manage their pregnancies. The medical and biological sciences fields have thoroughly studied the pertinent issues, and it is their recommendations that should be followed. If a gestational date is set beyond which deliberate pregnancy termination should be considered inappropriate, that date should be determined by our many national pediatric societies, the American Society for Reproductive Medicine, and the American College of Obstetrics and Gynecology, with recommendations for exceptions determined. These should be solid guidelines, not laws, taking into account that each situation is unique and that the government does not have the professional expertise required to be making such decisions for the patient. In fact, it should be against the law for legislators to “dabble” in Medicine while in office. The clinical application of health care must be in control of the experts who undergo upwards of twelve years of intense education to become capable of taking care of a human being in times of medical need. They are experts who have dedicated their entire lives to women’s health. Complicated matters such as these can only be properly managed by the patient and their medical advisors.