Despite years of fighting calls to “defund Planned Parenthood,” the reproductive healthcare organization may now voluntarily remove itself from a massive government funding program, after a federal appeals court allowed a controversial new abortion rule to go forward.

For months, Planned Parenthood has been battling a new Trump administration rule that bars taxpayer-funded family planning clinics from talking with their patients about abortion, or referring them to abortion providers. Planned Parenthood deemed the measure a “gag rule” and said it would pull out of Title X—the program that administers the funds—rather than comply with the new regulations.

The court ruling Friday put that declaration to the test: The 9th U.S. Circuit Court of Appeals declined to rehear its previous order allowing the rule to go forward. 

“The full court has been advised of the motions for full court en banc reconsideration and no judge has requested a vote on whether to rehear the matter as a full en banc court,” Chief Judge Sidney Thomas wrote. “The motions for full court en banc reconsideration are denied.”

In a statement, Planned Parenthood leadership said they would consider their options and announce next steps on Monday. “We refuse to cower to this president,” acting PPFA President and CEO Alexis McGill Johnson said. “The gag rule is unethical, dangerous, and we will not subject our patients to it.”

The Title X program provides funding for family planning services to an estimated 4 million people every year, the majority of whom are low-income and people of color. While Planned Parenthood serves more than 40 percent of these patients, the rule will also affect independent clinics and doctors' offices. Approximately 60 percent of women get their usual medical care from a Title X-supported healthcare center, according to the Guttmacher Institute.

“If Planned Parenthood is forced to withdraw from Title X funding because of Trump, countless patients will not have access to basic services like contraception and pap smears,” NARAL president Ilyse Hogue tweeted. “This will disproportionately affect low income and rural women. This Administration may not care but we do!”

Planned Parenthood, several medical organizations, and 21 states filed a challenge to the new Title X rule in May, claiming the change would cause “significant public health impacts.” A federal judge in Oregon blocked the rule in April, calling it a “ham-fisted approach to public health policy,” but the 9th circuit court ruled in June that it could go forward.

Planned Parenthood appealed the 9th circuit's decision in July, and this month issued a letter saying they would pull out of the Title X program if the ruling was not overturned.

“Planned Parenthood has long been firmly committed to its Title X patients and to the Title X program, which it has served for nearly 50 years,” attorneys for the organization wrote. “With deep regret, however, its direct grantees now have no option but to withdraw from the Title X program.”

HHS fired back with its own letter, claiming the healthcare provider sought “extraordinary, if not unprecedented, relief, based on self-inflicted harms.”

“If the seven Planned Parenthood direct grantees insist on providing abortion referrals even within a federally funded program, and feel so strongly that they would withdraw from the program and the public they serve, that is their own choice, not a consequence of the Rule,” attorneys for HHS wrote.

HHS officials have already begun enforcing the rule, according to a notice it sent to Title X grantees last month. An HHS spokesperson told CNN they would consider funding a new organization that complies with the rules to fulfill Planned Parenthood’s obligations.