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(NEW YORK) — Health care groups and advocates have long warned that the overturn of Roe v. Wade could pose wider threats to reproductive healthcare and that anti-abortion groups’ attacks on reproductive freedoms would not stop at abortion care.

Those warnings materialized earlier this year when in vitro fertilization care was suspended at three of Alabama’s largest providers after a state Supreme Court decision put providers at risk of prosecution.

Now, physicians and experts warn the same could happen in other states with fetal personhood laws.

Further moves by conservative groups and lawmakers have also signaled what other reproductive freedoms could be at risk.

Fetal personhood and IVF

Fetal personhood laws, which classify fetuses, embryos or fertilized eggs as “people” could significantly undermine IVF patients’ ability to make decisions about their care, including what to do with frozen embryos, according to the Center for Reproductive Rights.

“In the IVF context, embryo personhood would be extremely harmful to patients and providers, who could be criminalized, for example, for discarding an embryo or for transferring an embryo that then does not implant,” Karla Torres, senior counsel at the Center for Reproductive Rights, told ABC News in an interview.

Fertility specialists suspended care in Alabama after the state Supreme Court issued a decision saying embryos are children, raising concerns that IVF specialists could face wrongful death lawsuits over handling of embryos. One facility said they even suspended the transfer of embryos to facilities in other states amid the confusion caused by the decision.

The ruling from the court came as part of a lawsuit filed by couples whose embryos were destroyed after a patient wandered into a fertility clinic through an unsecured door, removing several embryos and dropping them to the floor. The couples whose embryos were destroyed filed a wrongful death suit that was thrown out by a lower court that ruled embryos are not people.

The Alabama Supreme Court then reversed the lower court decision and said frozen embryos are children. After facing intense backlash, lawmakers passed legislation that would protect IVF care in the state, allowing care to resume.

“The bill, though, did not address the central finding in the seat Supreme Court’s ruling, which is that cryopreserved embryos constitute ‘unborn children’ under the state’s Wrongful Death Act,” Torres said.

There are currently 11 states with broad fetal personhood laws on the books which could impact IVF treatments, according to Pregnancy Justice, a nonprofit organization that advocates for pregnant people.

An additional five states define a person to include a fetus throughout their criminal code and two more states — Alaska and Wyoming — define an “unborn child” as a human “at any stage of development,” according to Pregnancy Justice.

“The legal question is: at what point should a citizen be protected? And where I take issue with the Alabama ruling, is that they utilize their religious beliefs that life begins at fertilization. And that crossed a line, which shouldn’t be crossed due to the alleged separation of church and state, that they now are saying that life gets protected,” Dr. Eve Feinberg, a physician and fertility specialist at Northwestern University in Illinois, told ABC News.

“It’s very dangerous for the provision of safe fertility care and I think it’s very dangerous from a litigation standpoint, in the numerous instances where pregnancies may end through no fault or embryos may stop growing through no fault,” Feinberg said.

Less than half of oocytes — cells from ovaries — retrieved in a single IVF cycle become an embryo that could become viable.

“[Most] of everything that you start with stops growing and developing in IVF and that’s just in the laboratory,” Feinberg said.

Between 20 to 50% of embryos implanted stop growing after they are implanted, Feinberg said.

After patients are done with IVF, some choose to donate unused embryos left over from IVF to science. A key part of how the fertility field has advanced is research on human embryos, according to Feinberg.

Surrogacy

Fertility patients who grow their families with the help of a gestational carrier, or surrogate, often do not live in the same state as the surrogate, but one fertility specialist told ABC News the overturn of Roe has changed how patients feel.

“We have had patients who have gestational carriers who live in Texas or other red states, and it really makes them question whether they feel comfortable having somebody in one of those states carry their child,” Feinberg said.

“I’ve had a number of patients who have turned down really otherwise good candidates to be a gestational carrier because the GC lives in an unfavorable state,” Feinberg said.

Intended parents who turned down surrogates in other states are concerned about not wanting to continue a pregnancy with a fatal fetal anomaly incompatible with life or the surrogate facing potential obstetric complications, like their water breaking before the fetus is viable, Feinberg said.

“Intended parents just don’t want to be in a situation where the medical care of the person carrying their pregnancy is compromised. Texas laws are putting women at risk of death period,” Feinberg said.

The usage of surrogates has increased in recent years due to several factors, including high cancer survivorship, which may leave survivors unable to carry a pregnancy; the number of cesarean section deliveries having “skyrocketed,” bringing an increased risk of postpartum hemorrhage and hysterectomies; and women surviving conditions, like congenital heart defects that were corrected as babies, that leave them unable to carry their own pregnancies, Feinberg said.

Patients, who are more commonly using surrogacy, never thought twice about what state a potential carrier lived in before Roe was overturned, Feinberg said.

“It’s driving up the cost of surrogacy, it is further diminishing the pool of available surrogates, and … women who sign up to be surrogates — they may be risking their lives in ways that they never thought about previously,” Feinberg said.

Contraception

Indiana lawmakers recently passed new legislation that would require hospitals to offer postpartum patients with long acting reversible contraceptives.

“The bill author ended up getting advice from [anti-abortion group] Right to Life that they should remove IUDs specifically from the bill because Right to Life considers IUDs to be abortifacients[, causing abortions]. So the bill was represented in its amended form to only specifically include subdermal implants,” Dr. Carrie Rouse, a maternal fetal medicine specialist in Indiana, told ABC News in an interview.

“It creates this two-tiered approach to contraception where implants are good and IUDs are bad IUDs cause abortion, which is absolutely not true, but it sets the precedent,” Rouse said.

An IUD is birth control placed in the uterus while a contraceptive implant is placed in the arm.

Lessons to learn from

Feinberg pointed to strict laws that used to regulate IVF care in Italy — mandating that only three eggs be fertilized in a single IVF cycle and that everything that is fertilized has to be transferred — as a cautionary tale for lawmakers in the U.S.

“IVF success rates were very low and the multiple pregnancy rate particularly that triplet rate was very high — unacceptably high,” Feinberg said.

This led to very high risk pregnancies and many children being born premature or with congenital anomalies, Feinberg said.

“Ultimately, the government said, Okay, we’re not going to interfere. And they, they lifted the bans on how IVF was mandated to be practiced. I think what’s very scary, is we are now potentially moving towards that,” Feinberg said.

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(NEW YORK) — Francesca McGinn, a 16-year-old high school student from Chicago, struggled with her weight nearly her entire life.

It wasn’t until late last year, after seeing a family member have success taking a medication for weight loss, that Francesca said she thought there could be a different way for herself.

In her first appointment with a doctor who specializes in pediatric weight management, Francesca said she was told for the first time in her life that she was not to blame for her weight issues.

Following her appointment, Francesca began to take Wegovy, an injectable medication that is U.S. Food and Drug Administration-approved for weight loss for patients with severe obesity, or who are overweight and have one or more weight-associated conditions like high blood pressure or high cholesterol.

In 2022, the FDA also approved Wegovy as a treatment for teenagers with obesity.

Since starting the medication, Francesca said she has both lost weight and changed the way she thinks about herself and her body.

“It lifted off a weight of just stress of constantly thinking of what I need to stop eating and what I need to start eating,” she told ABC News’ Good Morning America. “In fifth grade, I started worrying about what I was eating, and there were some points where I thought about not eating … This medicine really changed my thinking.”

Over the past several years, medications that can lead to weight loss, from Wegovy to Zepbound, Ozempic and Mounjaro, have changed the landscape of obesity medicine, from how weight loss is treated medically to how the public perceives thought about obesity.

As the drugs have become more widely available and skyrocketed in popularity, a rising number of teenagers, specifically teenage girls, like Francesca, have tapped into their use.

Among the young people being prescribed GLP-1 medications, an overwhelming majority, 60%, are female, according to data published in May in the Journal of the American Medical Association.

Among all young people, the number of prescriptions for GLP-1 weight loss medications rose from 8,000 to more than 60,000 between 2020 and 2023.

Why more girls than boys are on weight loss medications than boys

Pediatric endocrinologists from across the country who spoke with GMA said the reasons why more girls are prescribed medications for weight loss are varied.

Sophia, a 17-year-old from Colorado, said she started taking weight loss medications last year to help treat polycystic ovary syndrome, or PCOS, a reproductive hormone imbalance that can cause problems with the menstrual cycle and lead to the formation of multiple ovarian cysts and infertility, according to the U.S. Office on Women’s Health.

After going on a medication used for weight loss, Sophia, who asked that her last name not be used, said she has lost around 80 pounds in total.

“It was like a light at the end of the tunnel,” Sophia said. “It’s given me a new life. I have a lot more confidence. I feel a lot better. My mood is a lot better … I don’t feel the struggle.”

The fact that girls battle hormonal and insulin-related conditions like PCOS, which the medications are proving to be able to treat, is one reason they are being prescribed more, according to Dr. Melanie Cree, Sophia’s doctor and a pediatric endocrinologist at Children’s Hospital Colorado.

The exact cause of PCOS is unknown, but people with this condition have higher levels of androgens, such as testosterone, and insulin resistance, which is a risk factor for Type 2 diabetes.

Both Ozempic and Mounjaro are approved by the U.S. Food and Drug Administration to treat Type 2 diabetes, but some doctors prescribe the medication “off-label” for weight loss, as is permissible by the FDA.

Like Wegovy, Zepbound is FDA-approved as a weight loss management treatment for people with obesity, or those who are overweight with at least one related underlying condition, such as high blood pressure. Both Zepbound and Mounjaro contain the same active ingredient, tirzepatide, while Ozempic and Wegovy both contain a different active ingredient, semaglutide.

“When girls have PCOS and extra weight, they have a much higher risk for type 2 diabetes, they have insulin resistance, extra fat and inflammation in their liver, higher rates of depression and really seem to struggle,” said Cree, who is currently leading a research study on the impact of GLP-1 drugs on young women with PCOS. “We’ve really seen how, how much weight loss makes a difference in this patient population, and how badly these patients are struggling.”

Young girls are particularly at risk for complications from obesity and type 2 diabetes, according to experts including Dr. Caren Mangarelli, a pediatrician who works with the Lurie Children’s Hospital’s Pediatric Wellness & Weight Management Program, citing data showing among the growing number of young people with Type 2 diabetes, the majority are female.

“We’re seeing younger and younger kids with disease processes that we think of as adult diseases,” Mangarelli said. “And most young adults and adolescents who have type 2 diabetes also have obesity. They usually come together.”

Doctors say they are willing to put teenagers on medications for weight loss because they know the long-term damage that can come from having type 2 diabetes in childhood.

“We know that youth-onset, type 2 diabetes is more aggressive than adult-onset. It is more progressive, so it actually goes from being a mild disease to a moderate disease to a severe disease quicker,” said Dr. Alaina Vidmar, a pediatric endocrinologist and pediatric obesity medicine specialist and Medical Director of the Healthy Weight Clinic at Children’s Hospital Los Angeles. “And we know that the long-term complications occur much earlier if you are diagnosed before the age of 18 than if you are diagnosed later in life.”

She continued, “So if we can do something early to prevent all of that from happening, we are ultimately setting up that young person for a much healthier life.”

Type 2 diabetes, caused by the body not using or making insulin well, increases a child’s risk of everything from eye disease and nerve problems to heart disease and stroke and kidney disease, according to the National Library of Medicine.

Mangarelli said while it may seem alarming to people that such a growing number of teenagers are using medications for weight loss, she believes the medications are only reaching a small percentage of teens in need.

Nearly 20%, or around 14.7 million children and adolescents ages 2 to 19 in the U.S. are considered obese, according to the CDC.

“I would argue that in real life, these numbers are so, so small in terms of the amount of patients who could potentially benefit from the drug, whether for type 2 diabetes and/or obesity,” Mangarelli said. “If you look at the actual numbers, it’s such a small number of patients on the drugs.”

One obstacle to young people accessing the medications is that not all private insurance plans or state Medicaid plans cover the medications, according to Mangarelli. Out of pocket costs for the drugs can run as high as over $1,000 per month.

Another obstacle is that some doctors remain hesitant to prescribe the medications for teens.

The U.S. Preventive Services Task Force, an influential medical group whose policies often guide insurance coverage, chose not to recommend weight loss medications for children in newly-released guidelines for treating obesity, saying there is not enough long-term data to recommend the medications. Instead, the Task Force recommended that children over the age of 6 with obesity should be referred to intensive lifestyle programs by their doctors for treatment.

The American Academy of Pediatrics, on the other hand, recommends the integration of prescription weight-loss medications for children 12 and older as part of a comprehensive treatment plan for children with obesity.

In its guidelines, the AAP says doctors need to weigh the medications’ “indications, risks, and benefits.”

Among all medications used for weight loss, the most commonly reported side effects are nausea and constipation, but irreversible gallbladder and pancreatic disease are also reported. Makers of these drugs recommend having a conversation about the side effect profile and personalized risks with a healthcare professional before starting.

Girls, body image and weight loss medications

An unsurprising factor also likely fueling the different number of girls than boys on weight loss medications, doctors say, is the reality that young girls tend to feel the pressure of society’s standards of beauty — i.e. thinness — more than boys, a sentiment echoed by both Sophia and Francesca.

“High school is hard, and being a girl is hard,” Sophia said, adding of the impact of losing weight, “Just feeling better in my own body has made a big difference.”

“Something I’ve done since middle school is compare myself to all the other girls that I see and wondering, why can’t I be like that,” Francesca said, adding of the data showing more girls than boys are on GLP-1 drugs, “I’m not very surprised.”

Mangarelli, who works at Lurie Children’s Hospital, where Francesca was treated, said she tries to strike a balance in her practice between body acceptance with young female patients and the reality that weight loss can improve a child’s health both in the short and long term.

“Unfortunately, I do believe that that females experience more stigma and discrimination of bias, specifically, than males do, according to body size,” Mangarelli said, adding, “So we need to both promote healthy at every size, self-love, self-acceptance, at the same time as we look for more effective treatments and use effective treatments to help our patients.”

Mangarelli and the other doctors GMA spoke with all said that a large part of their time with pediatric patients is spent educating both them and their parents that weight struggles are not the child’s fault, the same message that Francesca said was life-changing when she first heard it from her doctor.

“We start all of our visits by level-setting,” said Vidmar. “I start by saying that living in a larger body is not anyone’s fault, it is how they were made. And that it is probably very likely that they have been made to believe or told on multiple occasions, unfortunately, by multiple people that that is something that they are doing wrong, or a failure of their self-will or self-discipline, which is just not correct or accurate or scientifically-founded.”

Vidmar said another part of her message to kids and parents alike is that obesity is a chronic condition and should not be treated any differently when it comes to considering different treatment options, like medications.

“There’s a lot of chronic diseases in pediatrics and we do lots of different things to control them,” she said, citing asthma as an example of one. “Pediatric obesity is no different. It’s a complex, chronic disease that has multiple tools and each individual person is going to need to find what tool kit they need to control that for their whole life.”

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(NEW YORK) — Facing high fines and potential jail time for providing abortions, Dr. Jennifer Smith, an OB-GYN in Missouri, has had to refer patients out of state.

“I’ve had a patient bleeding through her clothes in the second trimester who had to drive to Illinois for care, because in Missouri, we couldn’t prioritize her life over the life of her fetus,” Smith told reporters during a press conference last week.

The facility where Smith works once brought in patients from across state borders, but now has to do the opposite.

“I had a patient in the second trimester who did have ruptured membranes, but in Missouri, the law does not give us permission to deliver this patient as long as the baby has a heartbeat,” she said.

Another patient seen by a colleague suffered from preeclampsia at 22 weeks and had to “drive hours” to find a hospital that would provide her with care.

“As it relates to pregnancy and abortion care, patients are forced to drive across the border to smaller, less-equipped hospitals just to get the care that they need,” Smith said.

Obstetrics and gynecological care in much of the U.S. has transformed in the two years since Roe v. Wade was overturned, leaving physicians facing tough decisions as they try to provide patients with quality care and struggle to interpret unclear, confusing and strict state abortion laws.

Physicians interviewed by ABC News across several states said they are relying on each other to determine what emergency and lifesaving care they can legally provide patients.

Since the U.S. Supreme Court overturned Roe v. Wade in 2022, ending federal protections for abortion rights, at least 14 states have ceased nearly all abortion services and seven others have restricted care.

Chilling effect

Last year, Indiana was receiving patients from other states until its near-total ban went into effect in August. Since then, physicians have developed workflows to confer over which patients can receive an abortion under exceptions to the ban.

The new workflow is just one way the ban has transformed care in the state. At least six facilities in Indiana have closed their labor and delivery departments, further reducing access to care, according to Dr. Carrie Rouse, a maternal fetal medicine specialist in Indiana.

A public battle between the state attorney general and a complex family planning physician has also created a chilling effect among doctors across the state.

Dr. Caitlin Bernard, one of two complex family planning specialists in the state, came under the national spotlight after it was revealed she provided abortion care to a 10-year-old rape victim from out of state after Roe was overturned.

After she became outspoken about the consequences of abortion bans, the state attorney general tried to strip her of her medical license. Bernard was required to pay after a medical licensing board found that she violated HIPPA — which protects patient health information — “even though the representative from the American Medical Association who came and testified during that medical licensing board hearing said specifically that she did not,” Rouse said.

“The feeling — and I think the reality — is that she was being punished for being an abortion provider, and I think that is very scary for people,” Rouse said.

Rouse added, “Dr. Barnard was essentially punished for providing evidence-based health care and I think the thing that all of us can and should be thinking is: ‘Well, am I going to be next?'”

Care denied

Even in cases that could meet exceptions to bans, Florida hospitals are very hesitant to schedule abortions, according to one physician.

A patient whose fetus had a diagnosis of Trisomy 18, which is described as incompatible with life, and was diagnosed with cervical dilation that was impossible to close, did not qualify for the exception, according to Dr. Cecilia Grande, an OB-GYN in Miami.

The patient’s options were to wait for her water to break or develop a fever — a sign of an infection — otherwise she would have to leave the state to get care, Grande said.

“I know that if a patient has an emergency, they can get to the emergency room right away. But that doesn’t necessarily mean that they can get the care they need,” Grande told reporters at a press conference last week discussing the state of abortion care nationwide. “I want my colleagues in the emergency room to be able to act to help my patients in their moment of need.”

Will it come back to ‘haunt us’?

After the Tennessee trigger ban prohibiting nearly all abortions went into effect in September 2022, physicians struggled to interpret the law and reach a consensus over when they could provide care.

Dr. Sarah Osmundson, a maternal fetal medicine specialist at Vanderbilt University Medical Center, told ABC News that physicians are still struggling to provide care in Tennessee nearly two years after the ban went into effect — with zero guidance on how they should interpret laws and worries about facing prosecution. But some physicians have begun to provide care more liberally.

“Some of us have really taken a stance that if there is a situation that can impact mom’s life — even if it’s not an immediate, life-threatening circumstance — we feel compelled to provide care for those patients,” Osmundson said.

“We have a responsibility as physicians, as clinicians, to take care of patients’ health first,” Osmundson said. “Whether that comes back to haunt us, I don’t know.”

Still, physicians are relying on having input from other doctors before providing abortion care due to state laws.

“We still see patients that come in to us later than was necessary from outside places because they are not getting the care that they should get and that’s largely based on these laws, which make physicians appropriately very scared for own personal safety,” Osmundson said.

Dr. Leilah Spung, a maternal fetal medicine specialist, was the only dilation and evacuation — a second trimester abortion procedure — provider in Chattanooga when Roe was overturned.

“I knew what I needed to do to take care of patients, but I also knew it could send me to jail,” Spung told ABC News. “So that changed my litmus test.”

“At some point, I was going to do something that was going to land me with a felony charge — I was sure of it — because I also wasn’t going to let anyone die,” Spung said.

Months later, Spung would leave the state to practice medicine in Colorado.

“I had a giant target on my back,” Spung said. “Everyone knew exactly what I was doing.”

“I was unwilling to stay and put myself and my family at risk like that. Especially when I was only a year out from 11 years of training,” Spung said.

The threat of prosecution is top of mind for physicians providing care under bans. After a Texas woman asked a state court for an emergency abortion last year and a lower court ruled she could get one, state Attorney General Ken Paxton sent a letter to Houston hospitals threatening liability if they provided the woman, Kate Cox, with an abortion. The Texas Supreme Court later overturned the court ruling and denied Cox an abortion.

By that point, Cox had already decided to leave the state to get an abortion.

Left unsupported

Spung said she felt unsupported by medical facilities in Tennessee when it came to providing lifesaving abortion care.

“I tried really hard with the other abortion care doctors in the state to come up with a unified response to certain emergencies that might come up — the common things like PPROM, significant vaginal bleeding, ectopic pregnancy, cesarean-section scar ectopic pregnancies,” Spung said.

“We worked really hard to get all of the hospitals on board so that everybody was providing the same care … [and] it is seen as the standard of care instead of something outside the bounds of the law,” Spung said. “That just didn’t happen.”

Hospitals were unwilling to have a unified conversation and it was left up to physicians to make the tough decisions, Spung said.

“Anytime there was someone with a complicated pregnancy that may or may not need abortion care, I was the call. I was the person who answered those questions. I was the one who figured out where they could go, who could see them, whether or not they could legally be taken care of in the state or not,” Spung said.

At Vanderbilt, a committee of physicians review patient cases before determining whether they can provide emergency care in line with Tennessee’s abortion ban. But in Chattanooga, it was left up to Spung to make those decisions, she said.

Physicians in Tennessee have also lobbied to add an exception that would permit abortions in cases of fatal fetal anomalies, but lawmakers were not receptive to the push, according to Osmundson. Meanwhile, physicians are regularly seeing patients with fatal fetal anomalies.

“There are huge delays in care for women who are facing these very severe fetal anomalies that are not compatible with life and they are, you know, either forced to continue that pregnancy in the state of Tennessee to watch their child die, or they have to go out of state,” Osmundson said.

In Colorado, Spung’s practice has seen patients from across states with abortion bans, including Texas, Kansas, Nebraska, Wyoming, Idaho, Utah, North Dakota, South Dakota and Oklahoma.

“Our later abortion numbers increased eight times in the year after Dobbs and people are traveling at least 250 miles one way for care,” Spung said.

‘Strength in numbers’

Meanwhile, physicians in North Carolina and Ohio were able to do what Tennessee physicians attempted unsuccessfully.

In Ohio — where an abortion ban has been blocked by a court order — physicians brought together major hospital academic systems and came up with a unified approach to emergency conditions and how they would treat them, according to Spung.

In North Carolina, abortion providers came together and began meeting regularly to confer over care.

“We felt like we had strength in numbers, if we could be pretty unified with how care was being delivered across the state, then there was going to be less discrepancy, less confusion and less likelihood that any of those procedures would be flagged if everybody was doing things kind of the same,” Dr. Clayton Alfonso, an OB-GYN in the state, told ABC News.

“That being said, every institution has their own attorney group and so not everything is perfectly similar,” Alfonso said. “But we try to keep it as close as possible.”

Physicians in the state have resisted requests from legislators to compile a list of conditions that meet exceptions, saying a list could never include all the emergency conditions, diagnoses or complications that arise during pregnancy. But internally, specialists have established a list of conditions they believe meet the exceptions, according to Alfonso, which they are keeping close.

Hospitals and facilities respond to bans

Medical facilities’ responses to bans have varied around the country, in part due to differences between bans.

In North Carolina, Duke University Medical Center’s administration and its OB-GYN chair have been “very supportive” of physicians since the ban went into effect, Alfonso said.

“We were told to care for the patient, and we’ll figure it out on the back end afterwards. [The hospital] said, ‘Trust your medical opinion, your medical judgment — there is no board, there is no conferring,'” Alfonso said.

When it comes to determining what fetal anomalies are “life-limiting” — the term used in the state law — and meet the exception, physicians have relied on high-risk obstetric physicians.

“I believe they have an internal list of things that they’ve written down that they know that they do as ‘life-limiting,’ but that list has not been circulated. It’s been kept pretty close, in trying to make sure that it doesn’t get into the wrong hands of potential future legislation,” Alfonso said.

Compounding the access crisis

The risks and tough decisions physicians are having to make are already driving some away from states with bans, creating what Spung called a “brain drain,” especially of physicians trained to provide complex, lifesaving, medically necessary abortions.

And replacing them will be incredibly difficult.

“There are going to be times where patients come in and are miscarrying and are bleeding to death in front of you, and you don’t have time to give them medication to open their cervix to help them deliver. You need to take them to the operating room and remove the pregnancy and the safest way to do that is either with a dilation and curettage or dilation and evacuation,” Spung said.

An entire generation of OB-GYN providers in states with abortion bans will be unable to get that training.

“It’s going to become an entire vacuum,” Spung said. “Knowing how to safely provide that care can quite honestly save lives.”

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