Due to 2012's national budget cuts, the AHR was removed. The regulation of assisted reproduction was then delegated to each province. [ 95 ]  This delegation provides provinces with a lot of leeway to do as they please. As a result, provinces like Quebec, Alberta and Manitoba have put almost the full costs of IVF on the public healthcare bill. [ 96 ]  Dr. Santiago Munne, developer of the first PGD test for Down's syndrome and founder of Reprogenetics, saw these provincial decisions as an opportunity for his company to grow and open more Reprogenetics labs around Canada. He dismissed all controversies regarding catalogue babies and states that he had no problem with perfect babies. [ 96 ]


Ontario, however, has no concrete regulations regarding PGD. Since 2011, the Ministry of Children and Youth Services in Ontario advocates for the development government-funded 'safe fertility' education, embryo monitoring and assisted reproduction services for all Ontarians. This government report shows that Ontario not only has indefinite regulations regarding assisted reproduction services like IVF and PGD, but also does not fund any of these services. The reproductive clinics that exist are all private and located only in Brampton, Markham, Mississauga, Scarborough, Toronto, London and Ottawa. [ 97 ]  In contrast, provinces such as Alberta and Quebec not only have more clinics, but have also detailed laws regarding assisted reproduction and government funding for these practices.


Before 2010, the usage of PGD was in a legal grey area. [ 98 ]  In 2010, the  Federal Court of Justice of Germany  ruled that PGD can be used in exceptional cases. [ 98 ]  On 7 July 2011, the  Bundestag  passed a law that allows PGD in certain cases. The procedure may only be used when there is a strong likelihood that parents will pass on a genetic disease, or when there is a high genetic chance of a stillbirth or miscarriage. [ 99 ]  On 1 February 2013, the  Bundesrat  approved a rule regulating how PGD can be used in practice. [ 98 ]


In Hungary, PGD is allowed in case of severe hereditary diseases (when genetic risk is above 10%).
The preimplantation genetic diagnosis for aneuploidy (PGS/PGD-A) is an accepted method as well. It is currently recommended in case of multiple miscarriages, and/or several failed IVF treatments, and/or when the mother is older than 35 years. [ 100 ]  Despite being an approved method, PGD-A is available at only one Fertility Clinic in Hungary. [ 101 ] [ better source needed ]


In India, Ministry of Family Health and Welfare, regulates the concept under the  Pre-Conception and Pre-Natal Diagnostic Techniques Act, 1994 . The Act was further been revised after 1994 and necessary amendment were made are updated timely on the official website of the Indian Government dedicated for the cause. [ 102 ]  The use of PGD for sex identification/selection of child is illegal in India. [ 103 ] [ 104 ]


As of 2006, clinics in Mexico legally provided PGD services. [ 105 ]


In South Africa, where the right to reproductive freedom is a constitutionally protected right, it has been proposed that the state can only limit PGD to the degree that parental choice can harm the prospective child or to the degree that parental choice will reinforce societal prejudice. [ 106 ]


The preimplantation genetic diagnosis is allowed in  Ukraine  and from November 1, 2013, is regulated by the order of the Ministry of health of Ukraine "On approval of the application of assisted reproductive technologies in Ukraine" from 09.09.2013 No. 787. [ 107 ]


In the UK, assisted reproductive technologies are regulated under the Human Fertilization and Embryology Act (HFE) of 2008. However, the HFE Act does not address issues surrounding PGD. Thus, the HFE Authority (HFEA) was created in 2003 to act as a national regulatory agency that issues licenses and monitors clinics providing PGD. The HFEA only permits the use of PGD where the clinic concerned has a license from the HFEA and sets out the rules for this licensing in its Code of Practice. [ 108 ]  Each clinic, and each medical condition, requires a separate application where the HFEA check the suitability of the genetic test proposed and the staff skills and facilities of the clinic. Only then can PGD be used for a patient.


The HFEA strictly prohibits sex selection for social or cultural reasons, but allows it to avoid sex-linked disorders. They state that PGD is not acceptable for, "social or psychological characteristics, normal physical variations, or any other conditions which are not associated with disability or a serious medical condition." It is however accessible to couples or individuals with a known family history of serious genetic diseases. [ 109 ]  Nevertheless, the HFEA regards  intersex  variations as a "serious genetic disease", such as  5-alpha-reductase deficiency , a trait associated with some elite women athletes. [ 110 ]  Intersex advocates argue that such decisions are based on social norms of sex gender, and cultural reasons. [ 111 ]


No uniform system for regulation of assisted reproductive technologies, including genetic testing, exists in the United States. The practice and regulation of PGD most often fall under state laws or professional guidelines as the federal government does not have direct jurisdiction over the practice of medicine. To date, no state has implemented laws directly pertaining to PGD, therefore leaving researchers and clinicians to abide by guidelines set by the professional associations. The  Centers for Disease Control and Prevention  (CDC) states that all clinics providing  IVF  must report pregnancy success rates annually to the federal government, but reporting of PGD use and outcomes is not required. Professional organizations, such as the  American Society for Reproductive Medicine  (ASRM), have provided limited guidance on the ethical uses of PGD. [ 112 ]  The  American Society for Reproductive Medicine  (ASRM) states that "PGD should be regarded as an established technique with specific and expanding applications for standard clinical practice." They also state, "While the use of PGD for the purpose of preventing sex-linked diseases is ethical, the use of PGD solely for sex selection is discouraged." [ 113 ]


In 2024, the Alabama Supreme Court ruled in an influential case that frozen embryos in test tubes should be considered children, thus raising complex legal questions with implications for reproductive care extending far beyond Alabama. [ 114 ]


In Spain, preimplantation genetic diagnosis is not allowed to be carried out in an open and accessible way for everyone to avoid eugenics. That is why it is only legalized in high-risk cases.


There are three essential requirements (except for the exceptions allowed by the Bioethics Committees) for a preimplantation genetic diagnosis to be carried out on the embryo. All three must be met:


Any type of disease that does not meet these three requirements must go through a Bioethics Committee and be approved by it before PGD can be performed.


Legislation began late, ten years after the birth in the United Kingdom of  Louise Brown , the first person conceived by IVF.


In a study of 135 IVF clinics, 88% had websites, 70% mentioned PGD and 27% of the latter were university- or hospital-based and 63% were private clinics. Sites mentioning PGD also mentioned uses and benefits of PGD far more than the associated risks. Of the sites mentioning PGD, 76% described testing for single-gene diseases, but only 35% mentioned risks of missing target diagnoses, and only 18% mentioned risks for loss of the embryo. 14% described PGD as new or controversial. Private clinics were more likely than other programs to list certain PGD risks like for example diagnostic error, or note that PGD was new or controversial, reference sources of PGD information, provide accuracy rates of genetic testing of embryos, and offer gender selection for social reasons. [ 115 ]


Prelude Fertility  is a network of fertility clinics in the United States that offer fertility services including  in vitro fertilization (IVF) ,  egg donation ,  genetic testing , and egg freezing. [ 1 ] [ 2 ]  As of 2019, the Prelude Fertility Network of clinics included 23 fertility practices and 36 locations in the U.S. and more than 60 affiliated reproductive endocrinologists. [ 3 ]


Prelude Fertility was founded by  Martin Varsavsky  following his and his wife’s experience with fertility treatment and IVF. [ 1 ] [ 4 ]


The company launched in October 2016 when Varsavsky secured funding from  Lee Equity Partners  to purchase a majority stake in Reproductive Biology Associates, an IVF clinic in Atlanta, and My Egg Bank, the largest frozen donor egg bank in the U.S. [ 1 ] [ 5 ]


In September 2017, Prelude acquired a majority stake in Pacific Fertility Center in  San Francisco . [ 6 ]  The following month, Prelude acquired Vivere Health. [ 2 ] [ 7 ]  In March 2018, Prelude acquired the Advanced Fertility Center of Chicago. [ 8 ]  In October 2018, Prelude announced a partnership with  NYU Langone . [ 9 ]  In March 2019, Prelude announced a partnership with Inception Fertility and also announced TJ Farnsworth as the company’s new CEO. [ 10 ]  The partnership made Prelude the largest fertility services provider in the U.S and added Aspire Fertility clinics to the Prelude Network. [ 10 ] [ 11 ]


Jean Marian Purdy  (25 April 1945 – 16 March 1985) was a British  nurse ,  embryologist  and pioneer of  fertility  treatment. She was responsible with  Robert Edwards  and  Patrick Steptoe  for developing  in vitro fertilisation  (IVF);  Louise Joy Brown , the first "test-tube baby", was born on 25 July 1978, and Purdy was the first to see the embryonic cells dividing. Purdy was a co-founder of the  Bourn Hall Clinic  but her role there and in the development of IVF was ignored for 30 years. Following the publication of Edwards' papers in the 2010s, her vital contributions to IVF have been publicly recognised.


Jean Marian Purdy was born in  Cambridge  on 25 April 1945 to George Robert Purdy, a technician at the  Cavendish Laboratory , and Gladys May Southgate, [ 1 ]  a homemaker. [ 2 ]  She had one older brother, John. [ 3 ]  She attended  Cambridgeshire High School for Girls  between 1956 and 1963 [ 4 ]  where she became a  prefect , joined sports teams and played violin in the orchestra. She trained to be a nurse at  Addenbrooke's Hospital  in Cambridge. [ 2 ]


After gaining registration as a nurse, Purdy moved to  Southampton General Hospital . She became homesick and applied for a research post locally to work on  tissue rejection . She later transferred to  Papworth Hospital  in  Cambridgeshire  where the first  open-heart surgeries  (and later,  heart transplants ) were pioneered in Britain. [ 2 ] [ 4 ]  In 1968, she took the position of research assistant to  physiologist   Robert Edwards  at the  Physiological Laboratory in Cambridge. [ 2 ]


In 1968, Edwards began to collaborate with  obstetrician  and  gynaecologist   Patrick Steptoe , who had introduced  laparoscopy  (a  minimally invasive surgical procedure  performed in the  abdomen ) for gynaecology in the United Kingdom. [ 5 ] [ 2 ]  This technique was crucial for harvesting  oocytes  without the need for major surgery. [ 2 ]  Purdy began her work with Steptoe and Edwards as a  lab technician , [ 6 ]  with the aim of developing  in vitro fertilisation  (IVF; in which an  egg  is combined with  sperm  outside the living organism). [ 7 ]  Purdy systematically recorded the essential details of each case. She also apparently spent more time in at the laboratory in  Oldham  than Edwards did, recording the results of  endocrine  monitoring, organising laboratory equipment and supplies, and running various tests. [ 4 ]  Purdy was not involved in laparoscopic  oocyte  retrievals or the manipulation of  embryos . [ 2 ] [ 8 ]


Edwards only allowed Purdy in the lab, with the exception of American scientist  Joseph Schulman . Purdy regularly worked away from home, sometimes managing the lab alone. [ 2 ]  In 1969 she travelled with Edwards to  California , United States, to carry out research. [ 9 ]  She played a significant and increasingly vital role, to the extent that, when she took time off to care for her sick mother, work had to pause. [ 6 ]  Without Purdy’s systematic approach to research, the IVF project may have faltered. [ 10 ]


During this time the team endured criticism and hostility from the national funding agency  Medical Research Council  (MRC), who saw the Cambridge institution’s clinical facilities as problematic. The MRC were antagonised by the applicants' high media profile and viewed IVF as experimental. In February 1971, funding from the MRC was sought but declined. [ 11 ]  In mid-1974, Edwards became depressed by a lack of progress and funding, as well as the long commute to Oldham. Edwards gave Purdy the choice of giving up research to work on a unrelated project. [ 12 ]  According to Purdy's childhood friend Rosemary Carter, [ 13 ]  Purdy asserted her support in the IVF project and encouraged Edwards to continue their research. [ 12 ]


It was Purdy who first saw that a fertilised  egg cell  was dividing to make new cells. [ 14 ]  According to Purdy's obituary in  The Times , Purdy was the first person to identify and describe the formation of human  blastocysts . [ 2 ]   Louise Joy Brown , the first human born following conception by IVF, was born on 25 July 1978. [ 15 ] [ 16 ]  Brown's birth vindicated the development team and pressured the MRC to quickly became a significant backer of the team's research. [ 11 ]  To train specialists, the team founded the  Bourn Hall Clinic  in 1980. [ 2 ] [ 17 ]  The  Bourn Hall  property was suggested by Purdy and she played a major role in setting up Bourn Hall's IVF program. She was formally titled the "technical director". [ 18 ]  Purdy was a co-author on 26 papers with Steptoe and Edwards, [ 14 ]  and 370 IVF children were conceived during her career. [ 2 ]


Purdy has been remembered by friends and colleagues as unassuming with a gentle demeanour. [ 14 ] [ 19 ] [ 2 ]  She acted as a "go-between" for Edwards and Steptoe's strong personalities. [ 2 ]  Purdy often interacted with both prospective husbands and wives on retrieval day. She also had an artistic side, evident from her collection of  classical music  records. [ 19 ]


Purdy was also a deeply religious  Christian  and rebutted religious criticisms of IVF. [ 19 ] [ 2 ]  The  Roman Catholic Church  raised objections to her work in her lifetime. [ 15 ]


Purdy died at the age of 39 in Addenbrooke's Hospital [ 20 ]  from  malignant melanoma [ 4 ] [ 2 ]  on 16 March 1985. [ 13 ]  She had only been ill for a short time, [ 20 ]  and during her illness a room was arranged for her in Bourn Hall where she could work. [ 21 ] [ 2 ]  She was buried in  Grantchester ,  Cambridgeshire , [ 13 ] [ 21 ]  beside her mother and grandmother. [ 21 ] [ 2 ]


Despite being a central figure in the development of IVF, Purdy's contributions were largely forgotten by the public and scientific community. [ 22 ] [ 10 ]  The factors that contributed to this include her tragic early death, her role as a lab technician and her gender. [ 6 ] [ 2 ] [ 23 ]  Edwards was awarded the 2010  Nobel Prize in Physiology or Medicine  for his work on the development of in vitro fertilisation; [ 24 ] [ 25 ]  however, because the Nobel Prize is not awarded posthumously, neither Purdy nor Steptoe were eligible for consideration. [ 14 ]


In 1980 a plaque was planned to honor the development of IVF. The plaque's text, as approved by administrators, excluded Purdy's name. Edwards protested against this omission but his objections were rejected by an administrator. The Oldham NHS Trust received a letter of complaint from Edwards in 1981. [ 6 ]  In his 1989 autobiography Edwards maintained Purdy's importance and described the core team as a "threesome". [ 14 ] [ 2 ]


In a plenary lecture in 1998, celebrating the 20th anniversary of clinical IVF, Edwards gave tribute to Jean Purdy, saying: "There were three original pioneers in IVF and not just two". [ 2 ]  Purdy's importance was recognised following the publication of Edwards' papers in the 2010s. [ 26 ] [ 27 ] [ 23 ] [ 28 ]  In 2015, Professor  Andrew Steptoe  of the  Royal Society of Biology  (Patrick Steptoe's son) unveiled a  blue plaque  that acknowledged the three people involved in developing IVF. [ 29 ] [ 30 ]  In 2018, to mark the 40th anniversary of IVF, Bourn Hall unveiled a memorial to Jean Purdy, the "world's first IVF nurse and embryologist. Co-founder of Bourn Hall Clinic". [ 31 ]


University College London 's award for the  MRes  (Master of Research) Reproductive Science and Women's Health is named after Purdy. [ 32 ]


Purdy, Edwards, and Steptoe's work was dramatised in Gareth Farr's 2024 play  A Child of Science , which premiered at the  Bristol Old Vic . Purdy was portrayed by  Meg Bellamy . [ 33 ] [ 34 ]  Also in 2024, Purdy was portrayed by  Thomasin McKenzie  in the  biographical   drama film   Joy , which similarly follows the development of IVF. [ 35 ] [ 36 ]


Emeritus Professor  Sittampalam Shanmugaratnam  (4 July 1928 – 6 August 2001), also known as  Shan Ratnam , was a Singaporean obstetrician and gynaecologist.


He was professor and head of the department of Obstetrics and  Gynaecology  of the  National University Hospital  of  Singapore  and specialized in  human reproduction  research. He was a medical pioneer and leader in the field of Obstetrics and Gynaecology, both in Singapore and internationally. At the peak of his career, he was the Secretary-General of the Asia and Oceania Federation of Obstetrics and Gynaecology (AOFOG) and the President of the International Federation of Obstetrics and Gynaecology.


His work placed Singapore at the forefront in the international medical arena and established himself as a prominent figure in world of Obstetrics and Gynaecology. [ 1 ]  His work on contraception also contributed to Singapore's success in population control. The National University Hospital research laboratory for prostaglandin research was initiated and propelled by his vision and energy. He was also the founder of the  IVF  programme for childless couples.


As a young man, Ratnam began his career as a  houseman  (trainee medical officer) at the  Singapore General Hospital  in 1959. He also began teaching at the  University of Singapore  in 1963.


After obtaining his M.R.C.O.G (and later, the F.R.C.S.) in 1964 in England, he was appointed to the post of Professor and Head of the Department of Obstetrics and  Gynaecology  in  Singapore , a post which he held for 25 years.


In 1972, Ratnam's Obstetrics and Gynaecology department received the accolade as being one of "13 research centres in human reproduction in the world", recognition conferred by the  World Health Organization .


In 1970 he was made Chief Examiner and Director (1972) of Postgraduate Medical Studies at the  National University of Singapore . He was a member of the editorial boards of several learned journals, including the International Journal of Obstetrics & Gynaecology, and International Journal of Prenatal and Perinatal Studies.


Ratnam's book,  Cries from Within , was written to explain the procedure for  sex change operations  in 1970. He also led conception of the first  in-vitro fertilization  process in Asia, in 1983. He tried out IVF experiments on  rats  prior to his first, successful attempt on using IVF to conceive babies.


In 1977, he was awarded the Singapore Gold  Public Administration Medal . His learned articles and conference papers run into the hundreds, and he has edited or co-edited 15 books to his credit. [ 2 ]


Ratnam served as the secretary general of the Asia and Oceania Federation of Obstetrics and Gynaecology for seventeen years, and was a member of the executive board of the International Federation of Obstetrics and Gynaecology from 1969 to 1982, president-elect from 1982 to 1985, and president from 1985 to 1988.


Ratnam was awarded the Sims Black Travelling Professorship and the Visiting Professorship of the South African representative committee, both by the  Royal College of Obstetricians and Gynaecologists , in 1982 and 1994 respectively. [ 3 ]


In 1987, he also pioneered the procedure of giving birth to a baby born from frozen  embryo transfer . He was part of a team of clinicians and scientists which led to the world's first  microinjection  baby via human ampullary  coculture  in 1991. [ 4 ]


Ratnam also contributed to gynaecology through research. He had credit to 378 research papers in the referred International Journals, 232 research papers in the referred local and regional journals, including nineteen non-referred journals.


His career as a research scientist and teacher continued at the National University of Singapore despite his official retirement in 1998, as  Emeritus  Professor of  Gynaecology  and  Obstetrics . He was a world authority on sex change operations, developing new techniques for  transsexualism ,  embryo replacement , in vitro and controlled fertilisation.


His work with transsexual patients was shown in a documentary called "Shocking Asia".  In this documentary, he was shown talking about his background with transsexual patients.  He talked about how he first got involved with "the problem" (referring to the patient's penis) and how he used  cadavers  to come up with his technique of sexual reassignment surgery.  It also shows his assistant, Dr Lim, taking some final pictures of a patient before her surgery.


Professor Ratnam suffered a stroke in December 1999. He developed heart complications and passed away from pneumonia at 6.55 p.m. on 6 August 2001 in the  National University Hospital  of  Singapore  at the age of 73. [ 1 ]


Many of his former students are now members in the O&G field including the current head of department at the National University Hospital, Dr P. C. Wong. He  was a  Hindu  during his lifetime. He had two children; one son and one daughter. A centre at  Camden Medical Centre  was named after him, SSR International (Private International). The centre is currently run by his nephew C. Anandakumar.


Repeated implantation failure  ( RIF ) is the repeated  failure of the embryo to implant  onto the side of the  uterus  wall following  IVF  treatment. [ 1 ]   Implantation  happens at 6–7 days after conception and involves the embedding of the growing  embryo  into the mothers uterus and a connection being formed. [ 2 ]  A successful implantation can be determined by using an  ultrasound  to view the  sac  which the baby grows in, inside the uterus. [ 1 ]


However, the exact definition of RIF is debated. Recently the most commonly accepted definition is when a woman under 40 has gone through three unsuccessful cycles of IVF, when in each cycle four good quality eggs have been transferred. [ 3 ]


Repeated implantation failure should not be confused with recurrent IVF failure. Recurrent IVF failure is a much more broad term and includes all repeated failures to get pregnant from IVF. Repeated implantation failure specifically refers to those failures due to unsuccessful implanting to the uterus wall. [ 1 ]


An unsuccessful implantation can result from problems with the mother or with the embryo. It is essential that the mother and embryo are able to communicate with each other during all stages of  pregnancy , and an absence of this communication can lead to an unsuccessful implantation and a further unsuccessful pregnancy. [ 4 ]


During implantation, the embryo must cross the  epithelial  layer of the maternal  endometrium  before invading and implanting in the  stroma  layer. Maternal factors, including congenital uterine abnormalities,  fibroids ,  endometrial polyps , intrauterine adhesions,  adenomyosis ,  thrombophilia  and  endometriosis , can reduce the chances of implantation and result in RIF. [ 1 ]


Congenital uterine abnormalities are irregularities in the uterus which occur during the mothers foetal development. [ 1 ]


Two  Hox genes  have been identified to assist in the development and receptivity of the uterus and endometrium,  Hoxa10  and  Hoxa11 . [ 5 ]  Hoxa10 has been shown to change the upper uterine segment into  oviduct -like structures, creating a smaller uterus that appears normal. Embryo transfer into the lower uterine segment does not allow for implantation, so the Hoxa10 gene has multiple effects throughout the uterus. [ 6 ]   Hoxa11 mutations alter the endometrial gland development and reduce the secretion of  Leukaemia-Inhibitory factor  (LIF) which is required for implantation. [ 5 ]


Fibroids  are  benign tumours  found in the  smooth muscle  of the uterus, they are often asymptomatic but can cause pelvic pain. They effect implantation rates by altering the shape and  cytokine  composition of the uterus. Removal of  submucosal  fibroids has shown to increase implantation rates. [ 1 ]


Endometrial polyps  are benign tumours found in the endometrium which factor into female infertility. There has been limited research into if their removal increases the chances of implantation and pregnancy. [ 1 ]


Intrauterine adhesions ( Asherman's Syndrome ) occur from scar tissue within the uterus which cause the closure of part or all of the uterus. The  adhesions  prevent embryos from implanting by reducing the surface area and decreasing the receptivity. [ 7 ]  Intrauterine adhesions normally occur after damage has been caused to the  endometrium , either through removal of unwanted pregnancies,  miscarriage ,  infection , and surgical damage. [ 1 ]


Thrombophilia  is a condition which makes the blood more likely to clot and this increases  cardiovascular  risk, meaning the individual is at higher risk of  heart attacks ,  strokes  or  DVTs . [ 8 ]  In pregnancy it can lead to a disruption in the flow of blood to the  placenta  and the uterus wall. This can lead to a decreased receptivity of the uterus wall for a pregnancy and can lead to a miscarriage further on. However, how significantly this contributes to RIF is not fully known but each case should be assessed on a personal basis by a clinician  [ 4 ]


The successful implantation of an embryo not only relies on a receptive uterine environment in the mother but also on the quality of the embryo itself. Embryo quality and probability of implantation can be affected by maternal and paternal genetic abnormalities as well as  zona pellucida  dysfunction and poor  embryo transfer  technique. [ 1 ]


The quality of the  sperm  that  fertilizes  an egg is a key contributor to the overall quality of the embryo. Abnormalities in  DNA fragmentation  and chromosomal arrangements are the main source of genetic deviation in males that can affect embryo quality. [ 9 ]  DNA fragmentation occurs when the strands of DNA are separated to form two separate strands, this disrupts the genetic information that is coded in genes. Depending on the severity of the fragmentation, this can lead to the dysfunction of specific genes which may or may not be essential for embryo survival and in this case the initiation of implantation. DNA fragmentation can happen spontaneously in cells that undergo programmed cell death ( apoptosis ) where DNA is broken apart by enzymes called  endonucleases . However, since the male DNA isn't activated until around day 3 after fertilisation, it is often difficult to diagnose sperm genetic abnormalities because morphological studies could identify a good quality oocyte when initial transfer occurs, but due to DNA fragmentation in the sperm, the embryo will die after day 3 of growth. [ 9 ]


Oocyte  quality is also a main contributor to overall embryo quality since it is the DNA of the oocyte that is mainly involved in the first 3 days of embryo growth following fertilization. A major source of genetic abnormalities are  balanced translocations  (Figure 1). [ 9 ]


A translocation involves the exchange of segments of chromosomes that are not a homologous pair. In most cases, this leads to balanced translocations, in which no DNA is lost therefore is usually asymptomatic. However, as female gametes are formed, it is probable that 2/3 of embryos produced will have unbalanced translocations within their DNA if fertilised by sperm with a balanced translocation too. Translocation mutations can occur at any point during fertilization or even the first meiotic division that the oocyte undergoes during foetal life. [ 9 ]


The female egg ( oocyte ) is surrounded by a layer of  glycoproteins  called the  zona pellucida . Once fertilisation has occurred, this layer will harden to prevent further sperm entering and maintain the shape of the fertilized egg ( zygote ) as it divides to form a  blastocyst  (Figure 2). [ 10 ]  Once the  inner cell mass  -  the group of cells within the blastocyst that go on to form the embryo - starts to expand,  lysin  enzymes secreted by the inner cell mass will act on the zona pellucida and weaken the hardened structure. Eventually, this will cause the rupture of the zona pellucida, allowing the blastocyst to hatch and begin to implant into the uterine wall. [ 1 ]


If the zona pellucida fails to thin in preparation for rupture, this will prevent the blastocyst from hatching and therefore be unable to implant, therefore this is a probable cause of repeated implantation failure (RIF). This is supported by a study which showed that implantation rates in women who received assisted zona pellucida hatching - use of synthetic chemical to artificially weaken the zona pellucida - increased. [ 1 ]


Women with RIF should undergo ovarian function testing to explore their levels of  FSH ,  AMH  and any other hormones or  follicle  counts which may indicate the overall behaviour of the  ovarian reserve . [ 1 ]  Male partners may also be offered laboratory testing of sperm DNA integrity. [ 1 ]


In the instance of  genetic testing ,  karyotyping  may be made available to couples with RIF to exclude the possibility of balanced chromosomal translocations. [ 6 ]   Ultrasounds  may be used to oversee the morphological growth and development of follicles throughout IVF treatment, in addition to assessing endometrial thickness. [ 1 ] [ 6 ]


Hysteroscopy  is an essential part of investigating a couple’s RIF pathology and is used as a diagnostic tool to examine the  cervical canal  and  uterine cavity . [ 1 ]


In depth reviews of the underlying causes of a couple's  infertility  should be undertaken with a qualified fertility specialist in order to make decisions regarding further management. [ 1 ]


Modifiable risk factors include  smoking ,  alcohol consumption  and  BMI . [ 1 ]  Women with RIF should be advised to abstain from both alcohol and smoking, and male partners may also consider cessation of smoking due to effects associated with weaker sperm counts and damage to sperm DNA and motility. [ 1 ]  An ideal BMI target for women with RIF is between 19 and 29; [ 1 ]   obese  women may consider structured weight-loss programmes and regular exercise over  bariatric surgery  due to potential  folate ,  iron ,  vitamin B12  and other nutritional deficiencies. [ 1 ]


Table below showing the main first-line treatments for couples undergoing RIF. [ 6 ]


Sentara Norfolk General Hospital (SNGH)  is a large  academic hospital , which serves as the primary teaching institution for the adjacent  Eastern Virginia Medical School .  Located in  Norfolk, Virginia , in the  Ghent  neighborhood and adjacent to Downtown, the hospital serves as the Hampton Roads region's only Level I  trauma center . [ 1 ]   The hospital is interconnected to the Sentara Heart Hospital; however, it is considered a separate institution. Together with the  adjacent  Children's Hospital of the King's Daughters ,  Eastern Virginia Medical School  and the Norfolk Department of Health, the Eastern Virginia Medical Center is the largest conglomerate center for health in  Hampton Roads . [ 2 ]  For a time, the  U.S. News & World Report  rated it the best in Virginia. [ 3 ] [ 4 ]  In 2016, SNGH is tied with  VCU Medical Center  ranked as #2 while  University of Virginia Health System  ranked first. [ 5 ]


In 1888 the forerunner to Norfolk General, the 25-bed Retreat for the Sick, was opened in downtown Norfolk. [ 6 ]  At this time there were fewer than 200 hospitals in the entire country. In 1892 the Retreat for the Sick opened the first  nursing school  in Norfolk. The hospital moved to a new location in 1896 and was renamed Norfolk Protestant Hospital in 1898. The hospital moved again in 1903 and witnessed a fire in 1906, though there were no deaths. Norfolk Protestant was renamed Norfolk General in the 1930s and the first  open-heart surgery  in Virginia was performed there in 1967.


In 1981  Elizabeth Carr  was born at the hospital, becoming America's first  in-vitro fertilization  baby. [ 7 ]  The first  heart transplant  performed in Hampton Roads occurred at the hospital in 1989.


After medical school at  Harvard Medical School  and training in general surgery and critical care, Suffolk native, Dr.  L.D. Britt  returned to Hampton Roads and built a well–respected general surgery program and established Norfolk General Hospital as Hampton Roads' only Level 1 trauma center.


In 2016, the hospital is nationally ranked in two specialties by  U.S. News & World Report . [ 8 ]


Patrick Christopher Steptoe   CBE   FRS [ 1 ]  (9 June 1913 – 21 March 1988) was an English  obstetrician  and  gynaecologist  and a pioneer of  fertility  treatment. Steptoe was responsible with biologist and physiologist  Robert Edwards  and the nurse and embryologist  Jean Purdy  for developing  in vitro fertilisation .  Louise Joy Brown , the first  test-tube baby , was born on 25 July 1978. [ 3 ] [ 4 ]  Edwards was awarded the 2010  Nobel Prize in Physiology or Medicine  for his work on the development of in vitro fertilisation; Steptoe and Purdy were not eligible for consideration because the Nobel Prize is not awarded posthumously. [ 5 ]


Patrick Christopher Steptoe was born on 19 June 1913. [ 6 ]  Born in  Oxford , Steptoe was educated at The Grammar School,  Witney  (since 1968 the comprehensive  Henry Box School ) in  Oxfordshire . He went to  King's College London  and graduated from  St George's Hospital Medical School ,  London  in 1939. He served in the Royal Navy from 1939–1946 and attained the rank of Lieutenant Commander.


From 1947 to 1949 he was chief assistant in obstetrics and gynaecology at  St. George's Hospital , then senior registrar at the  Whittington Hospital  (formerly known as Highgate Hospital) and obtained his  FRCS(Ed)  in 1950. His chief at Highgate, Kathleen Harding, was credited by Steptoe as teaching him a great deal about the management of infertility.


After the  Second World War , he studied  obstetrics  and, in 1951 he started to work at the  Oldham & District General Hospital . From  Raoul Palmer  he learned the technique of  laparoscopy  and promoted its usefulness. In 1967 he published  Laparoscopy in Gynaecology . Subsequently,  Robert Edwards , a physiologist from the  University of Cambridge , contacted him and got him interested in collaborating in the development of  in vitro  fertilization. [ 7 ]


Steptoe became the Director of the Centre for Human Reproduction,  Oldham , in 1969. Using laparoscopy, he collected the  ova  from volunteering infertile women who saw his place as their last hope to achieve a pregnancy. Edwards and   Jean Purdy  provided the laboratory expertise. During this time they had to endure criticism and hostility to their work. Finally, in 1978, the birth of Louise Brown changed everything. Although he encountered further criticism, other clinics were able to follow the lead and patients responded. To accommodate the increased patient number and train specialists, he, Purdy, and Edwards founded the  Bourn Hall Clinic ,  Cambridgeshire  in 1980 of which Steptoe was a Medical Director until his death. [ 8 ] [ 9 ]


In 1979, Steptoe received the Golden Plate Award of the  American Academy of Achievement . [ 10 ]


In the  1988 New Year Honours , he was appointed  Commander of the Most Excellent Order of the British Empire  (CBE), just a week after the 1,000th test-tube baby, conceived with his help, was born. [ 11 ]


Steptoe was elected a  Fellow of the Royal Society  in March 1987. [ 1 ]  His nomination reads:


Steptoe was the first in Britain to use laparoscopy for the routine diagnosis of gynaecological disorders, and the first anywhere to use it as a standard technique for sterilization. He sought to develop it for the treatment of infertility and, by 1969, succeeded in using it for the first time to recover  oocytes  from preovulatory ovaries. During the next ten years he recovered many oocytes, which were fertilized and nurtured by Edwards, and implanted them in the  uterus  through the  cervix  uteri, thus helping to clarify many fundamental aspects of human  ovulation ,  fertilization , and implantation. After more than 100 attempts a pregnancy was obtained which was carried to term. Now the technique, as used by Steptoe and others, is so successful that almost a third of women accepted for treatment have healthy infants. His achievement is particularly remarkable as it was obtained in a district hospital with only local backing. [ 12 ]


A plaque was unveiled at the Bourn Hall Clinic in July 2013 by  Louise Brown  and Alastair MacDonald – the world's first IVF baby boy – commemorating Steptoe and Edwards. [ 13 ] [ 14 ]  Steptoe is also commemorated with a plaque at the Maternity Ward at the Royal Oldham Hospital, [ 15 ]  and at 52 West End, Witney. [ 16 ]


Steptoe is buried in Bourn, St Helena and St Mary Churchyard.


Steptoe, Edwards, and Purdy work was dramatised in Gareth Farr's 2024 play  A Child of Science , which premiered at  Bristol Old Vic ; Steptoe was portrayed by  Jamie Glover . [ 17 ]


In the 2024 biographical film  Joy , Steptoe is portrayed by  Bill Nighy . [ 18 ]


Carlos Sueldo  is a  physician  and  professor  of obstetrics and gynaecology ( OB/GYN ) for the  University of California, San Francisco . Dr. Sueldo is also the founder (1984) and present Director of the  in vitro fertilization  IVF Fertility Center. [ 1 ] [ 2 ]  Dr. Sueldo concurrently serves as the Scientific Director at the Center for Gynecology and Reproduction (CEGYR) in  Buenos Aires ,  Argentina , and is a founding board member of the World Endometriosis Research Foundation.


Dr. Carlos Sueldo was born and raised in Buenos Aires, Argentina, where he completed Medical School at the  University of Buenos Aires  (UBA) and graduated in 1970.  Dr. Sueldo completed an internship and residency in obstetrics and gynaecology in the department of OB/GYN at the  Chicago Medical School  in 1976. After two years as a junior faculty member in the same department, Professor Sueldo moved to California and joined the OB/GYN department at the University of California at San Francisco, as a clinical assistant, then associate, and as professor in 1994. He also completed a fellowship in reproductive endocrinology at the  University of Southern California  (1982–83).


As part of the American Society for Reproductive Medicine (ASRM), Dr. Sueldo is Chairman of The International Membership Committee, and Member of the International Advisory Committee. He is also a member of and frequent lead presenter and discussant at numerous other international reproductive societies, including the Argentine Society of Reproductive Medicine. Dr. Sueldo was also a lead researcher in developing the innovative virtual hysterosalpingography method, a non-invasive image-diagnostic procedure that offers valuable information as to the existence of causal anomalies of infertility.


Professor Carlos Sueldo is the recipient of numerous scientific awards and distinctions from around the world, and has also authored numerous articles in peer-reviewed reproductive medicine journals.


Virtus Health  is an Australian company, headquartered in  Sydney , that provides  assisted reproductive technology , specialist  pathology  and  day hospital  services. [ 1 ]  Today, Virtus is one of the top five providers of assisted reproductive services in the world with a presence in Australia, Singapore, Ireland, the UK and Denmark. [ 2 ]


The company operates seven specialist day hospitals across Queensland, NSW, Victoria and Tasmania, supporting procedures in fertility, IVF and gynaecology, plastic and cosmetic procedures, dentistry, ophthalmology, urology, orthopaedics and general surgery.


Virtus Diagnostics was established as a separate division in 2015 and offers general pathology services as well as specialist fertility and  genetic testing . [ 3 ]


Virtus Health completed a number of acquisition, including Canberra Fertility Centre in 2016, [ 4 ]  IDS Pathology in 2015, [ 5 ]  Rotunda IVF in 2015, [ 6 ]  TasIVF in 2014 [ 7 ]  IVF Sunshine Coast in 2014, [ 8 ]  and Sims IVF in 2014. [ 9 ]


Virtus Health listed on the  Australian Stock Exchange  in June 2013. On 4 August 2022 Virtus Health was de-listed from the ASX following its acquisition by private equity firm  BGH Capital . [ 10 ]


John Webster   FRCOG  (born 4 July 1936) is an English  obstetrician  and  gynaecologist . Present at the world's first  in vitro fertilisation  (IVF) birth,  Louise Brown , Webster has continued to develop and further research in the field of IVF.


Webster graduated from  University of Liverpool  in 1960, gaining an  MB ChB . From 1960 to 1963, he was a House Officer at  Clatterbridge Hospital  in Liverpool. From 1963 to 1964, he was the Senior House Officer to Mr  Patrick Steptoe . From 1964 to 1974, Webster practised in Canada. From 1974 to 1980, he was a specialist in obstetrics and gynaecology and infertility as  registrar  /  consultant  to Mr Patrick Steptoe at  Oldham General Hospital . It was during this time that Webster was involved with early pioneering research into  in vitro fertilization  with Patrick Steptoe and  Bob Edwards . He was also awarded his MRCOG during this period. [ 1 ]


Webster was present at the birth of  Louise Brown  (world's first IVF baby, born 25 July 1978) and assisted Patrick Steptoe with the delivery. [ 2 ]


In 1980, Webster was invited by Steptoe and Edwards to establish with them the world's first IVF clinic at  Bourn Hall . Webster served as Deputy Medical Director at Bourn Hall from 1980 to 1985. [ 1 ]


In 1985 Webster established an IVF Unit ( CARE Fertility ) at the Park Hospital in Nottingham, the sixth unit in the UK, and the first in the Midlands. He served there as a Medical Director from 1985 to July 2006. He was also present at the opening of the new purpose built building which houses CARE Fertility in Nottingham, and is named after him, John Webster House. [ 3 ]


In 1988 Webster was elected a Fellow of the  Royal College of Obstetricians and Gynaecologists .


Edwin Carlyle  " Carl "  Wood ,  AC   CBE   FRCS   ,  FRANZCOG  (28 May 1929 – 23 September 2011) was a prominent  Australian   gynaecologist , best known for his pioneering work developing and commercialising the technique of  in-vitro fertilisation  (IVF). [ 1 ]  He gained considerable international and national attention for his wide-ranging contributions in the field of women's health over a period of almost 50 years, although not all of it was positive given the controversial nature of many of his endeavours. [ 2 ]


After completing his education at  Wesley College ,  Melbourne , Wood graduated in medicine with honours at  Melbourne University  in 1952. He then held positions as Research Associate at the  Rockefeller Institute  in  New York , and Senior Lecturer in Obstetrics and Gynaecology at Queen Charlotte's and  Chelsea Hospital  for Women in  London  before becoming the Foundation Professor and Chairman of the  Monash University  Department of Obstetrics and Gynaecology at the  Queen Victoria Hospital  and  Monash Medical Centre  in 1964. [ 1 ]


Wood received international acclaim in the 1970s for his pioneering work in the fields of obstetric physiology and foetal monitoring as well as in  psychosomatic   obstetrics  and gynaecology,  birth control  and finally in  in-vitro fertilisation .  In 1988 he was recognised with the  Axel Munthe Award in Reproductive Science . [ 1 ]


Wood led the Monash University IVF team in the development of the IVF technique during the late 1970s and early 1980s. His team were responsible for a number of innovations including the world's first IVF pregnancy 1973, world's first IVF baby developed using a frozen embryo 1983, world's first donor egg baby 1983, world's first IVF baby using sperm retrieval surgery 1986 and world's first Microinjection Intra Fallopian Transfer (MIFT) IVF baby 1992. [ 3 ]  The most important development, however, was the use of pharmaceutical and hormonal stimulation of ovaries for more control of egg maturation and collection, which transformed IVF from an experimental technique to a successful clinical treatment. [ 4 ] [ better source needed ]


Wood held many wide-ranging positions while Chairman of Obstetrics and Gynaecology at  Monash University . These included, among others, Foundation Chairman Medical Advisory Committee, Family Planning Association of  Victoria  1970–72, Chairman  Artificial Insemination  by Donor (AID) Service, Melbourne Family Medical Centre, Monash University 1976–78, Foundation President of Victorian Association for the Study of  Sex Education , Research and Therapy 1982, and President, International Society for Gynaecologic Endoscopy 1997–98. He was Chairman and Director, In Vitro Fertilisation Program Melbourne Family Medical Centre Monash University 1978–86, where he carried out most of his pioneering work in this field.  He also jointly established the  Endometriosis  Care Clinic of Australia (ECCA) in 1998, a charitable foundation to assist Australian women suffering from this disease.


Wood was an invited speaker at over 90 national and international meetings, and wrote 23 books, 59 chapters and 400 papers in refereed medical and scientific journals.


The Carl Wood Endowment was established by the Monash University Department of Obstetrics and Gynaecology to provide funds for the research development of young clinicians.  More recently the Carl Wood Chair was established by the same department.


Wood has been called variously the  father , [ 1 ]   grandfather [ 5 ]  and godfather [ 6 ]  of IVF.


He died on 23 September 2011 after suffering from an  Alzheimer's -type dementia.


Abortion  is the termination of a  pregnancy  by removal or expulsion of an  embryo  or  fetus . [ nb 1 ] [ 2 ]  An abortion that occurs without intervention is known as a  miscarriage  or "spontaneous abortion"; these occur in approximately 30% to 40% of all pregnancies. [ 3 ] [ 4 ]  When deliberate steps are taken to end a pregnancy, it is called an  induced abortion , or less frequently "induced miscarriage". The unmodified word  abortion  generally refers to an induced abortion. [ 5 ] [ 6 ]  The most common reasons given for having an abortion are for birth-timing and limiting family size. [ 7 ] [ 8 ] [ 9 ]  Other reasons reported include  maternal health ,  an inability to afford a child ,  domestic violence , lack of support, feeling they are too young, wishing to complete education or advance a career, and not being able or willing to raise a child conceived as a result of  rape  or  incest . [ 7 ] [ 9 ] [ 10 ]


When done legally in industrialized societies, induced abortion is  one of the safest procedures in medicine . [ 11 ] :  1   [ 12 ]   Unsafe abortions —those performed by people lacking the necessary skills, or in inadequately resourced settings—are responsible for between 5–13% of  maternal deaths , especially in the  developing world . [ 13 ]  However,  medication abortions  that are  self-managed  are highly effective and safe throughout the  first trimester . [ 14 ] [ 15 ] [ 16 ]  Public health data show that making safe abortion legal and accessible reduces maternal deaths. [ 17 ] [ 18 ]


Modern methods use  medication  or  surgery  for abortions. [ 19 ]  The drug  mifepristone  (aka RU-486) in combination with  prostaglandin  appears to be as safe and effective as surgery during the  first  and  second trimesters  of pregnancy. [ 19 ] [ 20 ]  The most common surgical technique involves  dilating  the  cervix  and using a  suction device . [ 21 ]   Birth control , such as  the pill  or  intrauterine devices , can be used immediately following abortion. [ 20 ]  When performed legally and safely on a woman who desires it, an induced abortion does not increase the risk of long-term  mental  or physical problems. [ 22 ]  In contrast,  unsafe abortions  performed by unskilled individuals, with hazardous equipment, or in unsanitary facilities cause between 22,000 and 44,000 deaths and 6.9 million hospital admissions each year. [ 23 ]  The  World Health Organization  states that "access to legal, safe and comprehensive abortion care, including  post-abortion care , is essential for the attainment of the highest possible level of sexual and reproductive health". [ 24 ]   Historically , abortions have been attempted using  herbal medicines , sharp tools,  forceful massage , or other  traditional methods . [ 25 ]


Around 73 million abortions are performed each year in the world, [ 26 ]  with about 45% done unsafely. [ 27 ]  Abortion rates changed little between 2003 and 2008, [ 28 ]  before which they decreased for at least two decades as access to  family planning  and birth control increased. [ 29 ]  As of 2018 [update] , 37% of the world's women had access to legal abortions without limits as to reason. [ 30 ]  Countries that permit abortions have different limits on how late in pregnancy abortion is allowed. [ 31 ]  Abortion rates are similar between countries that restrict abortion and countries that broadly allow it, though this is partly because countries which restrict abortion tend to have higher  unintended pregnancy  rates. [ 32 ]


Globally, there has been a widespread trend towards greater legal access to abortion since 1973, [ 33 ]  but  there remains debate  with regard to moral, religious, ethical, and legal issues. [ 34 ] [ 35 ]  Those who  oppose abortion  often argue that an embryo or fetus is a person with a  right to life , and thus equate abortion with  murder . [ 36 ] [ 37 ]  Those who  support abortion's legality  often argue that it is a woman's  reproductive right . [ 38 ]  Others favor legal and accessible abortion as a public health measure. [ 39 ]   Abortion laws  and views of the procedure are different around the world. In some countries abortion is legal and women have the right to make the choice about abortion. [ 40 ]  In some areas, abortion is legal only in specific cases such as rape, incest,  fetal defects , poverty, and risk to a woman's health. [ 41 ]


An induced abortion is a medical procedure to end a pregnancy. [ 42 ]  In present-day English, the term  abortion , when used without further qualification, generally refers to induced abortion. [ 6 ]


A pregnancy can be intentionally aborted in several ways. The abortion method depends upon the  gestational age  of the embryo or fetus, which gains mass as the pregnancy progresses. [ 43 ] [ 44 ]   Abortion laws , regional availability, and the personal preference of the women and her doctor may inform the women's choice of a specific abortion procedure.


Abortions can be characterized as either therapeutic or elective. When an abortion is performed for medical reasons, the procedure is referred to as a therapeutic abortion. Medical reasons for therapeutic abortion include saving the life of the pregnant woman, preventing harm to the woman's  physical  or  mental health , preventing the birth of a child who will have a significantly increased chance of mortality or morbidity, and  reducing  the number of fetuses to lessen health risks associated with  multiple pregnancy . [ 45 ] [ 46 ]  An abortion is referred to as elective or voluntary when it is performed at the request of the woman for non-medical reasons. [ 46 ]  Confusion sometimes arises over the term  elective  because " elective surgery " generally refers to all scheduled surgery, whether medically necessary or not. [ 47 ]


About one in five pregnancies worldwide ends with an induced abortion. [ 28 ]  Most abortions result from unintended pregnancies. [ 7 ] [ 48 ]  In the United Kingdom, 1 to 2% of abortions are done because of genetic problems in the fetus. [ 22 ]


Miscarriage, also known as spontaneous abortion, is the unintentional expulsion of an embryo or fetus before the 24th  week of gestation . [ 49 ]  A pregnancy that ends before 37 weeks of gestation resulting in a  live-born  infant is a " premature birth " or a "preterm birth". [ 50 ]  When a fetus dies  in utero  after  viability , or during  delivery , it is usually termed " stillborn ". [ 51 ]   Premature births  and  stillbirths  are generally not considered to be miscarriages, although usage of these terms can sometimes overlap. [ 52 ]


Studies of pregnant women in the US and China have shown that between 40% and 60% of embryos do not progress to birth. [ 53 ] [ 54 ] [ 55 ]  The vast majority of miscarriages occur before the woman is  aware that she is pregnant , [ 46 ]  and many pregnancies spontaneously abort before medical practitioners can detect an embryo. [ 56 ]  Between 15% and 30% of known pregnancies end in clinically apparent miscarriage, depending upon the age and health of the pregnant woman. [ 57 ]  80% of these spontaneous abortions happen in the first trimester. [ 58 ]


The most common cause of spontaneous abortion during the first trimester is  chromosomal abnormalities  of the embryo or fetus, [ 46 ] [ 59 ]  accounting for at least 50% of sampled early pregnancy losses. [ 60 ]  Other causes include  vascular disease  (such as  lupus ),  diabetes , other  hormonal problems , infection, and abnormalities of the uterus. [ 59 ]  Advancing maternal age and a woman's history of previous spontaneous abortions are the two leading factors associated with a greater risk of spontaneous abortion. [ 60 ]  A spontaneous abortion can also be caused by accidental  trauma ; intentional trauma or stress to cause miscarriage is considered induced abortion or  feticide . [ 61 ]


Medical abortions are those induced by  abortifacient  pharmaceuticals. Medical abortion became an alternative method of abortion with the availability of  prostaglandin   analogs  in the 1970s and the  antiprogestogen   mifepristone  (also known as RU-486) in the 1980s. [ 20 ] [ 19 ] [ 62 ] [ 63 ]


The most common early first trimester medical abortion regimens use mifepristone in combination with  misoprostol  (or sometimes another prostaglandin analog,  gemeprost ) up to 10 weeks (70 days) gestational age, [ 64 ] [ 65 ]   methotrexate  in combination with a prostaglandin analog up to 7 weeks gestation, or a prostaglandin analog alone. [ 19 ]  Mifepristone–misoprostol combination regimens work faster and are more effective at later gestational ages than methotrexate–misoprostol combination regimens, and combination regimens are more effective than misoprostol alone, particularly in the second trimester. [ 62 ] [ 66 ]  Medical abortion regimens involving mifepristone followed by misoprostol in the cheek between 24 and 48 hours later are effective when performed before 70 days' gestation. [ 65 ] [ 64 ]


In very early abortions, up to 7 weeks  gestation , medical abortion using a mifepristone–misoprostol combination regimen is considered to be more effective than surgical abortion ( vacuum aspiration ), especially when clinical practice does not include detailed inspection of aspirated tissue. [ 67 ]  Early medical abortion regimens using mifepristone, followed 24–48 hours later by  buccal  or vaginal misoprostol are 98% effective up to 9 weeks gestational age; from 9 to 10 weeks efficacy decreases modestly to 94%. [ 64 ] [ 68 ]  If medical abortion fails, surgical abortion must be used to complete the procedure. [ 69 ]


Early medical abortions account for the majority of abortions before 9 weeks gestation in  Britain , [ 70 ]   France , [ 71 ]   Switzerland , [ 72 ]   United States , [ 73 ]  and the  Nordic countries . [ 74 ]


Medical abortion regimens using mifepristone in combination with a prostaglandin analog are the most common methods used for second trimester abortions in  Canada , most of Europe,  China  and  India , [ 63 ]  in contrast to the United States where 96% of second trimester abortions are performed surgically by  dilation and evacuation . [ 75 ]


A 2020  Cochrane Systematic Review  concluded that providing women with medications to take home to complete the second stage of the procedure for an early medical abortion results in an effective abortion. [ 76 ]  Further research is required to determine if self-administered medical abortion is as safe as provider-administered medical abortion, where a health care professional is present to help manage the medical abortion. [ 76 ]  Safely permitting women to self-administer abortion medication has the potential to improve access to abortion. [ 76 ]  The review also noted a research gap concerning methods to support women who take medication at home for a self-administered abortion. [ 76 ]


Up to 15 weeks' gestation,  suction-aspiration  or vacuum aspiration are the most common surgical methods of induced abortion. [ 77 ]   Manual vacuum aspiration  (MVA) consists of removing the  fetus  or  embryo ,  placenta , and membranes by suction using a manual syringe, while  electric vacuum aspiration  (EVA) uses an electric pump. Both techniques can be used very early in pregnancy. MVA can be used up to 14 weeks but is more often used earlier in the U.S. EVA can be used later. [ 75 ]


MVA, also known as "mini-suction" and " menstrual extraction ", or EVA can be used in very early pregnancy when cervical dilation may not be required.  Dilation and curettage  (D&C) refers to opening the cervix (dilation) and removing tissue (curettage) via suction or sharp instruments. D&C is a standard gynecological procedure performed for a variety of reasons, including examination of the uterine lining for possible malignancy, investigation of abnormal bleeding, and abortion. The  World Health Organization  recommends  sharp curettage  only when suction aspiration is unavailable. [ 78 ]


Dilation and evacuation  (D&E), used after 12 to 16 weeks, consists of opening the  cervix  and emptying the uterus using surgical instruments and suction. D&E is performed vaginally and does not require an incision.  Intact dilation and extraction  (D&X) refers to a variant of D&E sometimes used after 18 to 20 weeks when removal of an intact fetus improves surgical safety or for other reasons. [ 79 ]


Abortion may also be performed surgically by hysterotomy or gravid hysterectomy.  Hysterotomy abortion  is a procedure similar to a  caesarean section  and is performed under  general anesthesia . It requires a smaller incision than a caesarean section and can be used during later stages of pregnancy. Gravid hysterectomy refers to removal of the whole uterus while still containing the pregnancy. Hysterotomy and hysterectomy are associated with much higher rates of maternal morbidity and mortality than D&E or induction abortion. [ 80 ]


First trimester procedures can generally be performed using  local anesthesia , while second trimester methods may require  deep sedation  or  general anesthesia . [ 81 ] [ 82 ] [ 83 ]


In places lacking the necessary medical skill for dilation and extraction, or when preferred by practitioners, an abortion can be induced by first  inducing labor  and then  inducing fetal demise  if necessary. [ 84 ]  This is sometimes called "induced miscarriage". This procedure may be performed from 13 weeks gestation to the third trimester. Although it is very uncommon in the United States, more than 80% of induced abortions throughout the second trimester are labor-induced abortions in Sweden and other nearby countries. [ 85 ]


Only limited data are available comparing labor-induced abortion with the dilation and extraction method. [ 85 ]  Unlike D&E, labor-induced abortions after 18 weeks may be complicated by the occurrence of brief fetal survival, which may be legally characterized as live birth. For this reason, labor-induced abortion is legally risky in the United States. [ 85 ] [ 86 ]


Historically, a number of herbs reputed to possess abortifacient properties have been used in  folk medicine . Such herbs include  tansy ,  pennyroyal ,  black cohosh , and the now-extinct  silphium . [ 87 ] : 44–47, 62–63, 154–155, 230–231


In 1978, one woman in Colorado died and another developed organ damage when they attempted to terminate their pregnancies by taking pennyroyal oil. [ 88 ]
Because the indiscriminant use of herbs as abortifacients can cause serious—even lethal—side effects, such as  multiple organ failure , [ 89 ]  such use is not recommended by physicians.


Abortion is sometimes attempted by causing trauma to the abdomen. The degree of force, if severe, can cause serious internal injuries without necessarily succeeding in inducing  miscarriage . [ 90 ]  In Southeast Asia, there is an ancient tradition of attempting abortion through forceful abdominal massage. [ 91 ]  One of the  bas reliefs  decorating the temple of  Angkor Wat  in Cambodia depicts a demon performing such an abortion upon a woman who has been sent to the  underworld . [ 91 ]


Reported methods of unsafe,  self-induced abortion  include misuse of  misoprostol  and insertion of non-surgical implements such as knitting needles and  clothes hangers  into the uterus. These and other methods to terminate pregnancy may be called "induced miscarriage".  Such methods are rarely used in countries where surgical abortion is legal and available. [ 92 ]


The health risks of abortion depend principally on how, and under what conditions, the procedure is performed. The  World Health Organization  (WHO) defines  unsafe abortions  as those performed by unskilled individuals, with hazardous equipment, or in unsanitary facilities. [ 93 ]  Legal abortions performed in the  developed world  are among the safest procedures in medicine. [ 11 ] [ 94 ]  According to a 2012 study in  Obstetrics & Gynecology , in the United States the risk of maternal mortality is 14 times lower after induced abortion than after childbirth. [ 95 ]  The CDC estimated in 2019 that US pregnancy-related mortality was 17.2 maternal deaths per 100,000 live births, [ 96 ]  while the US abortion mortality rate was 0.43 maternal deaths per 100,000 procedures. [ 12 ] [ 97 ] [ 98 ]  In the UK, guidelines of the Royal College of Obstetricians and Gynaecologists state that "Women should be advised that abortion is generally safer than continuing a pregnancy to term." [ 99 ]  Worldwide, on average, abortion is safer than carrying a pregnancy to term. A 2007 study reported that "26% of all pregnancies worldwide are terminated by induced abortion," whereas "deaths from improperly performed [abortion] procedures constitute 13% of maternal mortality globally." [ 100 ]  In Indonesia in 2000 it was estimated that 2 million pregnancies ended in abortion, 4.5 million pregnancies were carried to term, and 14–16 percent of maternal deaths resulted from abortion. [ 101 ]


In the US from 2000 to 2009, abortion had a mortality rate lower than  plastic surgery , lower or similar to running a marathon, and about equivalent to traveling 760 miles (1,220 km) in a passenger car. [ 12 ]  Five years after seeking abortion services, women who gave birth after being denied an abortion reported worse health than women who had either first or second trimester abortions. [ 102 ]  The risk of abortion-related mortality increases with gestational age, but remains lower than that of childbirth. [ 103 ]  Outpatient abortion is as safe from 64 to 70 days' gestation as it before 63 days. [ 104 ]


There is little difference in terms of safety and efficacy between medical abortion using a combined regimen of mifepristone and misoprostol and surgical abortion (vacuum aspiration) in early first trimester abortions up to 10 weeks gestation. [ 67 ]  Medical abortion using the prostaglandin analog misoprostol alone is less effective and more painful than medical abortion using a combined regimen of mifepristone and misoprostol or surgical abortion. [ 105 ] [ 106 ]


Vacuum aspiration  in the first trimester is the safest method of surgical abortion, and can be performed in a  primary care office ,  abortion clinic , or hospital. Complications, which are rare, can include  uterine perforation ,  pelvic infection , and retained products of conception requiring a second procedure to evacuate. [ 107 ]  Infections account for one-third of abortion-related deaths in the United States. [ 108 ]  The rate of complications of vacuum aspiration abortion in the first trimester is similar regardless of whether the procedure is performed in a hospital, surgical center, or office. [ 109 ]  Preventive antibiotics (such as  doxycycline  or  metronidazole ) are typically given before abortion procedures, [ 110 ]  as they are believed to substantially reduce the risk of postoperative uterine infection; [ 81 ] [ 111 ]  however, antibiotics are not routinely given with abortion pills. [ 112 ]  The rate of failed procedures does not appear to vary significantly depending on whether the abortion is performed by a doctor or a  mid-level practitioner . [ 113 ]


Complications after second trimester abortion are similar to those after first trimester abortion, and depend somewhat on the method chosen. [ 114 ]  The risk of death from abortion approaches roughly half the risk of death from childbirth the farther along a woman is in pregnancy; from one in a million before 9 weeks gestation to nearly one in ten thousand at 21 weeks or more (as measured from the last menstrual period). [ 115 ] [ 116 ]  It appears that having had a prior surgical uterine evacuation (whether because of induced abortion or treatment of miscarriage) correlates with a small increase in the risk of preterm birth in future pregnancies. The studies supporting this did not control for factors not related to abortion or miscarriage, and hence the causes of this correlation have not been determined, although multiple possibilities have been suggested. [ 117 ] [ 118 ]


Current evidence finds no relationship between most induced abortions and  mental health problems [ 22 ] [ 119 ]  other than those expected for any unwanted pregnancy. [ 120 ]  A report by the  American Psychological Association  concluded that a woman's first abortion is not a threat to mental health when carried out in the first trimester, with such women no more likely to have mental-health problems than those carrying an unwanted pregnancy to term; the mental-health outcome of a woman's second or greater abortion is less certain. [ 120 ] [ 121 ]  Some older reviews concluded that abortion was associated with an increased risk of psychological problems; [ 122 ]  however, later reviews of the medical literature found that previous reviews did not use an appropriate control group. [ 119 ]  When a control group is utilized, receiving abortion is not associated with adverse psychological outcomes. [ 119 ]  However, women seeking abortion who are denied access to abortion have an increase in anxiety after the denial. [ 119 ]


Although some studies show negative mental-health outcomes in women who choose abortions after the first trimester because of fetal abnormalities, [ 123 ]  more rigorous research would be needed to show this conclusively. [ 124 ]  Some proposed negative psychological effects of abortion have been referred to by anti-abortion advocates as a separate condition called " post-abortion syndrome ", but this is not recognized by medical or psychological professionals in the United States. [ 125 ]


A 2020 long term-study among US women found that about 99% of women felt that they made the right decision five years after they had an abortion. Relief was the primary emotion with few women feeling sadness or guilt. Social stigma was a main factor predicting negative emotions and regret years later.  The researchers also stated: "These results add to the scientific evidence that emotions about an abortion are associated with personal and social context, and are not a product of the abortion procedure itself." [ 126 ]


Some purported risks of abortion are promoted primarily by anti-abortion groups, [ 127 ] [ 128 ]
but lack scientific support. [ 127 ]  For example, the question of a link between  induced abortion and breast cancer  has been investigated extensively. Major medical and scientific bodies (including the WHO,  National Cancer Institute ,  American Cancer Society ,  Royal College of OBGYN  and  American Congress of OBGYN ) have concluded that abortion does not cause breast cancer. [ 129 ]


In the past even illegality has not automatically meant that the abortions were unsafe. Referring to the U.S., historian  Linda Gordon  states: "In fact, illegal abortions in this country have an impressive safety record." [ 130 ] : 25


According to  Rickie Solinger ,


A related myth, promulgated by a broad spectrum of people concerned about abortion and public policy, is that before legalization abortionists were dirty and dangerous back-alley butchers.... [T]he historical evidence does not support such claims. [ 131 ] : 4


A 1940s American physician spoke of his pride in having performed 13,844 illegal abortions without any fatalities. [ 132 ]
In 1870s New York City, the abortionist/midwife  Madame Restell  (Anna Trow Lohman) is said to have lost very few women among her more than 100,000 patients [ 133 ] —a lower mortality rate than the childbirth mortality rate at the time. In 1936, obstetrics and gynecology professor   Frederick J. Taussig  wrote that a cause of increasing mortality during the years of illegality in the U.S. was that


With each decade of the past fifty years the actual and proportionate frequency of this accident [perforation of the uterus] has increased, due, first, to the increase in the number of instrumentally induced abortions; second, to the proportionate increase in abortions handled by doctors as against those handled by midwives; and, third, to the prevailing tendency to use instruments instead of the finger in emptying the uterus. [ 134 ]


Women seeking an abortion may use unsafe methods, especially when abortion is legally restricted. They may attempt  self-induced abortion  or seek the help of a person without proper medical training or facilities. This can lead to severe complications, such as incomplete abortion,  sepsis , hemorrhage, and damage to internal organs. [ 135 ]


Unsafe abortions are a major cause of injury and death among women worldwide. Although data are imprecise, it is estimated that approximately 20 million unsafe abortions are performed annually, with 97% taking place in  developing countries . [ 11 ]  Unsafe abortions are believed to result in millions of injuries. [ 11 ] [ 136 ]  Estimates of deaths vary according to methodology, and have ranged from 37,000 to 70,000 in the past decade; [ 11 ] [ 137 ] [ 138 ]  deaths from unsafe abortion account for around 13% of all  maternal deaths . [ 139 ]  The  World Health Organization  believes that mortality has fallen since the 1990s. [ 140 ]  To reduce the number of unsafe abortions, public health organizations have generally advocated emphasizing the legalization of abortion, training of medical personnel, and ensuring access to reproductive-health services. [ 141 ]


A major factor in whether abortions are performed safely or not is the legal standing of abortion. Countries with restrictive abortion laws have higher rates of unsafe abortion and similar overall abortion rates compared to countries where abortion is legal and available. [ 137 ] [ 28 ]  For example, the  1996 legalization of abortion in South Africa  led to an immediate reduction in abortion-related complications, [ 142 ]  with abortion-related deaths dropping by more than 90%. [ 143 ]  Similar reductions in maternal mortality have been observed after other countries have liberalized their abortion laws, such as  Romania  and  Nepal . [ 144 ]  A 2011 study concluded that in the United States, some state-level anti-abortion laws are correlated with lower rates of abortion in that state. [ 145 ]  The analysis, however, did not take into account travel to other states without such laws to obtain an abortion. [ 146 ]  In addition, a lack of access to effective contraception contributes to unsafe abortion. It has been estimated that the incidence of unsafe abortion could be reduced by up to 75% (from 20 million to 5 million annually) if modern family planning and maternal health services were readily available globally. [ 147 ]  Rates of such abortions may be difficult to measure because they can be reported variously as miscarriage, "induced miscarriage", "menstrual regulation", "mini-abortion", and "regulation of a delayed/suspended menstruation". [ 11 ] [ 148 ]


Forty percent of the world's women are able to access therapeutic and elective abortions within gestational limits, [ 31 ]  while an additional 35 percent have access to legal abortion if they meet certain physical, mental, or socioeconomic criteria. [ 41 ]  While  maternal mortality  seldom results from safe abortions, unsafe abortions result in 70,000 deaths and 5 million disabilities per year. [ 137 ]  Complications of unsafe abortion account for approximately an eighth of maternal mortalities worldwide, [ 149 ]  though this varies by region. [ 150 ]  Secondary infertility caused by an unsafe abortion affects an estimated 24 million women. [ 151 ]  The rate of unsafe abortions has increased from 44% to 49% between 1995 and 2008. [ 28 ]  Health education, access to family planning, and improvements in health care during and after abortion have been proposed to address consequences of unsafe abortion. [ 152 ]


There are two commonly used methods of measuring the incidence of abortion:


In many places, where abortion is illegal or carries a heavy social stigma, medical reporting of abortion is not reliable. [ 154 ]  For this reason, estimates of the incidence of abortion must be made without determining certainty related to  standard error . [ 28 ]  The number of abortions performed worldwide was characterized as stable in the early 2000s, with 41.6 million having been performed in 2003 and 43.8 million having been performed in 2008. [ 28 ]  The abortion rate worldwide was 28 per 1000 women per year, though it was 24 per 1000 women per year for developed countries and 29 per 1000 women per year for developing countries. [ 28 ]  The same 2012 study indicated that in 2008, the estimated abortion percentage of known pregnancies was at 21% worldwide, with 26% in developed countries and 20% in developing countries. [ 28 ]


On average, the incidence of abortion is similar in countries with restrictive abortion laws and those with more liberal access to abortion. [ 155 ]  Restrictive abortion laws are associated with increases in the percentage of abortions performed unsafely. [ 31 ] [ 156 ] [ 155 ]  The unsafe abortion rate in developing countries is partly attributable to lack of access to modern contraceptives; according to the  Guttmacher Institute , providing access to contraceptives would result in about 14.5 million fewer unsafe abortions and 38,000 fewer deaths from unsafe abortion annually worldwide. [ 157 ]


The rate of legal, induced abortion varies extensively worldwide. According to the report of employees of Guttmacher Institute it ranged from 7 per 1000 women per year (Germany and Switzerland) to 30 per 1000 women per year (Estonia) in countries with complete statistics in 2008. The proportion of pregnancies that ended in induced abortion ranged from about 10% (Israel, the Netherlands and Switzerland) to 30% (Estonia) in the same group, though it might be as high as 36% in Hungary and Romania, whose statistics were deemed incomplete. [ 158 ] [ 159 ]


An American study in 2002 concluded that about half of women having abortions were using a form of  contraception  at the time of becoming pregnant. Inconsistent use was reported by half of those using  condoms  and three-quarters of those using the  birth control pill ; 42% of those using condoms reported failure through slipping or breakage. [ 160 ]   Of the other half of women, who were not using contraception at the time of becoming pregnant, the vast majority had used contraception at some point in the past, indicating some level of dissatisfaction with the contraceptive options available to them.  Indeed, 32% of these contraceptive nonusers cited concerns about contraceptive methods as their reason for nonuse, [ 160 ]  and a more recent study found similar results. [ 161 ]   Taken together, these statistics suggest that new contraceptive methods, such as non-hormonal contraceptives or  male contraceptives , could reduce unintended pregnancy and abortion rates. [ 162 ]


The Guttmacher Institute has found that "most abortions in the United States are obtained by minority women" because minority women "have much higher rates of unintended pregnancy". [ 163 ]  In a 2022 analysis by the  Kaiser Family Foundation , while people of color comprise 44% of the population in Mississippi, 59% of the population in Texas, 42% of the population in Louisiana, and 35% of the population in Alabama, they comprise 80%, 74%, 72%, and 70%, respectively, of those receiving abortions. [ 164 ]


Abortion rates vary depending on the stage of pregnancy and the method practiced. In 2003, the  Centers for Disease Control and Prevention  (CDC) reported that 26% of reported legal induced abortions in the United States were known to have been obtained at the end of 6 weeks of gestation or less, 18% at 7 weeks, 15% at 8 weeks, 18% at 9 through 10 weeks, 10% at 11 through 12 weeks, 6% at 13 through 15 weeks, 4% at 16 through 20 weeks and 1% at more than 21 weeks. 91% of these were classified as having been done by " curettage " ( suction-aspiration ,  dilation and curettage ,  dilation and evacuation ), 8% by " medical " means ( mifepristone ), >1% by " intrauterine instillation " (saline or  prostaglandin ), and 1% by "other" (including  hysterotomy  and  hysterectomy ). [ 165 ]  According to the CDC, due to data collection difficulties the data must be viewed as tentative and some fetal deaths reported beyond 20 weeks may be natural deaths erroneously classified as abortions if the removal of the dead fetus is accomplished by the same procedure as an induced abortion. [ 9 ]


The Guttmacher Institute estimated there were 2,200  intact dilation and extraction  procedures in the US during 2000; this accounts for <0.2% of the total number of abortions performed that year. [ 166 ]  Similarly, in England and Wales in 2006, 89% of terminations occurred at or under 12 weeks, 9% between 13 and 19 weeks, and 2% at or over 20 weeks. 64% of those reported were by vacuum aspiration, 6% by D&E, and 30% were medical. [ 167 ]  There are more second trimester abortions in developing countries such as China, India and Vietnam than in developed countries. [ 168 ]


There are both medical and non-medical reasons to have an abortion later in pregnancy (after 20 weeks). A study was conducted from 2008 to 2010 at the University of California San Francisco where more than 440 women were asked about why they experienced delays in obtaining abortion care, if there were any. This study found that almost half of individuals who obtained an abortion after 20 weeks did not suspect that they were pregnant until later in their pregnancy. [ 169 ]  Other barriers to abortion care found in the study included lack of information about where to access an abortion, difficulties with transportation, lack of insurance coverage, and inability to pay for the abortion procedure. [ 169 ]


Medical reasons for seeking an abortion later in pregnancy include  fetal anomalies  and health risk to the pregnant person. [ 170 ]  There are prenatal tests that can diagnose  Down Syndrome  or  cystic fibrosis  as early as 10 weeks into gestation, but structural fetal anomalies are often detected much later in pregnancy. [ 169 ]  A proportion of structural fetal anomalies are lethal, which means that the fetus will almost certainly die before or shortly after birth. [ 169 ]  Life-threatening conditions may also develop later in pregnancy, such as  early severe preeclampsia , newly diagnosed cancer in need of urgent treatment, and  intrauterine infection (chorioamnionitis) , which often occurs along with  premature rupture of the amniotic sac (PPROM) . [ 169 ]  If serious medical conditions such as these arise before the fetus is viable, the person carrying the pregnancy may pursue an abortion to preserve their own health. [ 169 ]


The reasons why women have abortions are diverse and vary across the world. [ 9 ] [ 7 ] [ 8 ]  Some of the reasons may include an inability to afford a child, domestic violence, lack of support, feeling they are too young, and the wish to complete education or advance a career. [ 10 ]  Additional reasons include not being able or willing to raise a child conceived as a result of rape or incest. [ 7 ] [ 171 ]


Some abortions are undergone as the result of societal pressures. [ 172 ]  These might include the preference for children of a specific sex or race, disapproval of single or early motherhood, stigmatization of people with disabilities, insufficient economic support for families, lack of access to or rejection of contraceptive methods, or efforts toward  population control  (such as China's  one-child policy ). These factors can sometimes result in compulsory abortion or  sex-selective abortion . [ 173 ]  In cultures where there is a preference for male children, some women have sex selective abortions, which have partially replaced the earlier practice of female  infanticide . [ 173 ]


Some abortions are performed due to concerns over  maternal health . In 1990s, women cited maternal health as their main motivating factor in about a third of abortions in three of 27 countries analyzed. In seven additional countries, about 7% of abortions were maternal health related. [ 9 ] [ 7 ]


In the U.S., the Supreme Court decisions in  Roe v. Wade  and  Doe v. Bolton : "ruled that the state's interest in the life of the fetus became compelling only at the point of viability, defined as the point at which the fetus can survive independently of its mother. Even after the point of viability, the state cannot favor the life of the fetus over the life or health of the pregnant woman. Under the right of privacy, physicians must be free to use their "medical judgment for the preservation of the life or health of the mother." On the same day that the Court decided Roe, it also decided Doe v. Bolton, in which the Court defined health very broadly: "The medical judgment may be exercised in the light of all factors—physical, emotional, psychological, familial, and the woman's age—relevant to the well-being of the patient. All these factors may relate to health. This allows the attending physician the room he needs to make his best medical judgment." [ 174 ] : 1200–1201


The rate of cancer during pregnancy is 0.02–1%, and in many cases, cancer of the mother leads to consideration of abortion to protect the life of the mother, or in response to the potential damage that may occur to the fetus during treatment. This is particularly true for  cervical cancer , the most common type of which occurs in 1 of every 2,000–13,000 pregnancies, for which initiation of treatment "cannot co-exist with preservation of fetal life (unless  neoadjuvant chemotherapy  is chosen)". Very early stage cervical cancers (I and IIa) may be treated by  radical hysterectomy  and pelvic  lymph node  dissection,  radiation therapy , or both, while later stages are treated by radiotherapy. Chemotherapy may be used simultaneously. Treatment of breast cancer during pregnancy also involves fetal considerations, because  lumpectomy  is discouraged in favor of modified  radical mastectomy  unless late-term pregnancy allows follow-up radiation therapy to be administered after the birth. [ 175 ]


Exposure to a single chemotherapy drug is estimated to cause a 7.5–17% risk of  teratogenic  effects on the fetus, with higher risks for multiple drug treatments. Treatment with more than 40  Gy  of radiation usually causes spontaneous abortion. Exposure to much lower doses during the first trimester, especially 8 to 15 weeks of development, can cause  intellectual disability  or  microcephaly , and exposure at this or subsequent stages can cause reduced intrauterine growth and birth weight. Exposures above 0.005–0.025 Gy cause a dose-dependent reduction in  IQ . [ 175 ]  It is possible to greatly reduce exposure to radiation with abdominal shielding, depending on how far the area to be irradiated is from the fetus. [ 176 ] [ 177 ]


The process of birth itself may also put the mother at risk. According to Li  et al. , "[v]aginal delivery may result in dissemination of neoplastic cells into lymphovascular channels, haemorrhage, cervical laceration and implantation of malignant cells in the episiotomy site, while abdominal delivery may delay the initiation of non-surgical treatment." [ 178 ]


Congenital disorders , revealed by  prenatal screening , motivate some women to seek abortions. [ 7 ]   Health outcomes of preterm births  include a significant probability of long-term  neurodevelopmental impairment  before gestational age of 29 weeks, with a higher probability with decreasing gestational age. [ 179 ]


In the United States, public opinion shifted after television personality  Sherri Finkbine 's was exposed to  thalidomide , a  teratogen , in her fifth month of pregnancy. Unable to obtain a legal abortion in the United States, Finkbine traveled to Sweden. From 1962 to 1965, an outbreak of  German measles  left 15,000 babies with severe birth defects. In 1967, the  American Medical Association  publicly supported liberalization of abortion laws. A  National Opinion Research Center  poll in 1965 showed 73% supported abortion when the mother's life was at risk, 57% when birth defects were present and 59% for pregnancies resulting from rape or incest. [ 180 ]


Since  ancient times , abortions have been done using a number of methods, including  herbal medicines  acting as  abortifacients , sharp tools through the use of force, or through other  traditional medicine  methods. [ 25 ]  Induced abortion has a long history and can be traced back to civilizations as varied as ancient China (abortifacient knowledge is often attributed to the mythological ruler  Shennong ), [ 182 ]   ancient India  since its  Vedic age , [ 183 ]   ancient Egypt  with its  Ebers Papyrus  ( c.  1550 BCE ), and the Roman Empire in the time of  Juvenal  ( c.  200 CE ). [ 25 ]  One of the earliest known artistic representations of abortion is in a  bas relief  at Angkor Wat ( c.  1150 ). Found in a series of  friezes  that represent judgment after death in  Hindu  and  Buddhist  culture, it depicts the technique of abdominal abortion. [ 91 ]


In Judaism  (Genesis 2:7), the fetus is not considered to have a human soul until it is safely outside of the woman, is viable, and has taken its first breath. [ 184 ] [ 185 ] [ 186 ]  The fetus is considered valuable property of the woman and not a human life while in the womb (Exodus 21:22-23). While  Judaism  encourages people to  be fruitful and multiply  by having children, abortion is allowed and is deemed necessary when a pregnant woman's life is in danger. [ 187 ] [ 188 ]  Several religions, including Judaism, which disagree that  human life begins at conception , support the legality of abortion on  religious freedom  grounds. [ 189 ]   In Islam , abortion is traditionally permitted until a point in time when Muslims believe the soul enters the fetus, [ 25 ]  considered by various theologians to be at conception, 40 days after conception, 120 days after conception, or at  quickening . [ 190 ]  Abortion is largely heavily restricted or forbidden in areas of high  Islamic  faith such as the  Middle East and North Africa . [ 191 ]


Some medical scholars and abortion opponents have suggested that the  Hippocratic Oath  forbade physicians in  Ancient Greece  from performing abortions; [ 25 ]  other scholars disagree with this interpretation, [ 25 ]  and state that the medical texts of  Hippocratic Corpus  contain descriptions of abortive techniques right alongside the Oath. [ 192 ]  The physician  Scribonius Largus  wrote in 43 CE that the Hippocratic Oath prohibits  abortion , as did  Soranus of Ephesus , although apparently not all doctors adhered to it strictly at the time. According to Soranus' 1st or 2nd century CE work  Gynaecology , one party of medical practitioners banished all abortives as required by the Hippocratic Oath; the other party to which he belonged was willing to prescribe abortions only for the sake of the mother's health. [ 193 ] [ 194 ]  In  Politics  (350 BCE),  Aristotle  condemned infanticide as a means of population control. He preferred abortion in such cases, [ 195 ] [ 196 ]  with the restriction that it "must be practised on it before it has developed sensation and life; for the line between lawful and unlawful abortion will be marked by the fact of having sensation and being alive." [ 197 ]


In the  Catholic Church , opinion was divided on how serious abortion was in comparison with such acts as contraception and oral or anal sex. [ 198 ] : 155–167   The  Catholic Church  did not begin vigorously opposing abortion until the 19th century. [ 25 ] [ 189 ]  As early as ~100 CE, the  Didache  taught that abortion was sinful. [ 199 ]  Several historians argue that prior to the 19th century most Catholic authors did not regard termination of pregnancy before  quickening  or  ensoulment  as an abortion. [ 200 ] [ 201 ] [ 202 ]  Among these authors were the  Doctors of the Church , such as  St. Augustine ,  St. Thomas Aquinas , and  St. Alphonsus Liguori . In 1588,  Pope Sixtus V  ( r.    1585–1590) was the only Pope before  Pope Pius IX  (in his 1869  bull ,  Apostolicae Sedis ) to institute a Church policy labeling all abortion as homicide and condemning abortion regardless of the stage of pregnancy. [ 203 ] [ 198 ] : 362–364  [ 87 ] : 157–158   Sixtus V's pronouncement was reversed in 1591 by  Pope Gregory XIV . [ 204 ]  In the recodification of  1917 Code of Canon Law ,  Apostolicae Sedis  was strengthened, in part to remove a possible reading that excluded excommunication of the mother. [ 205 ]  Statements made in the  Catechism of the Catholic Church , the codified summary of the Church's teachings, considers abortion from the moment of conception as homicide and called for the end of legal abortion. [ 206 ]


Denominations that support abortion rights with some limits include the  United Methodist Church ,  Episcopal Church ,  Evangelical Lutheran Church in America  and  Presbyterian Church USA . [ 207 ]  A 2014 Guttmacher survey of abortion patients in the United States found that many reported a religious affiliation: 24% were Catholic while 30% were Protestant. [ 208 ]  A 1995 survey reported that Catholic women are as likely as the general population to terminate a pregnancy,  Protestants  are less likely to do so, and  evangelical Christians  are the least likely to do so. [ 9 ] [ 7 ]  A 2019  Pew Research Center  study found that most  Christian denominations  were against overturning  Roe v. Wade ,  which in the United States legalized abortion, at around 70%, except White Evangelicals at 35%. [ 209 ]


Abortion has been a fairly common practice, [ 211 ] [ 212 ]  and was not always illegal or controversial until the 19th century. [ 213 ] [ 214 ]  Under  common law , including early  English common law  dating back to  Edward Coke  in 1648, [ 215 ]  abortion was generally permitted before quickening (14–26 weeks after conception, or between the fourth and sixth month), [ 216 ] [ 217 ] [ 218 ]  and at women's discretion; [ 189 ]  it was whether abortion was performed after quickening that determined if it was a crime. [ 215 ]  In Europe and North America, abortion techniques advanced starting in the 17th century; the  conservatism  of most in the medical profession with regards to sexual matters prevented the wide expansion of abortion techniques. [ 25 ] [ 219 ] [ 220 ]  Other medical practitioners in addition to some physicians advertised their services, and they were not widely regulated until the 19th century when the practice, sometimes called  restellism , [ 221 ]  was banned in both the United States and the United Kingdom. [ 25 ] [ nb 2 ]


Some 19th-century physicians, one of the most famous and consequential being the American  Horatio Storer , [ 222 ]  argued for anti-abortion laws on  racist  and  misogynist  as well as moral grounds. [ 223 ] [ 224 ] [ 225 ]  Church groups were also highly influential in  anti-abortion movements , [ 25 ] [ 213 ] [ 223 ]  and religious groups more so since the 20th century. [ 222 ]  Some of the early  anti-abortion laws  punished only the doctor or abortionist, [ 189 ]  and while women could be criminally tried for a  self-induced abortion , [ 215 ]  they were rarely prosecuted in general. [ 213 ]  In the United States, some argued that abortion was more dangerous than childbirth until about 1930 when incremental improvements in abortion procedures relative to childbirth made abortion safer. [ nb 3 ]  Others maintain that in the 19th century early abortions under the hygienic conditions in which  midwives  usually worked were relatively safe. [ 226 ] [ 227 ] [ 228 ]  Several scholars argue that, despite improved medical procedures, the period from the 1930s until the 1970s saw more zealous enforcement of anti-abortion laws, alongside an increasing control of abortion providers by organized crime. [ nb 4 ]


In 1920,  Soviet Russia  became the first country to legalize abortion after  Lenin  insisted that no woman be forced to give birth. [ 229 ] [ 230 ]   Iceland  (1935) and  Sweden  (1938) would follow suit to legalize certain or all forms of abortion. [ 231 ]  In  Nazi Germany  (1935), a law permitted abortions for those deemed "hereditarily ill", while women considered of German stock were specifically prohibited from having abortions. [ 232 ]  Beginning in the second half of the 20th century, abortion was legalized in a greater number of countries. [ 25 ]  In  Japan , abortion was first legalized by the 1948 "Eugenics Protection Law" meant to prevent the births of "inferior" humans. As of 2022 [update] , due to Japan's continuing strongly patriarchal culture and traditional views on women's societal roles, women who want an abortion must normally get written permission from their partner. [ 233 ] [ 234 ]


Induced abortion has long been the source of considerable debate.  Ethical ,  moral ,  philosophical ,  biological ,  religious  and  legal  issues surrounding abortion are related to  value systems . Opinions of abortion may be about  fetal rights , governmental authority, and  women's rights .


In both public and private debate, arguments presented in favor of or against abortion access focus on either the moral permissibility of an induced abortion, or the justification of laws permitting or restricting abortion. [ 235 ]  The  World Medical Association  Declaration on Therapeutic Abortion notes, "circumstances bringing the interests of a mother into conflict with the interests of her unborn child create a dilemma and raise the question as to whether or not the pregnancy should be deliberately terminated." [ 236 ]  Abortion debates, especially pertaining to  abortion laws , are often spearheaded by groups advocating one of these two positions. Groups who favor greater legal restrictions on abortion, including complete prohibition, most often describe themselves as " pro-life " while groups who are against such legal restrictions describe themselves as " pro-choice ". [ 237 ]


Current laws pertaining to abortion are diverse. Religious, moral, and cultural factors continue to influence abortion laws throughout the world. The  right to life , the right to liberty, the right to  security of person , and the right to  reproductive health  are major issues of human rights that sometimes constitute the basis for the existence or absence of abortion laws.


In jurisdictions where abortion is legal, certain requirements must often be met before a woman may obtain a legal abortion (an abortion performed without the woman's consent is considered  feticide  and is generally illegal). These requirements usually depend on the age of the fetus, often using a  trimester -based system to regulate the window of legality, or as in the U.S., on a doctor's evaluation of the fetus'  viability . Some jurisdictions require a waiting period before the procedure, prescribe the distribution of information on  fetal development , or require that  parents be contacted  if their minor daughter requests an abortion. [ 238 ]  Other jurisdictions may require that a woman obtain the  consent of the fetus' father  before aborting the fetus, that abortion providers inform women of health risks of the procedure—sometimes including "risks" not supported by the medical literature—and that multiple medical authorities certify that the abortion is either medically or socially necessary. Many restrictions are waived in emergency situations. China, which has ended their [ 239 ]   one-child policy , and now has a three-child policy, [ 240 ]  has at times incorporated mandatory abortions as part of their population control strategy. [ 241 ]


Other jurisdictions ban abortion almost entirely. Many, but not all, of these allow legal abortions in a variety of circumstances. These circumstances vary based on jurisdiction, but may include whether the pregnancy is a result of rape or incest, the fetus' development is impaired, the woman's physical or mental well-being is endangered, or socioeconomic considerations make childbirth a hardship. [ 41 ]  In countries where abortion is banned entirely, such as  Nicaragua , medical authorities have recorded rises in maternal death directly and indirectly due to pregnancy as well as deaths due to doctors' fears of prosecution if they treat other gynecological emergencies. [ 242 ] [ 243 ]  Some countries, such as Bangladesh, that nominally ban abortion, may also support clinics that perform abortions under the guise of menstrual hygiene. [ 244 ]  This is also a terminology in traditional medicine. [ 245 ]  In places where abortion is illegal or carries heavy social stigma, pregnant women may engage in  medical tourism  and travel to countries where they can terminate their pregnancies. [ 246 ]  Women without the means to travel can resort to providers of illegal abortions or attempt to perform an abortion by themselves. [ 247 ]