Has vasectomy patient made teenager pregnant?
By 19 Angela has already had three first-trimester terminations but this time she is delighted to be pregnant. She has only just missed a period and has not yet broken the news to her parents or her partner. 'I'm with a really lovely man now,' she says. 'He's a bit older than me and he's so nice I can't believe he's stayed single. In fact, you know him. He's one of your patients.' She mentions his name, and you recognise it. You are not sure about whether he still lives with his wife and two children, but you do remember he had a vasectomy after the younger child was born three years ago.
Dr Nigel Lord
'The confidentiality issues on both sides here are complex'
Despite the revelations, to begin with I would deal with this normally. She is happily pregnant so I would congratulate her. I would discuss maintaining a healthy pregnancy, dealing with smoking, alcohol and dietary issues, including providing an 'Emma's diary'.
I would discuss antenatal care and refer her to the hospital-booking clinic. As a young mother-to-be, I would arrange for an early appointment with the community midwife. In view of the unusual circumstances I would confirm the pregnancy with a test, just in case there is an element of fiction here.
And fact versus fiction is the problem. It would be a dangerous and potentially damaging decision to believe everything she says is factually correct and then to act upon it as her moral guardian by discussing the matter with the man she names as the father. He may be innocent or guilty in this matter but I am not the judge of that. They may or may not be in a relationship.
He may or may not be the father. They may or may not know each other. They may or may not have had a previous relationship. If they did, it may have finished amicably or acrimoniously. The possible explanations of her revelations are numerous, and vary from her naming him being a symptom of erotomania to him having had a vasectomy reversal so as to father a child with Angela before leaving his wife and family. The only thing I am certain about is that I am certain about nothing. The confidentiality issues on both sides are also complex.
I would tread carefully and wait for things to develop, providing necessary support when called upon. Despite three terminations while young and the associated possibility that she may be socially or educationally disadvantaged, she is an adult and, to my previous knowledge, of sound mind.
She has to come to her own decisions. I would discuss her with colleagues and the community midwife. Some emotional or psychological crisis is inevitably going to need dealing with in the future but until then I cannot interfere. It will be an interesting nine months or so.
Dr Rachel Pryke
'As for his wife, I am in no position to go poking my oar in'
From the demographics of our practice area I suspect this scenario is not unusual, but I am not one to remember patients well, and before I leapt to any conclusions I would double check if it was the same chap we were both thinking of. With a list of 14,000 patients I could easily be wrong.
The scenario raises various moral issues but in real life I'm not sure there would be any dilemma at all. Confidentiality forbids me to discuss his details with anyone, including both this new partner and his wife. In the unlikely event that he should come in alone, I don't know how I would broach his fertility out of the blue. As for his wife, I am again in no position to go poking my oar in. If I was aware of one of the parties having a sexually transmitted disease then my position would be trickier, but this is not the case.
As he appears to be still fertile I could check up whether his postoperative semen analysis had been performed. If not done, then I might be able to concoct a plausible story about audits showing his had not been done. But he will probably be discovering this without my help as his girlfriend breaks the happy news.
I would broaden the discussion with Angela to explore how she would feel if this new relationship broke down as so many do and help her ponder on how she would feel about parenthood as a single mum. After three terminations she may feel determined to go ahead with this pregnancy whatever her circumstances.
I would steel myself for the ensuing consultation when the boyfriend marches her in to seek another termination. It is entirely her choice not his whether she continues her pregnancy.
Dr Michael Crawford
'I'd expect a call from Angela's partner about semen analysis'
Difficult times lie ahead for Angela. She is delighted to be pregnant to her new partner, whom she obviously trusts implicitly. Unfortunately she must surmount a multiplicity of problems: a married partner, and presumably a partner who is sterile and an unsuspecting father of the fetus.
Just because Angela and her partner are my patients does not mean I have any right to break confidentiality.
At this stage it is unlikely that serious harm will come to either party and an untimely intervention by myself would be wholly inappropriate. I would be thinking to myself how shortsighted Angela's partner must be to have admitted to being a patient of mine as I would be fully aware of his background both family and medical, though he may also be aware of the constraints of confidentiality.
With a vasectomy failure rate in the order of 1:2,000 it seems likely the father of the child is not the person Angela believes it to be. I would want to confirm Angela's pregnancy, calculate expected date of confinement and check fundal height if palpable to confirm or refute dates.
As part of a sexual history I would inquire of Angela if she has had any other partners over the past few months and ask her to consider if they could be the father. If she denies this then I would have no option other than to accept her word.
I would be advising her to inform her partner as soon as possible and arrange a review appointment for a week in advance to check all was going well and to discuss antenatal options with both of them.
I think, too, I could expect a phone call from Angela's partner requesting a further semen analysis which would also be dealt with confidentially.