Language of ART

The specific language of ART medicine
Terminology impacts gestational carrier contract provisions

Compiled by Margaret E. Swain, RN, JD, Director of AAARTA

There are numerous medical terms and procedures that are important for ART attorneys to understand. These are sometimes listed under a “definitions” section of the contract, or included or detailed as triggers for payment or reimbursement. When writing the definitions to be used in interpreting the provisions of the agreement, the drafter can select what s/he wants the words to mean within the context of the contract. However, keeping those definitions aligned with the universally accepted meanings will assist in unambiguous contract interpretation and general understanding of the terms.

The below glossary is not inclusive of every term, but will provide general guidance for the lawyer.

• Abortion: the premature exit of the products of conception (the fetus, fetal membranes and placenta) from the uterus. A spontaneous abortion is the same as a miscarriage. A pregnancy termination or induced abortion is the process of intentionally ending a pregnancy, usually through a surgical procedure (very early pregnancies may be ended through “medical abortion”, meaning the administration of a chemical agent that causes the contents of the uterus to be expelled). 

• Amniocentesis: a procedure in which amniotic fluid is removed from the uterus for testing and sometimes for treatment. The amniotic fluid (contained in the sac surrounding the fetus) contains cells and tissue from the fetus that can reveal the presence of genetic abnormalities and open neural tube defects. It is also used to test for lung maturity if a premature delivery is anticipated. During the procedure, under ultrasound guidance, a long needle is passed through the woman’s abdominal wall and into the amniotic sac. A small amount of fluid is withdrawn and sent to a lab for analysis. The test may be performed between 15 and 20 weeks of gestation. It is often used as a follow-up to less specific diagnostic tests that have indicated a possible issue with the fetus. The risk of miscarriage is about 0.7%.

• Bedrest: varying degrees of activity restriction sometimes recommended as a safeguard against pre-term delivery or other complications during pregnancy. Prescribed rest increases blood flow to the placenta and may slightly increase a baby’s birth weight. Bedrest is a spectrum, meaning anything from decreasing activity (no lifting or strenuous exercise), to remaining in a sitting or reclining position (only getting up for the bathroom), to total bedrest, meaning lying on the side (usually the left side) at all times, even when eating. Total bedrest may require hospitalization.

• Cell-free DNA test (eg., MaterniT21 PLUS): A non-invasive blood test to screen for (not diagnose) fetal aneuploidy. The test targets fetal cells circulating in the pregnant woman’s blood, and screens for trisomy 21, 18 and 13 and other abnormalities. ACOG recommends that follow-up pre-natal diagnostics be done to confirm test results (mostly, to evaluate positive results and to identify false positives).

• Cerclage placement: the surgeon inserts a stitch at the cervicovaginal junction, to prevent the premature opening of the uterine cervix. This procedure to used to manage cervical insufficiency in certain cases, and if indicated, is usually performed in the second trimester. 

• Cesarean delivery: (also referred to as a surgical birth, Cesarean-section or C-section the delivery of a baby through incisions in the woman’s abdomen and uterus). This type of delivery requires more recovery time than a vaginal birth, and carries with it the same potential complications as any other major surgery

• Chorionic villi sampling (chorionic villus sampling): a prenatal test in which a sample of chorionic villi is removed from the placenta. Under ultrasound guidance, the doctor will either use a long, thin needle inserted through the abdominal wall to access the placental tissue, or will insert a catheter through the cervix into the uterus and the placenta. The extracted tissue is then sent to a lab for analysis. This test may be performed between 10-13 weeks of pregnancy. Risk of miscarriage is small, approximately the same as amniocentesis, about 0.7%.

• D&C: Dilation and curettage is a procedure to remove tissue from inside the uterus after a first-trimester miscarriage, to gather tissue for diagnosis or to treat heavy bleeding. Dilation refers to the opening of the cervix and curettage refers to the mechanical removal of the tissue.

• D&E: Dilation and evacuation is an abortion done in the second trimester of pregnancy. It is generally a combination of vacuum aspiration and D&C, possibly assisted by using additional surgical instruments, such as forceps, and is typically to extract an expired fetus.

• Ectopic pregnancy: when a fertilized egg implants somewhere other than the main cavity of the uterus. They most often occur in one of the fallopian tubes (a tubal pregnancy), but can occur elsewhere, such as in the abdominal cavity, on the ovary or the cervix. The growing tissue might destroy the structure on, or in, which it is growing, or adjacent organs or tissue, and if left untreated, it may rupture and cause life-threatening blood loss. Although in very rare circumstances an abdominal cavity ectopic pregnancy might produce a live birth, these situations present grave risks for the mother and fetus. Ectopic pregnancies are serious medical emergencies and should be immediately addressed.

• Hysteroscopy: a hysteroscope (a thin, lighted tube) is inserted transvaginally into the uterus, so the clinician can examine the uterus and cervix. Carbon dioxide or saline is introduced into the uterine cavity to expand it and clear any blood or mucous for better visualization. The hysteroscope can be used diagnostically (to confirm results from other tests), or operatively, to treat conditions such as uterine polyps, adhesions and bleeding.

• Loss of a fallopian tube: the fallopian tube transports the unfertilized egg from the ovary, provides a place where fertilization may occur and then carries the fertilized egg to the uterus for implantation. In a woman with normal anatomy, each ovary is partnered with a fallopian tube. Losing a fallopian tube that is associated with a normally-functioning ovary means that eggs that are ovulated from that ovary about every other month will not be available for regular conception.

• Loss of an ovary: ovulation normally alternates between the two ovaries. When one is absent, the other takes over its function, and ovulation still occurs each month. It is theorized that women with one ovary may be more likely to have premature ovarian failure or experience menopause sooner than those with two functioning ovaries. 

• Loss of one ovary and one fallopian tube; the remaining ovary, if there is one, will take over the ovulation function, so the same issues as described in loss of ovary (above) will apply. 

• Loss of both ovaries and both fallopian tubes: there will be no eggs available for either natural or assisted reproduction. Loss of both ovaries in a premenopausal woman triggers “surgical” menopause. 

• Loss of uterus: alone, does not affect egg production or ovulation, but with no uterus, a woman is unable to gestate a pregnancy. If the ovaries are present, eggs may be surgically retrieved for use in ART.

• Multi-fetal pregnancy reduction (sometimes called selective fetal reduction): a procedure to reduce the number of fetuses in a multiple pregnancy, the goal of which is to optimize the chance of a healthy, successful, full-term pregnancy. The most common method of fetal reduction is ultrasonically-guided, transabdominal passage of a needle and injection of potassium chloride into the fetus, which stops the fetal heart. This is done during the first trimester and the fetus, which is quite small at that time, is absorbed by the woman’s body.

• Total hysterectomy: removal of the uterus and the cervix. A total hysterectomy with salpingo-oophorectomy is the removal of the uterus, cervix, fallopian tubes and ovaries.

• Uterine extraction: a minimally invasive removal of the uterus through a small abdominal incision and under laproscopic visualization. Specifically, the uterus is grasped, extracted from the abdominal cavity, dissected from the cervical stump while outside the body, and removed. 

• Weeks gestational age (or “weeks of pregnancy”) by medical definition, is determined by counting the first day of last menstrual period as Day 1 of pregnancy. This is distinguished from "weeks post-embryo transfer". There is about a two week difference between the two, so it is important to define exactly which determinant is being used when describing payment triggers.